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Algu K, Wales J, Anderson M, Omilabu M, Briggs T, Kurahashi AM. Naming racism as a root cause of inequities in palliative care research: a scoping review. BMC Palliat Care 2024; 23:143. [PMID: 38858646 PMCID: PMC11163751 DOI: 10.1186/s12904-024-01465-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/22/2024] [Indexed: 06/12/2024] Open
Abstract
BACKGROUND Racial and ethnic inequities in palliative care are well-established. The way researchers design and interpret studies investigating race- and ethnicity-based disparities has future implications on the interventions aimed to reduce these inequities. If racism is not discussed when contextualizing findings, it is less likely to be addressed and inequities will persist. OBJECTIVE To summarize the characteristics of 12 years of academic literature that investigates race- or ethnicity-based disparities in palliative care access, outcomes and experiences, and determine the extent to which racism is discussed when interpreting findings. METHODS Following Arksey & O'Malley's methodology for scoping reviews, we searched bibliographic databases for primary, peer reviewed studies globally, in all languages, that collected race or ethnicity variables in a palliative care context (January 1, 2011 to October 17, 2023). We recorded study characteristics and categorized citations based on their research focus-whether race or ethnicity were examined as a major focus (analyzed as a primary independent variable or population of interest) or minor focus (analyzed as a secondary variable) of the research purpose, and the interpretation of findings-whether authors directly or indirectly discussed racism when contextualizing the study results. RESULTS We identified 3000 citations and included 181 in our review. Of these, most were from the United States (88.95%) and examined race or ethnicity as a major focus (71.27%). When interpreting findings, authors directly named racism in 7.18% of publications. They were more likely to use words closely associated with racism (20.44%) or describe systemic or individual factors (41.44%). Racism was directly named in 33.33% of articles published since 2021 versus 3.92% in the 10 years prior, suggesting it is becoming more common. CONCLUSION While the focus on race and ethnicity in palliative care research is increasing, there is room for improvement when acknowledging systemic factors - including racism - during data analysis. Researchers must be purposeful when investigating race and ethnicity, and identify how racism shapes palliative care access, outcomes and experiences of racially and ethnically minoritized patients.
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Affiliation(s)
- Kavita Algu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada.
| | - Joshua Wales
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Michael Anderson
- Waakebiness-Bryce Institute for Indigenous Health, Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th floor, Toronto, ON, M5T 3M7, Canada
| | - Mariam Omilabu
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
| | - Thandi Briggs
- Home and Community Care Support Services Toronto Central, 250 Dundas St. W, Toronto, ON, M5T 2Z5, Canada
| | - Allison M Kurahashi
- Temmy Latner Centre for Palliative Care, 60 Murray Street, 4th Floor, Box 13, Toronto, ON, M5T3L9, Canada
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Slusser K, Velasco RAF, Coats H. Patient, Caregiver, and Clinician Perceptions of Palliative Care that Influence Access and Use: A Qualitative Meta-Synthesis. Am J Hosp Palliat Care 2024; 41:452-464. [PMID: 37345634 DOI: 10.1177/10499091231185344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2023] Open
Abstract
Objective: Benefits of integration of palliative care early in the trajectory of a patient's serious illness are well established in the literature. Yet, barriers to palliative care access in the US continue to exist. The purpose of this study is to synthesize existing qualitative data of patient, caregiver, and clinician perceptions of palliative care (PC) that influence PC access and use in the US. Methods: A formal qualitative meta-synthesis was completed. The meta-synthesis included 1) a systematic literature search of qualitative studies conducted from 2016 to 2021, 2) a critical appraisal of the included studies, and 3) a reciprocal translation of the study's findings through an interpretive thematic analysis. Results: Seven articles met inclusion criteria resulting in a sample size of patients (n=18), caregivers (n=15), and clinicians (n=118). Three themes emerged with associated subthemes: knowledge and opinions of PC (subthemes of patient and caregiver knowledge and awareness and clinician knowledge and beliefs); care coordination and collaboration (subthemes of communication and trust); and social and structural drivers (subthemes of socioeconomic demographics and time and resources). Conclusions: This qualitative meta-synthesis identifies barriers and facilitators to palliative care access and use. The study findings illuminate the commonalities and differences of the perceptions of the three key stakeholder groups. In addition, this qualitative meta-synthesis reveals the complexities within the US healthcare system, and the challenges patients and their caregivers face accessing PC.
