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Bernal-Sobrino JL, Arias-Horcajadas F, Varela-Rodríguez C, Losada-Pérez C, Blanco-Echevarría A, Xsdel Yerro Alvarez MJ, Martín-Mayor M, Rubio G. A 3-Year Retrospective Study of the Impact of Integrating an Addiction Liaison Team into an Outpatient Alcoholism Treatment Programme. Alcohol Alcohol 2023; 58:515-522. [PMID: 36760095 DOI: 10.1093/alcalc/agad004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 11/19/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The number of inpatients with alcohol and other substance-related problems (ASRP) in the general hospital population at any time is vast. To meet the needs of those patients, most hospitals have an Addiction Liaison Team (ALT) that diagnoses and initiates the treatment of the addictive disorder. In our hospital, this team is part of a more extensive and intensive Outpatient Alcoholism Treatment Programme that facilitates the continuity of care. AIM the main goal of this study is to evaluate the performance and effectiveness of our inpatient ALT. METHODOLOGY we carried out an observational cohort study of patients with ASRP admitted to the hospital from 2015 to 2017. We evaluated the performance and effectiveness of our ALT: referrals to the programme, inpatients mortality, readmissions to hospital, hospital length of stay (LOS) and medical or surgical treatment adherence. RESULTS out of 133,181 admissions, 17,387 (13.14%) were positive for ASRP, and 615 (3.54%) were referred to the ALT. Referred patients had less in-hospital mortality, shorter LOS and lower risk of readmissions during the first year of follow-up. Subjects treated in the programme had better therapeutic adherence. CONCLUSIONS integrating the ALT into an outpatient programme facilitates an earlier detection and initiation of treatment during the hospital stay and the continuity of care. Alcohol misuse conditions affect the patient's prognosis and health outcomes, so appropriate care is needed. Inclusion in the programme was associated with less risk of hospital mortality, fewer readmissions and a lower LOS.
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Affiliation(s)
- José L Bernal-Sobrino
- Control Management Department, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
| | - Francisco Arias-Horcajadas
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
- Psiquiatry Department, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
- Medical School at Universidad Complutense de Madrid, Pl. de Ramón y Cajal, s/n, 28040 Madrid, Spain
- Addictive-Disorders Research Network (Red de Trastornos adictivos-RETICS) at Instituto de Salud Carlos III, C/ Sinesio Delgado, 4 28029 - Madrid, Spain
| | - Carolina Varela-Rodríguez
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
- Quality of Care Unit, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
| | - Cristina Losada-Pérez
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
- Psiquiatry Department, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
| | - Agustín Blanco-Echevarría
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
- Medical School at Universidad Complutense de Madrid, Pl. de Ramón y Cajal, s/n, 28040 Madrid, Spain
- Internal Medicine Department, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
| | - María J Xsdel Yerro Alvarez
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
- Psiquiatry Department, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
| | - Marta Martín-Mayor
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
- Psiquiatry Department, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
- Medical School at Universidad Complutense de Madrid, Pl. de Ramón y Cajal, s/n, 28040 Madrid, Spain
| | - Gabriel Rubio
- Instituto de investigación Biomédica i+12, Carretera de Córdoba s/n 28041, Madrid, Spain
- Psiquiatry Department, Hospital Universitario 12 de Octubre, Carretera de Córdoba s/n 28041, Madrid, Spain
- Medical School at Universidad Complutense de Madrid, Pl. de Ramón y Cajal, s/n, 28040 Madrid, Spain
- Addictive-Disorders Research Network (Red de Trastornos adictivos-RETICS) at Instituto de Salud Carlos III, C/ Sinesio Delgado, 4 28029 - Madrid, Spain
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Sadowska K, Fong T, Horning DR, McAteer S, Ekwebelem MI, Demetres M, Reid MC, Shalev D. Psychiatric Comorbidities and Outcomes in Palliative and End-of-Life Care: A Systematic Review. J Pain Symptom Manage 2023; 66:e129-e151. [PMID: 37003308 PMCID: PMC10330030 DOI: 10.1016/j.jpainsymman.2023.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/14/2023] [Accepted: 03/16/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Although psychiatric comorbidities are common among individuals at end of life, their impact on outcomes is poorly understood. METHODS We conducted a systematic literature review of six databases following preferred reporting items for systematic reviews and meta-analyses guidelines and aimed at assessing the relationship between psychiatric comorbidities and outcomes in palliative and end-of-life care. Six databases were included in our search. This review is registered on PROSPERO (CRD42022335922). RESULTS Our search generated 7472 unique records. Eighty-eight full texts were reviewed for eligibility and 43 studies were included in the review. Clinically, psychiatric comorbidity was associated with poor quality of life, increased physical symptom burden, and low function. The impact of psychiatric comorbidity on health utilization varied, though many studies suggested that psychiatric comorbidity increased utilization of palliative care services. Quality of evidence was limited by lack of consistent approach to confounding variables as well as heterogeneity of the included studies. CONCLUSION Psychiatric comorbidity is associated with significant differences in care utilization and clinical outcome among patients at end of life. In particular, patients with psychiatric comorbidity and serious illness are at high risk of poor quality of life and high symptom burden. Our finding that psychiatric comorbidity is associated with increased utilization of palliative care likely reflects the complexity and clinical needs of patients with serious illness and mental health needs. These data suggest that greater integration of mental health and palliative care services may enhance quality-of-life among patients at end of life.
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Affiliation(s)
| | - Tina Fong
- Case Western Reserve University (T.F.), Cleveland, Ohio, USA
| | - Daniel R Horning
- Teacher's College (D.R.H.), Columbia University, New York, New York, USA
| | - Sandra McAteer
- School of Public Health (S.M.), University of Washington, Seattle, Washington, USA
| | - Maureen I Ekwebelem
- Division of Geriatrics and Palliative Medicine (M.I.E., M.C.R., D.S.), Weill Cornell Medicine, New York, New York, USA
| | - Michelle Demetres
- Samuel J. Wood Library & C.V. Starr Biomedical Information Center (M.D.), Weill Cornell Medicine, New York, USA
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine (M.I.E., M.C.R., D.S.), Weill Cornell Medicine, New York, New York, USA
| | - Daniel Shalev
- Division of Geriatrics and Palliative Medicine (M.I.E., M.C.R., D.S.), Weill Cornell Medicine, New York, New York, USA; Department of Psychiatry (D.S.), Weill Cornell Medicine, New York, New York, USA.