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Affiliation(s)
- Kim Slusser
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Heather Coats
- College of Nursing, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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3
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Yang C, Berkalieva A, Mazumdar M, Kwon D. Power calculation for detecting interaction effect in cross-sectional stepped-wedge cluster randomized trials: an important tool for disparity research. BMC Med Res Methodol 2024; 24:57. [PMID: 38431550 DOI: 10.1186/s12874-024-02162-0] [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: 05/16/2023] [Accepted: 01/25/2024] [Indexed: 03/05/2024] Open
Abstract
BACKGROUND The stepped-wedge cluster randomized trial (SW-CRT) design has become popular in healthcare research. It is an appealing alternative to traditional cluster randomized trials (CRTs) since the burden of logistical issues and ethical problems can be reduced. Several approaches for sample size determination for the overall treatment effect in the SW-CRT have been proposed. However, in certain situations we are interested in examining the heterogeneity in treatment effect (HTE) between groups instead. This is equivalent to testing the interaction effect. An important example includes the aim to reduce racial disparities through healthcare delivery interventions, where the focus is the interaction between the intervention and race. Sample size determination and power calculation for detecting an interaction effect between the intervention status variable and a key covariate in the SW-CRT study has not been proposed yet for binary outcomes. METHODS We utilize the generalized estimating equation (GEE) method for detecting the heterogeneity in treatment effect (HTE). The variance of the estimated interaction effect is approximated based on the GEE method for the marginal models. The power is calculated based on the two-sided Wald test. The Kauermann and Carroll (KC) and the Mancl and DeRouen (MD) methods along with GEE (GEE-KC and GEE-MD) are considered as bias-correction methods. RESULTS Among three approaches, GEE has the largest simulated power and GEE-MD has the smallest simulated power. Given cluster size of 120, GEE has over 80% statistical power. When we have a balanced binary covariate (50%), simulated power increases compared to an unbalanced binary covariate (30%). With intermediate effect size of HTE, only cluster sizes of 100 and 120 have more than 80% power using GEE for both correlation structures. With large effect size of HTE, when cluster size is at least 60, all three approaches have more than 80% power. When we compare an increase in cluster size and increase in the number of clusters based on simulated power, the latter has a slight gain in power. When the cluster size changes from 20 to 40 with 20 clusters, power increases from 53.1% to 82.1% for GEE; 50.6% to 79.7% for GEE-KC; and 48.1% to 77.1% for GEE-MD. When the number of clusters changes from 20 to 40 with cluster size of 20, power increases from 53.1% to 82.1% for GEE; 50.6% to 81% for GEE-KC; and 48.1% to 79.8% for GEE-MD. CONCLUSIONS We propose three approaches for cluster size determination given the number of clusters for detecting the interaction effect in SW-CRT. GEE and GEE-KC have reasonable operating characteristics for both intermediate and large effect size of HTE.
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Affiliation(s)
- Chen Yang
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Asem Berkalieva
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Madhu Mazumdar
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Institute for Healthcare Delivery Science, Mount Sinai Health System, New York, NY, USA
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deukwoo Kwon
- Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX, USA.
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Chuang E, Gugliuzza S, Ahmad A, Aboodi M, Gong MN, Barnato AE. "Postponing it Any Later Would not be so Great": A Cognitive Interview Study of How Physicians Decide to Initiate Goals of Care Discussions in the Hospital. Am J Hosp Palliat Care 2023:10499091231222926. [PMID: 38111300 PMCID: PMC11182887 DOI: 10.1177/10499091231222926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
BACKGROUND There are missed opportunities to discuss goals and preferences for care with seriously ill patients in the acute care setting. It is unknown which factors most influence clinician decision-making about communication at the point of care. OBJECTIVE This study utilized a cognitive-interviewing technique to better understand what leads clinicians to decide to have a goals of care (GOC) discussion in the acute care setting. METHODS A convenience sample of 15 oncologists, intensivists and hospitalists were recruited from a single academic medical center in a large urban area. Participants completed a cognitive interview describing their thought process when deciding whether to engage in GOC discussions in clinical vignettes. RESULTS 6 interconnected factors emerged as important in determining how likely the physician was to consider engaging in GOC at that time; (1) the participants' mental model of GOC, (2) timing of GOC related to stability, acuity and reversibility of the patient's condition, (3) clinical factors such as uncertainty, prognosis and recency of diagnosis, (4) patient factors including age and emotional state, (5) participants' role on the care team, and (6) clinician factors such as emotion and communication skill level. CONCLUSION Participants were hesitant to commit to the present moment as the right time for GOC discussions based on variations in clinical presentation. Clinical decision support systems that include more targeted information about risk of clinical deterioration and likelihood of reversal of the acute condition may prompt physicians to discuss GOC, but more support for managing discomfort with uncertainty is also needed.
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Affiliation(s)
- Elizabeth Chuang
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sabrina Gugliuzza
- Department of Internal Medicine, NYU Langone Health, Mineola, NY, USA
| | - Ammar Ahmad
- Department of Psychiatry and Behavioral Sciences, Montefiore Medical Center, New York, NY, USA
| | - Michael Aboodi
- Division of Pulmonary and Critical Care, Weill Cornell Medicine, New York, NY, USA
| | - Michelle Ng Gong
- Department of Medicine, Division of Critical Care, Albert Einstein College of Medicine, Bronx, NY, USA
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Rei KM, Reddy V, Brazdzionis J, Siddiqi J. Determinants and Disparities of Neurosurgery Patients Refusing Inpatient Palliative Care After Provider Recommendation. Cureus 2023; 15:e49925. [PMID: 38179361 PMCID: PMC10765216 DOI: 10.7759/cureus.49925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024] Open
Abstract
Background Disparities have been found in the utilization of palliative care (PC). However, a limitation of existing research is that it co-mingles factors affecting whether a patient is offered PC with factors affecting whether a patient accepts/refuses PC. Our objective is to identify the determinants and disparities of neurosurgery patients accepting/refusing inpatient PC after a provider recommends an inpatient PC consult. Methodology In this single-center retrospective cohort study, the last 750 consecutive neurosurgery patient medical records were screened. Inclusion criteria were as follows: (1) the patient was seen by the neurosurgery service during their hospitalization and (2) the patient had a documented inpatient PC consult ordered or the patient had at least one progress note documenting PC in the plan of care. Excluded were patients not seen by the neurosurgery service during the hospitalization in which the PC consult order or plan was documented. Analysis was performed using multivariate logistic regression with backward stepwise variable selection. Candidate variables included age, gender, race, ethnicity, language, marital status, insurance type, surrogate decision-maker (SDM) relationship to patient, advanced directive, Charlson Comorbidity Index (CCI), ambulation, activities of daily living (ADL) dependence, primary diagnosis category, Glasgow Coma Scale (GCS) at the time of admission, GCS at the time of PC consult, GCS at the time of discharge, duration of hospitalization, and hospitalization mortality. Results Of the last 750 neurosurgery patients, this study included 144 patients (33.3% female; mean age 57.53±19.89 years). Among these patients, 109 patients (75.7%) accepted PC and 35 patients (24.3%) refused PC. Univariate analysis showed that patients refusing PC tended to be older (p=0.003) and have a shorter duration of hospitalization (p=0.023). Chi-squared analysis found associations between PC acceptance/refusal and preferred language (p=0.026), religion (p<0.001), and SDM relationship to patient (p=0.004). Multivariate logistic regression found that predictors of PC refusal were older age (OR=0.965, p=0.049), non-English (OR=0.219, p=0.004), adult child SDM (OR=0.246, p=0.023), and other relative/friend SDM (OR=0.208, p=0.011). Religious patients were more likely to accept PC (OR=7.132, p<0.001). Race and ethnicity factors were not found to be significant predictors of PC refusal: Black (p=0.649), other race (p=0.189), and Hispanic (p=0.525). Conclusion Nearly one-quarter of neurosurgery patients offered PC refused this care. Predictors of PC refusal were older age, non-English, adult child SDM, and other relative/friend SDM. Religious patients were more likely to accept PC. Race and ethnicity were not found to be significant predictors of accepting/refusing PC, which may suggest these previously identified disparities stem from minority patients being offered less PC. Additional research is needed to replicate these findings among different patient populations. Because PC is compatible with life-prolonging therapies and aims to provide additional emotional and spiritual support to the patient and family, the finding that nearly one-quarter of patients refused PC may demonstrate a pervasive misconception and need for patient education.