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Nicholson BL, Flynn L, Savage B, Zha P, Kozlov E. Palliative Care Use in Advanced Cancer in the Garden State. Cancer Nurs 2023; 46:E253-E260. [PMID: 35398871 DOI: 10.1097/ncc.0000000000001105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cancer is the second leading cause of death in the United States. Patients with metastatic cancer have a high symptom burden. Major global and domestic cancer care recommendations advise integration of palliative care services for these patients. Palliative care is specialized care that can decrease cost, improve symptom burden, and improve quality of life. Patient factors driving the use of palliative care remain poorly understood but may include both physiological and psychological needs, namely, pain and depression, respectively. OBJECTIVE The objective of this study was to identify patient-level predictors associated with inpatient palliative care use in patients with metastatic cancer. METHODS This was a secondary analysis of the 2018 New Jersey State Inpatient Database. The sample was limited to hospitalized adults with metastatic cancer in New Jersey. Descriptive statistics characterized the sample. Generalized linear modeling estimated the effects of pain and depression on the use of inpatient palliative care. RESULTS The sample included 28 697 hospitalizations for patients with metastatic cancer. Within the sample, 4429 (15.4%) included a palliative care consultation. There was a 9.3% documented occurrence of pain and a 10.9% rate of depression. Pain contributed to palliative care use, but depression was not predictive of an inpatient care consultation. Age, income category, and insurance status were significant factors influencing use. CONCLUSION Understanding demographic and clinical variables relative to palliative care use may help facilitate access to palliative care for adults experiencing metastatic cancer. IMPLICATION FOR PRACTICE Increased screening for pain and depression may expand palliative care use for adults with metastatic cancer receiving inpatient care.
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Affiliation(s)
- Bridget L Nicholson
- Author Affiliations: Rutgers School of Nursing, Rutgers, The State University of New Jersey (Drs Nicholson, Flynn, Savage, and Zha); and Rutgers School of Public Health, Rutgers, The State University of New Jersey (Dr Kozlov)
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Curtis JR, Lee RY, Brumback LC, Kross EK, Downey L, Torrence J, LeDuc N, Mallon Andrews K, Im J, Heywood J, Brown CE, Sibley J, Lober WB, Cohen T, Weiner BJ, Khandelwal N, Abedini NC, Engelberg RA. Intervention to Promote Communication About Goals of Care for Hospitalized Patients With Serious Illness: A Randomized Clinical Trial. JAMA 2023; 329:2028-2037. [PMID: 37210665 PMCID: PMC10201405 DOI: 10.1001/jama.2023.8812] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Abstract
Importance Discussions about goals of care are important for high-quality palliative care yet are often lacking for hospitalized older patients with serious illness. Objective To evaluate a communication-priming intervention to promote goals-of-care discussions between clinicians and hospitalized older patients with serious illness. Design, Setting, and Participants A pragmatic, randomized clinical trial of a clinician-facing communication-priming intervention vs usual care was conducted at 3 US hospitals within 1 health care system, including a university, county, and community hospital. Eligible hospitalized patients were aged 55 years or older with any of the chronic illnesses used by the Dartmouth Atlas project to study end-of-life care or were aged 80 years or older. Patients with documented goals-of-care discussions or a palliative care consultation between hospital admission and eligibility screening were excluded. Randomization occurred between April 2020 and March 2021 and was stratified by study site and history of dementia. Intervention Physicians and advance practice clinicians who were treating the patients randomized to the intervention received a 1-page, patient-specific intervention (Jumpstart Guide) to prompt and guide goals-of-care discussions. Main Outcomes and Measures The primary outcome was the proportion of patients with electronic health record-documented goals-of-care discussions within 30 days. There was also an evaluation of whether the effect of the intervention varied by age, sex, history of dementia, minoritized race or ethnicity, or study site. Results Of 3918 patients screened, 2512 were enrolled (mean age, 71.7 [SD, 10.8] years and 42% were women) and randomized (1255 to the intervention group and 1257 to the usual care group). The patients were American Indian or Alaska Native (1.8%), Asian (12%), Black (13%), Hispanic (6%), Native Hawaiian or Pacific Islander (0.5%), non-Hispanic (93%), and White (70%). The proportion of patients with electronic health record-documented goals-of-care discussions within 30 days was 34.5% (433 of 1255 patients) in the intervention group vs 30.4% (382 of 1257 patients) in the usual care group (hospital- and dementia-adjusted difference, 4.1% [95% CI, 0.4% to 7.8%]). The analyses of the treatment effect modifiers suggested that the intervention had a larger effect size among patients with minoritized race or ethnicity. Among 803 patients with minoritized race or ethnicity, the hospital- and dementia-adjusted proportion with goals-of-care discussions was 10.2% (95% CI, 4.0% to 16.5%) higher in the intervention group than in the usual care group. Among 1641 non-Hispanic White patients, the adjusted proportion with goals-of-care discussions was 1.6% (95% CI, -3.0% to 6.2%) higher in the intervention group than in the usual care group. There was no evidence of differential treatment effects of the intervention on the primary outcome by age, sex, history of dementia, or study site. Conclusions and Relevance Among hospitalized older adults with serious illness, a pragmatic clinician-facing communication-priming intervention significantly improved documentation of goals-of-care discussions in the electronic health record, with a greater effect size in racially or ethnically minoritized patients. Trial Registration ClinicalTrials.gov Identifier: NCT04281784.