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Affiliation(s)
- Kyle M Rei
- Neurosurgery, California University of Science and Medicine, Colton, USA
| | - Vedhika Reddy
- Neurosurgery, California University of Science and Medicine, Colton, USA
| | - James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Javed Siddiqi
- Neurosurgery, Desert Regional Medical Center, Palm Springs, USA
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
- Neurosurgery, California University of Science and Medicine, Colton, USA
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Herasevich S, Soleimani J, Huang C, Pinevich Y, Dong Y, Pickering BW, Murad MH, Barwise AK. Diagnostic error among vulnerable populations presenting to the emergency department with cardiovascular and cerebrovascular or neurological symptoms: a systematic review. BMJ Qual Saf 2023; 32:676-688. [PMID: 36972982 DOI: 10.1136/bmjqs-2022-015038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 03/10/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Diagnostic error (DE) is a common problem in clinical practice, particularly in the emergency department (ED) setting. Among ED patients presenting with cardiovascular or cerebrovascular/neurological symptoms, a delay in diagnosis or failure to hospitalise may be most impactful in terms of adverse outcomes. Minorities and other vulnerable populations may be at higher risk of DE. We aimed to systematically review studies reporting the frequency and causes of DE in under-resourced patients presenting to the ED with cardiovascular or cerebrovascular/neurological symptoms. METHODS We searched EBM Reviews, Embase, Medline, Scopus and Web of Science from 2000 through 14 August 2022. Data were abstracted by two independent reviewers using a standardised form. The risk of bias (ROB) was assessed using the Newcastle-Ottawa Scale, and the certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS Of the 7342 studies screened, we included 20 studies evaluating 7436,737 patients. Most studies were conducted in the USA, and one study was multicountry. 11 studies evaluated DE in patients with cerebrovascular/neurological symptoms, 8 studies with cardiovascular symptoms and 1 study examined both types of symptoms. 13 studies investigated missed diagnoses and 7 studies explored delayed diagnoses. There was significant clinical and methodological variability, including heterogeneity of DE definitions and predictor variable definitions as well as methods of DE assessment, study design and reporting.Among the studies evaluating cardiovascular symptoms, black race was significantly associated with higher odds of DE in 4/6 studies evaluating missed acute myocardial infarction (AMI)/acute coronary syndrome (ACS) diagnosis compared with white race (OR from 1.18 (1.12-1.24) to 4.5 (1.8-11.8)). The association between other analysed factors (ethnicity, insurance and limited English proficiency) and DE in this domain varied from study to study and was inconclusive.Among the studies evaluating DE in patients with cerebrovascular/neurological symptoms, no consistent association was found indicating higher or lower odds of DE. Although some studies showed significant differences, these were not consistently in the same direction.The overall ROB was low for most included studies; however, the certainty of evidence was very low, mostly due to serious inconsistency in definitions and measurement approaches across studies. CONCLUSIONS This systematic review demonstrated consistent increased odds of missed AMI/ACS diagnosis among black patients presenting to the ED compared with white patients in most studies. No consistent associations between demographic groups and DE related to cerebrovascular/neurological diagnoses were identified. More standardised approaches to study design, measurement of DE and outcomes assessment are needed to understand this problem among vulnerable populations. TRIAL REGISTRATION NUMBER The study protocol was registered in the International Prospective Register of Systematic Reviews PROSPERO 2020 CRD42020178885 and is available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178885.