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Affiliation(s)
- J. Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Robert Y. Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | | | - Erin K. Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Nicole LeDuc
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Kasey Mallon Andrews
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Jennifer Im
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Crystal E. Brown
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - James Sibley
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
| | - William B. Lober
- Department of Biobehavioral Nursing and Health Informatics, University of Washington, Seattle
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - Trevor Cohen
- Department of Biomedical Informatics and Medical Education, University of Washington, Seattle
| | - Bryan J. Weiner
- Department of Health Systems and Population Health, University of Washington, Seattle
- Department of Global Health, University of Washington, Seattle
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Nauzley C. Abedini
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle
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Shalev D, Patterson M, Aytaman Y, Moya-Tapia MA, Blinderman CD, Silva MD, Reid MC. Operationalizing Depression Screening in Ambulatory Palliative Care: A Quality Improvement Project. J Pain Symptom Manage 2023; 65:e7-e13. [PMID: 36103939 PMCID: PMC9790031 DOI: 10.1016/j.jpainsymman.2022.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/27/2022] [Accepted: 09/01/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Depression is common in the palliative care setting and impacts outcomes. Operationalized screening is unusual in palliative care. LOCAL PROBLEM Lack of operationalized depression screening at two ambulatory palliative care sites. METHODS A fellow-driven quality improvement initiative to implement operationalized depression screening using the patient health questionnaire-2 (PHQ-2). The primary measure was rate of EMR-documented depression screening. Secondary measures were clinician perspectives on the feasibility and acceptability of implementing the PHQ-2. INTERVENTION The intervention is a clinic-wide implementation of PHQ-2 screening supported by note templates, brief clinician training, referral resources for clinicians, and opportunities for indirect psychiatric consultation. RESULTS Operationalized depression screening rates increased from 2% to 38%. All clinicians felt incorporation of depression screening was useful and feasible. CONCLUSIONS Operationalized depression screening is feasible in ambulatory palliative care workflow, though optimization through having screening be completed prior to clinician visit might improve uptake.
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Affiliation(s)
- Daniel Shalev
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine (D.S., M.D.S., M.C.R.), New York, New York, USA.
| | - Melissa Patterson
- Department of Medicine (M.P., M.A.M.T., C.D.B.), Columbia University Irving Medical Center, New York, New York, USA
| | - Yasemin Aytaman
- Department of Medicine (Y.A.), Brooklyn Campus of the VA NY Harbor Healthcare System, Brooklyn, New York, USA
| | - Manuel A Moya-Tapia
- Department of Medicine (M.P., M.A.M.T., C.D.B.), Columbia University Irving Medical Center, New York, New York, USA
| | - Craig D Blinderman
- Department of Medicine (M.P., M.A.M.T., C.D.B.), Columbia University Irving Medical Center, New York, New York, USA
| | - Milagros D Silva
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine (D.S., M.D.S., M.C.R.), New York, New York, USA
| | - M Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine (D.S., M.D.S., M.C.R.), New York, New York, USA
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Curtis JR, Lee RY, Brumback LC, Kross EK, Downey L, Torrence J, Heywood J, LeDuc N, Mallon Andrews K, Im J, Weiner BJ, Khandelwal N, Abedini NC, Engelberg RA. Improving communication about goals of care for hospitalized patients with serious illness: Study protocol for two complementary randomized trials. Contemp Clin Trials 2022; 120:106879. [PMID: 35963531 PMCID: PMC10042145 DOI: 10.1016/j.cct.2022.106879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/26/2022] [Accepted: 08/06/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although goals-of-care discussions are important for high-quality palliative care, this communication is often lacking for hospitalized older patients with serious illness. Electronic health records (EHR) provide an opportunity to identify patients who might benefit from these discussions and promote their occurrence, yet prior interventions using the EHR for this purpose are limited. We designed two complementary yet independent randomized trials to examine effectiveness of a communication-priming intervention (Jumpstart) for hospitalized older adults with serious illness. METHODS We report the protocol for these 2 randomized trials. Trial 1 has two arms, usual care and a clinician-facing Jumpstart, and is a pragmatic trial assessing outcomes with the EHR only (n = 2000). Trial 2 has three arms: usual care, clinician-facing Jumpstart, and clinician- and patient-facing (bi-directional) Jumpstart (n = 600). We hypothesize the clinician-facing Jumpstart will improve outcomes over usual care and the bi-directional Jumpstart will improve outcomes over the clinician-facing Jumpstart and usual care. We use a hybrid effectiveness-implementation design to examine implementation barriers and facilitators. OUTCOMES For both trials, the primary outcome is EHR documentation of a goals-of-care discussion within 30 days of randomization; additional outcomes include intensity of end-of-life care. Trial 2 also examines patient- or family-reported outcomes assessed by surveys targeting 3-5 days and 4-8 weeks after randomization including quality of goals-of-care communication, receipt of goal-concordant care, and psychological symptoms. CONCLUSIONS This novel study incorporates two complementary randomized trials and a hybrid effectiveness-implementation approach to improve the quality and value of care for hospitalized older adults with serious illness. CLINICAL TRIALS REGISTRATION STUDY00007031-A and STUDY00007031-B.
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Affiliation(s)
- J Randall Curtis
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America.
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lyndia C Brumback
- Department of Biostatistics, University of Washington, Seattle, WA, United States of America
| | - Erin K Kross
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Lois Downey
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Janaki Torrence
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Joanna Heywood
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Nicole LeDuc
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Kasey Mallon Andrews
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Jennifer Im
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States of America
| | - Bryan J Weiner
- Department of Health Systems and Population Health, University of Washington, Seattle, WA, United States of America; Department of Global Health, University of Washington, Seattle, WA, United States of America
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States of America
| | - Nauzley C Abedini
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Gerontology and Geriatric Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence at UW Medicine, University of Washington, Seattle, WA, United States of America; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA, United States of America
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Riley K, Hupcey JE, Kowalchik K. Palliative Care in Severe and Persistent Mental Illness: A Systematic Review. J Hosp Palliat Nurs 2022; 24:E88-E93. [PMID: 35285463 DOI: 10.1097/njh.0000000000000855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Severe and persistent mental illnesses refer to a group of psychiatric disorders causing severe dysfunction in patients and include diagnoses such as schizophrenia, bipolar disorder, and major depression. Patients with severe and persistent mental illnesses have a complex symptomatology and face complicated medical disparities creating a difficult care process and reduced quality of life. Palliative care, a holistic approach to care that aims to reduce symptoms and stress of illness in persons living with chronic diagnoses, is appropriate within this population to address the complexity of care needs but is currently underutilized. The purpose of this review was to systematically review the literature to determine what is currently known about palliative care utilization in the severe and persistently mentally ill population. The databases systematically searched include PubMed, Cumulative Index for Nursing and Allied Health Literature, PsycINFO, and MEDLINE, to find all articles relevant to the research question. Keywords include "palliative care," "end-of-life care," and "severe and persistent mental illness," including all subsets. Literature was reviewed per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The results of this systematic review helped synthesize current information about this developing topic to inform clinicians on how to best integrate palliative care to this population.