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Affiliation(s)
- Svetlana Herasevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Jalal Soleimani
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Chanyan Huang
- Department of Anaesthesiology, Sun Yat-sen University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Yuliya Pinevich
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Brian W Pickering
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohammad H Murad
- Center for Science of Healthcare Delivery, Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Amelia K Barwise
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Bioethics Research Program, Mayo Clinic, Rochester, MN, USA
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Hoe DF, Wang YH, Rahman A, Enguidanos S. Identifying Paths Forward: Expanding Palliative Care to Low-Income Patients in California. Am J Hosp Palliat Care 2022:10499091221131973. [PMID: 36218324 DOI: 10.1177/10499091221131973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Multiple studies demonstrate most consumers do not know about palliative care. And, since January 2018, California's Medi-Cal Managed Care patients have been eligible for palliative care services under Senate Bill 1004 (SB 1004). Yet, the uptake of palliative care services was underwhelming. The purpose of this study was to explore patient-centered barriers to palliative care. We recruited 27 adult Medicaid managed care patients from community-based sites in Los Angeles and conducted semi-structured qualitative interviews. Each participant was asked questions to elicit their knowledge about, and perspectives on, palliative care as well as their preferred communication approaches for receiving a referral to palliative care. The interviews were audio-recorded and transcribed verbatim. We used a grounded theory approach to guide our analysis of primary themes. Our findings indicated that the barriers to palliative care referrals among this population included lack of knowledge about palliative care and available services; the reliance on, and trust in, primary care physicians for information; language and cultural barriers; housing instability; and patient believing they are neither old enough nor sick enough to need palliative care. These findings emphasize the critical role primary care physicians play in advocating for low-income patients and the necessity for culturally sensitive education about palliative care. Promoting knowledge and understanding of palliative care among both primary care physicians and consumers is critical to ensuring access to care.
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Affiliation(s)
- Deborah F Hoe
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Yu-Hsuan Wang
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Anna Rahman
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
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Abedini NC, Downey L, Engelberg RA, Curtis JR, Sharma RK. End-of-life healthcare utilization and palliative care use among older adults with limited English proficiency. J Am Geriatr Soc 2022; 70:2847-2857. [PMID: 35670104 DOI: 10.1111/jgs.17913] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 05/02/2022] [Accepted: 05/06/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little is known about end-of-life healthcare utilization and palliative care use among older adults with serious illness and limited English proficiency (LEP). METHODS We conducted a retrospective analysis of seriously-ill older adults (65+) with and without LEP, from a large health system, who died between 2010 and 2018. Primary outcomes were measures of healthcare utilization in the last 30 and 180 days of life: hospitalization, emergency department (ED) visits, intensive care unit (ICU) admission, and 30-day readmission. Secondary outcomes were palliative care consultation and advance care planning documents. We used multivariate analyses adjusted for sociodemographic factors including race and ethnicity. RESULTS Among 18,490 decedents, 1363 had LEP. Patients with LEP were older at time of death (median age 80 vs 77 years), more likely to be female (48% vs 44%), of Asian descent (64% vs 4%), of Hispanic ethnicity (10% vs 2%), with <12th grade education (38% vs 9%), and Medicaid (36% vs 6%). In the last 30 days of life, patients with LEP had higher odds of ED visits (33% vs 20%; aOR 1.41, 95% CI 1.26-1.72; p < 0.001), readmission (12% vs 8%; aOR 1.64, 95% CI 1.30-2.07; p < 0.001), and in-hospital death (45% vs 37%; aOR 1.24, 95% CI 1.07-1.44; p = 0.005) compared to patients without LEP. Findings were similar in the last 180-days of life. Only 14% of patients with LEP and 10% of those without LEP received palliative care consultation in the last month of life. Patients with LEP were less likely to have advance care planning documents than patients without LEP (36% vs 40%; aOR 0.68, 95% CI 0.50-0.80; p < 0.001). CONCLUSIONS Older adults with serious illness and LEP have higher rates of end-of-life healthcare utilization. Additional research is needed to identify drivers of these differences and inform linguistically- and culturally-appropriate interventions to improve end-of-life care in this population.