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Fields L, Shalev D, Nathanson M, Shapiro PA. Palliative Care Training for Geriatric Psychiatry Fellows: A National Survey Project. Am J Geriatr Psychiatry 2022; 30:504-510. [PMID: 34535362 DOI: 10.1016/j.jagp.2021.08.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 06/30/2021] [Accepted: 08/16/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Palliative care is an essential part of the standard of care for individuals with serious medical illnesses. Integration of palliative care and mental health is important for elderly patients with medical and psychiatric comorbidities. Geriatric psychiatrists are natural stewards of palliative care-mental health integration, however this is contingent on palliative care training. Currently, palliative care training in geriatric psychiatry fellowship programs is uncharacterized. We surveyed geriatric psychiatry fellowship program directors in the United States to assess current palliative care training practices. METHODS Web-based anonymous survey of geriatric psychiatry fellowship training directors RESULTS: Forty-six percent (28/61) of program directors responded. Seventy one percent (20/28) of programs provide didactics on palliative care. Seventy-seven percent (20/26) of programs provide clinical experiences in palliative care. Sixty-three percent (15/24) have formalized interactions between geriatric psychiatry and palliative care fellows. CONCLUSIONS Palliative care training for geriatric psychiatry fellows is robust but unstandardized. Operationalizing palliative care training for geriatric psychiatrists may improve mental health integration into serious illness care.
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Affiliation(s)
- Lauren Fields
- Columbia University College of Physicians and Surgeons (LF), New York, NY
| | - Daniel Shalev
- Department of Medicine, Division of Geriatrics and Palliative Care, Weill Cornell Medicine (DS), New York, NY.
| | - Mark Nathanson
- Division of Geriatric Psychiatry, Department of Psychiatry (MN), Columbia University, New York, NY
| | - Peter A Shapiro
- Division of Consultation-Liaison Psychiatry, Department of Psychiatry (PAS), Columbia University, New York, NY
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Structured Interventions to Optimize Polypharmacy in Psychiatric Treatment and Nursing Homes: A Systematic Review. J Clin Psychopharmacol 2022; 42:169-187. [PMID: 35230048 DOI: 10.1097/jcp.0000000000001521] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Polypharmacy is a common clinical issue. It increases in prevalence with older age and comorbidities of patients and has been recognized as a major cause for treatment complications. In psychiatry, polypharmacy is also commonly seen in younger patients and can lead to reduced treatment satisfaction and incompliance. A variety of structured polypharmacy interventions have been investigated. This systematic review provides a comprehensive overview of the field and identifies research gaps. METHODS We conducted a systematic review on structured interventions aimed at optimizing polypharmacy of psychotropic and somatic medication in psychiatric inpatient and outpatient settings as well as nursing homes. A search protocol was registered with PROSPERO (CRD42020187304). Data were synthesized narratively. RESULTS Fifty-eight studies with a total of 30,554 participants met the inclusion criteria. Interventions were most commonly guided by self-developed or national guidelines, drug assessment scores, and lists of potentially inappropriate medications. Tools to identify underprescribing were less commonly used. Most frequently reported outcomes were quantitative drug-related measures; clinical outcomes such as falls, hospital admission, cognitive status, and neuropsychiatric symptom severity were reported less commonly. Reduction of polypharmacy and improvement of medication appropriateness were shown by most studies. CONCLUSIONS Improvement of drug-related outcomes can be achieved by interventions such as individualized medication review and educational approaches in psychiatric settings and nursing homes. Changes in clinical outcomes, however, are often nonsubstantial and generally underreported. Patient selection and intervention procedures are highly heterogeneous. Future investigations should establish standards in intervention procedures, identify and assess patient-relevant outcome measures, and consider long-term follow-up assessments.
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Edwards D, Anstey S, Coffey M, Gill P, Mann M, Meudell A, Hannigan B. End of life care for people with severe mental illness: Mixed methods systematic review and thematic synthesis (the MENLOC study). Palliat Med 2021; 35:1747-1760. [PMID: 34479457 PMCID: PMC8637363 DOI: 10.1177/02692163211037480] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Parity of esteem means that end-of-life care for people with severe mental illness should be of equal quality to that experienced by all. AIM To synthesise international, English language, research and UK policy and guidance relating to the organisation, provision, and receipt of end-of-life care for people with severe mental illness. DESIGN A mixed methods systematic review was conducted following the Evidence for Policy and Practice Information and Co-ordinating Centre approach and informed by a stakeholder group. We employed thematic synthesis to bring together data from both qualitative and quantitative studies, and from non-research material. We assessed the strength of synthesised findings using the Confidence in the Evidence from Reviews of Qualitative Research (CERQual) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches. DATA SOURCES Ten electronic databases were searched from inception to December 2019, along with 62 organisational websites. Quality appraisal was conducted using Critical Appraisal Skills Programme checklists or other study design-specific alternatives as necessary. RESULTS Of the 11,904 citations retrieved, 34 research publications were included plus 28 non-research items. The majority of research was of high or acceptable quality. An overarching synthesis including 52 summary statements, with assessments of confidence in the underpinning evidence, was produced using four themes: Structure of the system; Professional issues; Contexts of care; and Living with severe mental illness. CONCLUSIONS Implications for services and practice reflect evidence in which there is a high degree of confidence. Partnership should be developed across the mental health and end-of-life systems, and ways found to support people to die where they choose. Staff caring for people with severe mental illness at the end-of-life need education, support and supervision. End-of-life care for people with severe mental illness requires a team approach, including advocacy. Proactive physical health care for people with severe mental illness is needed to tackle problems of delayed diagnosis.