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Affiliation(s)
- Nauzley C Abedini
- Division of Gerontology and Geriatric Medicine, University of Washington, Seattle, Washington, USA
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Lois Downey
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
| | - Ruth A Engelberg
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - J Randall Curtis
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Rashmi K Sharma
- Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA
- Division of General Internal Medicine, University of Washington, Seattle, Washington, USA
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Gazaway S, Chuang E, Thompson M, White-Hammond G, Elk R. Respecting Faith, Hope, and Miracles in African American Christian Patients at End-of-Life: Moving from Labeling Goals of Care as "Aggressive" to Providing Equitable Goal-Concordant Care. J Racial Ethn Health Disparities 2022:10.1007/s40615-022-01385-5. [PMID: 35947300 PMCID: PMC10026148 DOI: 10.1007/s40615-022-01385-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 07/29/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022]
Abstract
In this article, we demonstrate first how the term "aggressive care," used loosely by clinicians to denote care that can negatively impact quality of life in serious illness, is often used to inappropriately label the preferences of African American patients, and discounts, discredits, and dismisses the deeply held beliefs of African American Christians. This form of biased communication results in a higher proportion of African Americans than whites receiving care that is non-goal-concordant and contributes to the prevailing lack of trust the African American community has in our healthcare system. Second, we invite clinicians and health care centers to make the perspectives of socially marginalized groups (in this case, African American Christians) the central axis around which we find solutions to this problem. Based on this, we provide insight and understanding to clinicians caring for seriously ill African American Christian patients by sharing their beliefs, origins, and substantive importance to the African American Christian community. Third, we provide recommendations to clinicians and healthcare systems that will result in African Americans, regardless of religious affiliation, receiving equitable levels of goal-concordant care if implemented. KEY MESSAGE: Labeling care at end-of-life as "aggressive" discounts the deeply held beliefs of African American Christians. By focusing on the perspectives of this group clinicians will understand the importance of respecting their religious values. The focus on providing equitable goal-concordant care is the goal.
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Affiliation(s)
- Shena Gazaway
- Department of Family, School of Nursing, University of Alabama Birmingham, Community, and Health Systems 1720 2nd Avenue South, AB, N485C,35294-1210, Birmingham, USA.
| | | | | | | | - Ronit Elk
- School of Medicine, UAB, Birmingham, AL, USA
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Starr LT, Ulrich C, Perez GA, Aryal S, Junker P, O’Connor NR, Meghani SH. Hospice Enrollment, Future Hospitalization, and Future Costs Among Racially and Ethnically Diverse Patients Who Received Palliative Care Consultation. Am J Hosp Palliat Care 2022; 39:619-632. [PMID: 34318700 PMCID: PMC8795236 DOI: 10.1177/10499091211034383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Palliative care consultation to discuss goals-of-care ("PCC") may mitigate end-of-life care disparities. OBJECTIVE To compare hospitalization and cost outcomes by race and ethnicity among PCC patients; identify predictors of hospice discharge and post-discharge hospitalization utilization and costs. METHODS This secondary analysis of a retrospective cohort study assessed hospice discharge, do-not-resuscitate status, 30-day readmissions, days hospitalized, ICU care, any hospitalization cost, and total costs for hospitalization with PCC and hospitalization(s) post-discharge among 1,306 Black/African American, Latinx, White, and Other race PCC patients at a United States academic hospital. RESULTS In adjusted analyses, hospice enrollment was less likely with Medicaid (AOR = 0.59, P = 0.02). Thirty-day readmission was less likely among age 75+ (AOR = 0.43, P = 0.02); more likely with Medicaid (AOR = 2.02, P = 0.004), 30-day prior admission (AOR = 2.42, P < 0.0001), and Black/African American race (AOR = 1.57, P = 0.02). Future days hospitalized was greater with Medicaid (Coefficient = 4.49, P = 0.001), 30-day prior admission (Coefficient = 2.08, P = 0.02), and Black/African American race (Coefficient = 2.16, P = 0.01). Any future hospitalization cost was less likely among patients ages 65-74 and 75+ (AOR = 0.54, P = 0.02; AOR = 0.53, P = 0.02); more likely with Medicaid (AOR = 1.67, P = 0.01), 30-day prior admission (AOR = 1.81, P = 0.0001), and Black/African American race (AOR = 1.40, P = 0.02). Total future hospitalization costs were lower for females (Coefficient = -3616.64, P = 0.03); greater with Medicaid (Coefficient = 7388.43, P = 0.01), 30-day prior admission (Coefficient = 3868.07, P = 0.04), and Black/African American race (Coefficient = 3856.90, P = 0.04). Do-not-resuscitate documentation (48%) differed by race. CONCLUSIONS Among PCC patients, Black/African American race and social determinants of health were risk factors for future hospitalization utilization and costs. Medicaid use predicted hospice discharge. Social support interventions are needed to reduce future hospitalization disparities.
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Affiliation(s)
- Lauren T. Starr
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Connie Ulrich
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - G. Adriana Perez
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Subhash Aryal
- BECCA (Biostatistics * Evaluation * Collaboration *
Consultation * Analysis) Lab, University of Pennsylvania School of Nursing,
Philadelphia, Pennsylvania
| | | | - Nina R. O’Connor
- University of Pennsylvania Perelman School of Medicine,
Philadelphia, Pennsylvania
| | - Salimah H. Meghani
- NewCourtland Center for Transitions and Health, University
of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
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11
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Marcewicz L, Kunihiro SK, Curseen KA, Johnson K, Kavalieratos D. Application of Critical Race Theory in Palliative Care Research: A Scoping Review. J Pain Symptom Manage 2022; 63:e667-e684. [PMID: 35231591 DOI: 10.1016/j.jpainsymman.2022.02.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 01/13/2022] [Accepted: 02/14/2022] [Indexed: 11/29/2022]
Abstract
CONTEXT Structural racism negatively impacts individuals and populations. In the medical literature, including that of palliative care, structural racism's influence on interracial differences in outcomes remains poorly examined. Examining the contribution of structural racism to outcomes is paramount to promoting equity. OBJECTIVES We examined portrayals of race and racial differences in outcomes in the palliative care literature and created a framework using critical race theory (CRT) to aid in this examination. METHODS We reviewed the CRT literature and iteratively developed a rubric to examine when and how differences between races are described. Research articles published in The Journal of Pain and Symptom Management presenting empiric data specifically including findings about racial differences were examined independently by three reviewers using the rubric. RESULTS Fifty-seven articles met inclusion criteria. Articles that specifically described racial differences were common in the topic areas of quality (75% of articles), hospice (53%), palliative care services (40%) and spirituality/religion (40%). The top three reasons posited for racial differences were patient preference (26%), physician bias (23%), and cultural barriers (21%). Using the CRT rubric we found that 65% of articles posited that a racial difference was something that needed to be rectified, while articles rarely provided narrative (5%) or other data on perspectives of people of color (11%) to explain assumptions about differences. CONCLUSION Palliative care research frequently highlights racial differences in outcomes. Articles that examine racial differences often assume that differences need to be fixed but posit reasons for differences without the narratives of those most affected by them.
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Affiliation(s)
- Lawson Marcewicz
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA; Atlanta VA Health Care System (L.M.), Decatur, Georgia, USA.
| | - Susan K Kunihiro
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Kimberly A Curseen
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Khaliah Johnson
- Division of Pediatric Palliative Medicine (K.J.), Department of Pediatrics, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Division of Palliative Medicine (L.M., S.K.K., K.A.C., D.K.), Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, Georgia, USA
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12
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Frydman JL, Berkalieva A, Liu B, Scarborough BM, Mazumdar M, Smith CB. Telemedicine Utilization in the Ambulatory Palliative Care Setting: Are There Disparities? J Pain Symptom Manage 2022; 63:423-429. [PMID: 34644615 PMCID: PMC8854351 DOI: 10.1016/j.jpainsymman.2021.09.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/27/2021] [Accepted: 09/29/2021] [Indexed: 12/25/2022]
Abstract
CONTEXT Given a shortage of specialty palliative care clinicians and geographic variation in availability, telemedicine has been proposed as one way to improve access to palliative care services for patients with cancer. However, the enduring digital divide raises questions about whether unequal access will exacerbate healthcare disparities. OBJECTIVES To examine factors associated with utilization of telemedicine as compared to in-person visits by patients with cancer in the ambulatory palliative care setting. METHODS We collected data on patients seen in Supportive Oncology clinic by palliative care clinicians with an in-person or telemedicine visit from March 1 to December 30, 2020. A logistic regression with generalized estimating equation was fit to assess the association between visit type and patient characteristics. RESULTS A total of 491 patients and 1783 visits were identified, including 1061 (60%) in-person visits and 722 (40%) telemedicine visits. Female patients were significantly more likely to utilize telemedicine than male patients (OR 1.46; 95% CI 1.11-1.90). Spanish-speaking patients (OR 0.32, 95% CI 0.17-0.61), those without insurance (OR 0.28, 95% CI 0.15-0.52), and those without an activated patient portal (Inactivated: OR 0.46, 95% CI 0.26-0.82; Pending Activation: OR 0.29, 95% CI 0.18-0.48) were less likely to utilize telemedicine. CONCLUSION Our study reveals disparities in telemedicine utilization in the ambulatory palliative care setting for patients with cancer who are male, Spanish-speaking, uninsured, or do not have an activated patient portal. In the wake of the COVID-19 pandemic, we can better meet the palliative care needs of patients with cancer through telemedicine only if equity is kept at the forefront of our discussions.