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Affiliation(s)
- Deborah Edwards
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Sally Anstey
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Michael Coffey
- Department of Public Health, Policy and
Social Sciences, College of Human and Health Sciences, Swansea University, Swansea,
UK
| | - Paul Gill
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
| | - Mala Mann
- Specialist Unit for Review Evidence,
University Library Services, Cardiff University, Cardiff, UK
| | - Alan Meudell
- Independent Service User Researcher,
Caerphilly, UK
| | - Ben Hannigan
- School of Healthcare Sciences, College
of Biomedical and Life Sciences, Cardiff University, Cardiff, UK
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Lee RY, Modes ME, Sathitratanacheewin S, Engelberg RA, Curtis JR, Kross EK. Conflicting Orders in Physician Orders for Life-Sustaining Treatment Forms. J Am Geriatr Soc 2020; 68:2903-2908. [PMID: 32936447 PMCID: PMC7744421 DOI: 10.1111/jgs.16828] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/17/2020] [Accepted: 08/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVES Many older persons with chronic illness use Physician Orders for Life-Sustaining Treatment (POLST) to document portable medical orders for emergency care. However, some POLSTs contain combinations of orders that do not translate into a cohesive care plan (eg, cardiopulmonary resuscitation [CPR] without intensive care, or intensive care without antibiotics). This study characterizes the prevalence and predictors of POLSTs with conflicting orders. DESIGN Retrospective cohort study. SETTING Large academic health system. PARTICIPANTS A total of 3,123 POLST users with chronic life-limiting illness who died between 2010 and 2015 (mean age = 69.7 years). MEASUREMENTS In a retrospective review of all POLSTs in participants' electronic health records, we describe the prevalence of POLSTs with conflicting orders for cardiac arrest and medical interventions, and use clustered logistic regression to evaluate potential predictors of conflicting orders. We also examine the prevalence of conflicts between POLST orders for antibiotics and artificial nutrition with orders for cardiac arrest or medical interventions. RESULTS Among 3,924 complete POLSTs belonging to 3,123 decedents, 209 (5.3%) POLSTs contained orders to "attempt CPR" paired with orders for "limited interventions" or "comfort measures only"; 745/3169 (23.5%) POLSTs paired orders to restrict antibiotics with orders to deliver non-comfort-only care; and, 170/3098 (5.5%) POLSTs paired orders to withhold artificial nutrition with orders to deliver CPR or intensive care. Among POLSTs with orders to avoid intensive care, orders to attempt CPR were more likely to be present in POLSTs completed earlier in the patient's illness course (adjusted odds ratio = 1.27 per twofold increase in days from POLST to death; 95% confidence interval = 1.18-1.36; P < .001). CONCLUSION Although most POLSTs are actionable by clinicians, 5% had conflicting orders for cardiac arrest and medical interventions, and 24% had one or more conflicts between orders for cardiac arrest, medical interventions, antibiotics, and artificial nutrition. These conflicting orders make implementation of POLST challenging for clinicians in acute care settings.
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Affiliation(s)
- Robert Y. Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Matthew E. Modes
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ruth A. Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
| | - Erin K. Kross
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Harborview Medical Center, University of Washington, Seattle, Washington
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Kan AD, Chong PH, Yeo ZZ. Impact of psychiatrist support in home-based hospice care: A qualitative case-series review. PROGRESS IN PALLIATIVE CARE 2020. [DOI: 10.1080/09699260.2020.1810458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Park T, Hegadoren K, Workun B. Working at the Intersection of Palliative End-of-Life and Mental Health Care: Provider Perspectives. J Palliat Care 2020; 37:183-189. [PMID: 32808560 DOI: 10.1177/0825859720951360] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE Palliative, end-of-life care (PEOLC) providers are poorly resourced in addressing the needs of patients with mental health challenges, and the dying experiences of this cohort-particularly those with a comorbid, chronic and persistent mental illness (CPMI)-are poorly documented. We sought to explore the experiences of PEOLC providers with regard to caring for patients with mental health challenges, and gather insights into ways of improving accessibility and quality of PEOLC for these patients. METHOD Twenty providers of PEOLC, from different disciplines, took part in semi structured interviews. The data were coded and analyzed using a reflexive, inductive-deductive process of thematic analysis. RESULTS The most prominent issues pertained to assessment of patients and differential diagnosis of CPMI, and preparedness of caregivers to deliver mental health interventions, given the isolation of palliative care from other agencies. Among the assets mentioned, informal relationships with frontline caregivers were seen as the main support structure, rather than the formal policies and procedures of the practice settings. Strategies to improve mental health care in PEOLC centered on holistic roles and interventions benefiting the entire palliative population, illustrating the participants saw little point in compartmentalizing mental illness, whether diagnosed or not. SIGNIFICANCE OF RESULTS Continuity of care and personal advocacy can significantly improve quality of life for end-of-life patients with mental health challenges, but bureaucracy and disciplinary siloing tend to isolate these patients and their caregivers. Improved interdisciplinary connectivity and innovative, hybridized roles encompassing palliation and psychiatry are 2 strategies to address this disconnect, as well as enhanced training in core mental health care competencies for PEOLC providers.
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Affiliation(s)
- Tanya Park
- Faculty of Nursing, 3158University of Alberta, Edmonton, Canada
| | - Kathy Hegadoren
- Faculty of Nursing, 3158University of Alberta, Edmonton, Canada
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Shalev D, Fields L, Shapiro PA. End-of-Life Care in Individuals With Serious Mental Illness. PSYCHOSOMATICS 2020; 61:428-435. [PMID: 32660874 PMCID: PMC7290196 DOI: 10.1016/j.psym.2020.06.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 06/07/2020] [Accepted: 06/08/2020] [Indexed: 01/26/2023]
Abstract
Background Approximately 4.5% of the population live with serious mental illness (SMI), a term referring to mental health disorders that are chronic, impair function, and require ongoing treatment. People living with SMI are at risk of premature mortality relative to people without SMI. Chronic medical illnesses contribute significantly to mortality among individuals with SMI. The standard of care for individuals with serious medical illnesses includes palliative care. However, the provision of palliative care has not been operationalized for individuals with SMI. Objectives To review existing data on end-of-life and palliative care for individuals with serious medical illness and comorbid serious mental illness. To operationalize the role of the consultation-liaison (C-L) psychiatrist in such care, with a particular eye towards redressing disparities. Methods In this narrative review, we draw upon a review of the literature on end-of-life and palliative care provision for individuals with serious medical illness and comorbid serious medical illness. We also draw upon the experiences of the authors in formulating best practices for the care of such patients. Results Individuals with SMI are at risk of suboptimal end-of-life care. Patient, clinician, and system-level factors all contribute to disparities including decreased access to palliative care, uneven continued engagement with mental health services, and low rates of advance care planning. C-L psychiatrists can use their expertise at the intersection of medicine and psychiatry to address such disparities by (1) correcting misassumptions, (2) promoting advance care planning, (3) engaging long-term caregivers, (4) recognizing social needs, (5) ensuring ongoing access to psychiatric treatment, and (6) addressing suffering. Conclusions There are significant disparities in the end-of-life care of individuals with SMI. C-L psychiatrists have expertise to ally with medical providers and redress these disparities.
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Affiliation(s)
- Daniel Shalev
- Department of Psychiatry, Columbia University, New York, NY.
| | - Lauren Fields
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY
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Bickel KE, Kennedy R, Levy C, Burgio KL, Bailey FA. The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis. J Gen Intern Med 2020; 35:505-513. [PMID: 31792872 PMCID: PMC7018872 DOI: 10.1007/s11606-019-05538-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 08/06/2019] [Accepted: 10/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization. OBJECTIVES To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration. DESIGN Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center. SUBJECTS Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011. MAIN MEASURES Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life. KEY RESULTS Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138). CONCLUSIONS PTSD's association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients. TRIAL REGISTRATION NCT00234286.
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Affiliation(s)
- Kathleen E Bickel
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA.
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA.
| | - Richard Kennedy
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cari Levy
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA
| | - Kathryn L Burgio
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - F Amos Bailey
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
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Wilson R, Hepgul N, Higginson IJ, Gao W. End-of-life care and place of death in adults with serious mental illness: A systematic review and narrative synthesis. Palliat Med 2020; 34:49-68. [PMID: 31608768 DOI: 10.1177/0269216319867847] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND People with serious mental illness have greater mortality risk than the general population. They experience health care inequalities throughout life; it is not clear if this persists to end of life. AIM Assess the empirical evidence describing end-of-life care and place of death for people with serious mental illness. DESIGN A systematic review of original, peer-reviewed research, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data were analysed using a narrative synthesis approach. DATA SOURCES Five online databases (Embase, PsycArticles, PsycINFO, Medline, PubMed) and additional sources were searched (without time restriction) for primary research reporting health care utilisation in the last year of life or place of death in adults with serious mental illness. RESULTS After full-text screening, 23 studies were included. We found studies reporting hospital admissions, emergency department care, palliative care, and general practitioner (GP) visits at end of life. We found conflicting evidence for the association between serious mental illness and end-of-life care, although different patient groups, settings and measures were used across studies. People with serious mental illness were more likely to die in care homes than the general population. There were no patterns for other places of death. CONCLUSIONS The evidence was sparse and heterogeneous, demonstrating variability in patterns and reporting of health care use and with little consensus on where people with serious mental illness are likely to die. Given that people with serious mental illness have increased mortality risk, this gap in the knowledge around end-of-life care outcomes is concerning; this area of research needs further development.
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Affiliation(s)
- Rebecca Wilson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Nilay Hepgul
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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A scoping review of palliative care for persons with severe persistent mental illness. Palliat Support Care 2019; 17:479-487. [DOI: 10.1017/s1478951519000087] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectivePeople with severe persistent mental illness (SPMI) experience a greater burden and severity of chronic disease, late diagnosis, and premature death compared with the general population. Those with SPMI also receive fewer medical treatments, poor quality of care, and are less likely to receive palliative care. A systematic scoping review was undertaken to determine the extent, range, and nature of research activity about people with SPMI requiring palliative care, and to identify gaps and opportunities for future research.MethodA systematic scoping review was undertaken in September 2017 and updated in May 2018 to map literature on this topic, determine the extent and range of what has been published, and report the findings. This five-stage framework was conducted by (1) identifying the research question; (2) identifying relevant studies; (3) determining study selection; (4) charting the data; and 5) collating, summarizing, and reporting the results. A narrative approach to analysis was used to synthesize and interpret findings. A search of multidisciplinary healthcare databases resulted in 46 included articles.ResultFour major themes were identified from the included studies: complexity of care; limited access to care (both through systems and healthcare providers); competence and autonomy; and the potential for relationships between mental health and palliative care.Significance of resultsThis review reveals a highly vulnerable population with complex needs that are not reliably being met by the healthcare system and providers. Research in this area must continue to develop using rigorous qualitative and quantitative study designs, and interventions should be developed and tested based on existing knowledge to inform care. The voices of people with SPMI in need of palliative care must be represented in future studies to address gaps. To expand a body of literature addressing mainly individuals, system perspectives and sociocultural analysis can bring much to contextualizing the experience of living with SPMI in the palliative phase of care. Adoption of a palliative approach, which promotes the principles of palliative care across nonspecialized care settings provided by nonspecialist palliative providers, has the potential to increase access to high-quality palliative treatment for people with SPMI.
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Spilsbury K, Rosenwax L, Brameld K, Kelly B, Arendts G. Morbidity burden and community-based palliative care are associated with rates of hospital use by people with schizophrenia in the last year of life: A population-based matched cohort study. PLoS One 2018; 13:e0208220. [PMID: 30496266 PMCID: PMC6264825 DOI: 10.1371/journal.pone.0208220] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/14/2018] [Indexed: 11/23/2022] Open
Abstract
Objective People with schizophrenia face an increased risk of premature death from chronic diseases and injury. This study describes the trajectory of acute care health service use in the last year of life for people with schizophrenia and how this varied with receipt of community-based specialist palliative care and morbidity burden. Method A population-based retrospective matched cohort study of people who died from 01/01/2009 to 31/12/2013 with and without schizophrenia in Western Australia. Hospital inpatient, emergency department, death and community-based care data collections were linked at the person level. Rates of emergency department presentations and hospital admissions over the last year of life were estimated. Results Of the 63508 decedents, 1196 (1.9%) had a lifetime history of schizophrenia. After adjusting for confounders and averaging over the last year of life there was no difference in the overall rate of ED presentation between decedents with schizophrenia and the matched cohort (HR 1.09; 95%CI 0.99–1.19). However, amongst the subset of decedents with cancer, choking or intentional self-harm recorded on their death certificate, those with schizophrenia presented to ED more often. Males with schizophrenia had the highest rates of emergency department use in the last year of life. Rates of hospital admission for decedents with schizophrenia were on average half (HR 0.53, 95%CI 0.44–0.65) that of the matched cohort although this varied by cause of death. Of all decedents with cancer, 27.5% of people with schizophrenia accessed community-based specialist palliative care compared to 40.4% of the matched cohort (p<0.001). Rates of hospital admissions for decedents with schizophrenia increased 50% (95% CI: 10%-110%) when enrolled in specialist palliative care. Conclusion In the last year of life, people with schizophrenia were less likely to be admitted to hospital and access community-based speciality palliative care, but more likely to attend emergency departments if male. Community-based specialist palliative care was associated with increased rates of hospital admissions.
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Affiliation(s)
- Katrina Spilsbury
- Centre for Population Health Research, Curtin University, Perth, Western Australia, Australia
- Institute for Health Research, The University of Notre Dame Australia, Perth Western Australia, Australia
| | - Lorna Rosenwax
- School of Occupational Therapy and Social Work, Curtin University, Perth, Western Australia, Australia
- * E-mail:
| | - Kate Brameld
- Centre for Population Health Research, Curtin University, Perth, Western Australia, Australia
| | - Brian Kelly
- Centre for Brain and Mental Health Research and School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, University of Western Australia, Perth, Western Australia, Australia
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
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Siddiqui N, Dwyer M, Stankovich J, Peterson G, Greenfield D, Si L, Kinsman L. Hospital length of stay variation and comorbidity of mental illness: a retrospective study of five common chronic medical conditions. BMC Health Serv Res 2018; 18:498. [PMID: 29945622 PMCID: PMC6020383 DOI: 10.1186/s12913-018-3316-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 06/19/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND With the increasing burden of mental illness globally, it is becoming common for hospitalised patients with chronic medical conditions to have a comorbidity of mental illness. This combination could prolong length of stay (LOS) of this patient cohort. We conducted an investigation in Tasmania, Australian hospitals to characterise this cohort and assess if co-morbidity of mental illness is a distinguishing factor that generates LOS variation across different chronic medical conditions. METHODS The retrospective study analysed 16,898 admissions of patients with a primary diagnosis of one of five chronic medical conditions: lung or colorectal cancer, chronic obstructive pulmonary disease (COPD), type II diabetes, ischaemic heart disease (IHD) and stroke. Data were from July 2010 to June 2015, across four hospitals that collectively cover 95% of public hospital admissions in Tasmania, Australia. Descriptive statistics were used to compare characteristics of patients between the scenarios of with and without co-morbidity of mental illness. We used negative binomial regression models to assess whether co-morbidity of mental illness, along with its sub-types, after adjustment for potential confounding variables, associated with LOS variation in patients of each medical condition. Based on the adjusted LOS variation, we estimated differences in bed days' use between patients with and without comorbidity of mental illness. RESULTS Patients with co-morbidity of mental illness were significantly younger in comparison to patients without mental illness. With each medical condition, patients with comorbidity of mental illness had incurred higher bed days' use than for those without mental illness. In cancer and stroke cohorts, co-morbidity of mental illness unfavourably affected the LOS variation by as high as 97% (CI: 49.9%-159%) and 109% (78%-146%), respectively. Though mental and behavioural disorders due to psychoactive substances was a dominant sub-type of mental illness across the medical conditions, it contributed significant unfavourable LOS variation only in the stroke patients i.e. 36.3% (CI: 16.2%-59.9%). CONCLUSIONS Mental illness consistently produced unfavourable LOS variation. Upskilling of healthcare teams and greater reporting and analysis of LOS variation for this patient cohort, and the sub-cohorts within it, are necessary to provide improved medical care and achieve system efficiencies.
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Affiliation(s)
- Nazlee Siddiqui
- Australian Institute of Health Services Management (AIHSM), Tasmanian School of Business and Economics, University of Tasmania, Rozelle campus, Cnr Glover and Church Streets, Sydney, NSW 2039 Australia
| | - Mitchell Dwyer
- School of Health Sciences, University of Tasmania, Tasmania, Australia
| | - Jim Stankovich
- Health Services Innovation Tasmania, School of Medicine, University of Tasmania, Tasmania, Australia
| | - Gregory Peterson
- Health Services Innovation Tasmania, School of Medicine, University of Tasmania, Tasmania, Australia
| | - David Greenfield
- Australian Institute of Health Services Management (AIHSM), Tasmanian School of Business and Economics, University of Tasmania, Rozelle campus, Cnr Glover and Church Streets, Sydney, NSW 2039 Australia
| | - Lei Si
- Centre for the Health Economy, Macquarie University, Sydney, Australia
| | - Leigh Kinsman
- Conjoint appointment, University of Tasmania and Tasmanian Health Service (North), Tasmania, Australia
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McNamara B, Same A, Rosenwax L, Kelly B. Palliative care for people with schizophrenia: a qualitative study of an under-serviced group in need. BMC Palliat Care 2018; 17:53. [PMID: 29580230 PMCID: PMC5870335 DOI: 10.1186/s12904-018-0309-1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 03/15/2018] [Indexed: 11/10/2022] Open
Abstract
Background People with schizophrenia are at risk of receiving poorer end of life care than other patients. They are often undertreated, avoid treatment and are about half as likely to access palliative care. There are limited options for end of life care for this under-serviced group in need. This study aims to address the paucity of research by documenting possible need, experiences of health care service use and factors affecting palliative care use for people with schizophrenia who have advanced life limiting illness. Methods Semi-structured interviews were undertaken with 16 experienced health professionals caring for people with schizophrenia in Western Australia. The interviews focussed on their perceptions and experiences of end of life care, their patients’ unmet needs, palliative care options, and suggested services to support this vulnerable group and improve health care provision. The research used a qualitative design and thematic analyses. Results The participants all advocated strongly for their patients and recognised their extreme vulnerability. They identified a range of challenges and unmet needs experienced by people with schizophrenia at the end of life including: illness factors such as the impact of schizophrenia on information processing and communication; social factors such as stigma, isolation and the absence of a carer; and health care factors such as late diagnosis, delayed access to care, and mismanagement in care. Four themes were organised into two domains with the first exploring the individual and social circumstances of people with schizophrenia, including the challenges they experience in the health care system. The second domain covers themes that discuss barriers and facilitators to people with schizophrenia receiving palliative care and key features in palliative care provision, including recognising declining health, communication and planning, and collaboration and capacity building in the broader health, mental health and palliative care sectors. Conclusions To ensure people with schizophrenia are well supported at the end of life a model of palliative care is required that offers both specialised services and capacity building within the pre-existing health workforce. Resources are needed to address the stigma and lack of services faced by this vulnerable group.
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Affiliation(s)
- Beverley McNamara
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Kent Street, Bentley, WA, Australia.
| | - Anne Same
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Kent Street, Bentley, WA, Australia
| | - Lorna Rosenwax
- School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Kent Street, Bentley, WA, Australia
| | - Brian Kelly
- School of Medicine and Public Health, University of Newcastle, University Drive, Callaghan, NSW, Australia
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Sathitratanacheewin S, Engelberg RA, Downey L, Lee RY, Fausto JA, Starks H, Dunlap B, Sibley J, Lober W, Loggers ET, Khandelwal N, Curtis JR. Temporal Trends Between 2010 and 2015 in Intensity of Care at End-of-Life for Patients With Chronic Illness: Influence of Age Under vs. Over 65 Years. J Pain Symptom Manage 2018; 55:75-81. [PMID: 28887270 PMCID: PMC5734983 DOI: 10.1016/j.jpainsymman.2017.08.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Revised: 08/25/2017] [Accepted: 08/25/2017] [Indexed: 11/21/2022]
Abstract
CONTEXT Recent analyses of Medicare data show decreases over time in intensity of end-of-life care. Few studies exist regarding trends in intensity of end-of-life care for those under 65 years of age. OBJECTIVES To examine recent temporal trends in place of death, and both hospital and intensive care unit (ICU) utilization, for age-stratified decedents with chronic, life-limiting diagnoses (<65 vs. ≥65 years) who received care in a large healthcare system. METHODS Retrospective cohort using death certificates and electronic health records for 22,068 patients with chronic illnesses who died between 2010 and 2015. We examined utilization overall and stratified by age using multiple regression. RESULTS The proportion of deaths at home did not change, but hospital admissions in the last 30 days of life decreased significantly from 2010 to 2015 (hospital b = -0.026; CI = -0.041, -0.012). ICU admissions in the last 30 days also declined over time for the full sample and for patients aged 65 years or older (overall b = -0.023; CI = -0.039, -0.007), but was not significant for younger decedents. Length of stay (LOS) did not decrease for those using the hospital or ICU. CONCLUSION From 2010 to 2015, we observed a decrease in hospital admissions for all age groups and in ICU admissions for those over 65 years. As there were no changes in the proportion of patients with chronic illness who died at home nor in hospital or ICU LOS in the last 30 days, hospital and ICU admissions in the last 30 days may be a more responsive quality metric than site of death or LOS for palliative care interventions.
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Affiliation(s)
- Seelwan Sathitratanacheewin
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Robert Y Lee
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James A Fausto
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Family Medicine, University of Washington, Seattle, Washington, USA
| | - Helene Starks
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioethics and Humanities, University of Washington, Seattle, Washington, USA
| | - Ben Dunlap
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - James Sibley
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - William Lober
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Bioinformatics and Medical Education, University of Washington, Seattle, Washington, USA
| | - Elizabeth T Loggers
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Seattle Cancer Care Alliance, Seattle, Washington, USA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - Nita Khandelwal
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, University of Washington, Seattle, Washington, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA.
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22
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Curtis JR, Sathitratanacheewin S, Starks H, Lee RY, Kross EK, Downey L, Sibley J, Lober W, Loggers ET, Fausto JA, Lindvall C, Engelberg RA. Using Electronic Health Records for Quality Measurement and Accountability in Care of the Seriously Ill: Opportunities and Challenges. J Palliat Med 2017; 21:S52-S60. [PMID: 29182487 DOI: 10.1089/jpm.2017.0542] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND As our population ages and the burden of chronic illness rises, there is increasing need to implement quality metrics that measure and benchmark care of the seriously ill, including the delivery of both primary care and specialty palliative care. Such metrics can be used to drive quality improvement, value-based payment, and accountability for population-based outcomes. METHODS In this article, we examine use of the electronic health record (EHR) as a tool to assess quality of serious illness care through narrative review and description of a palliative care quality metrics program in a large healthcare system. RESULTS In the search for feasible, reliable, and valid palliative care quality metrics, the EHR is an attractive option for collecting quality data on large numbers of seriously ill patients. However, important challenges to using EHR data for quality improvement and accountability exist, including understanding the validity, reliability, and completeness of the data, as well as acknowledging the difference between care documented and care delivered. Challenges also include developing achievable metrics that are clearly linked to patient and family outcomes and addressing data interoperability across sites as well as EHR platforms and vendors. This article summarizes the strengths and weakness of the EHR as a data source for accountability of community- and population-based programs for serious illness, describes the implementation of EHR data in the palliative care quality metrics program at the University of Washington, and, based on that experience, discusses opportunities and challenges. Our palliative care metrics program was designed to serve as a resource for other healthcare systems. DISCUSSION Although the EHR offers great promise for enhancing quality of care provided for the seriously ill, significant challenges remain to operationalizing this promise on a national scale and using EHR data for population-based quality and accountability.
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Affiliation(s)
- J Randall Curtis
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington
| | - Seelwan Sathitratanacheewin
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Helene Starks
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,3 Department of Bioethics and Humanities, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Robert Y Lee
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Erin K Kross
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - Lois Downey
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
| | - James Sibley
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - William Lober
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,5 Department of Bioinformatics and Medical Education, University of Washington , Seattle, Washington
| | - Elizabeth T Loggers
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,6 Seattle Cancer Care Alliance , Seattle, Washington.,7 Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle, Washington
| | - James A Fausto
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,4 Department of Family Medicine, University of Washington , Seattle, Washington
| | - Charlotta Lindvall
- 8 Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute , Boston, Massachusetts
| | - Ruth A Engelberg
- 1 Cambia Palliative Care Center of Excellence, University of Washington , Seattle, Washington.,2 Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington , Seattle, Washington
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