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Affiliation(s)
- Julia L Frydman
- Brookdale Department of Geriatrics and Palliative Medicine (J.L.F.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.B., M.M.), Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery, New York, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (A.B., B.L., M.M.), New York, New York, USA; Department of Population Health Science and Policy (B.L.), Icahn School of Medicine at Mount Sinai, Institute for Translational Epidemiology, New York, New York, USA; Ann B. Barshinger Cancer Institute (B.M.S.), University of Pennsylvania Health System, Lancaster, Pennsylvania, USA; Division of Hematology and Oncology, Department of Medicine (C.B.S.), Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Asem Berkalieva
- Brookdale Department of Geriatrics and Palliative Medicine (J.L.F.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.B., M.M.), Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery, New York, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (A.B., B.L., M.M.), New York, New York, USA; Department of Population Health Science and Policy (B.L.), Icahn School of Medicine at Mount Sinai, Institute for Translational Epidemiology, New York, New York, USA; Ann B. Barshinger Cancer Institute (B.M.S.), University of Pennsylvania Health System, Lancaster, Pennsylvania, USA; Division of Hematology and Oncology, Department of Medicine (C.B.S.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bian Liu
- Brookdale Department of Geriatrics and Palliative Medicine (J.L.F.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.B., M.M.), Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery, New York, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (A.B., B.L., M.M.), New York, New York, USA; Department of Population Health Science and Policy (B.L.), Icahn School of Medicine at Mount Sinai, Institute for Translational Epidemiology, New York, New York, USA; Ann B. Barshinger Cancer Institute (B.M.S.), University of Pennsylvania Health System, Lancaster, Pennsylvania, USA; Division of Hematology and Oncology, Department of Medicine (C.B.S.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Bethann M Scarborough
- Brookdale Department of Geriatrics and Palliative Medicine (J.L.F.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.B., M.M.), Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery, New York, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (A.B., B.L., M.M.), New York, New York, USA; Department of Population Health Science and Policy (B.L.), Icahn School of Medicine at Mount Sinai, Institute for Translational Epidemiology, New York, New York, USA; Ann B. Barshinger Cancer Institute (B.M.S.), University of Pennsylvania Health System, Lancaster, Pennsylvania, USA; Division of Hematology and Oncology, Department of Medicine (C.B.S.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Madhu Mazumdar
- Brookdale Department of Geriatrics and Palliative Medicine (J.L.F.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.B., M.M.), Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery, New York, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (A.B., B.L., M.M.), New York, New York, USA; Department of Population Health Science and Policy (B.L.), Icahn School of Medicine at Mount Sinai, Institute for Translational Epidemiology, New York, New York, USA; Ann B. Barshinger Cancer Institute (B.M.S.), University of Pennsylvania Health System, Lancaster, Pennsylvania, USA; Division of Hematology and Oncology, Department of Medicine (C.B.S.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Cardinale B Smith
- Brookdale Department of Geriatrics and Palliative Medicine (J.L.F.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy (A.B., M.M.), Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery, New York, New York, USA; Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai (A.B., B.L., M.M.), New York, New York, USA; Department of Population Health Science and Policy (B.L.), Icahn School of Medicine at Mount Sinai, Institute for Translational Epidemiology, New York, New York, USA; Ann B. Barshinger Cancer Institute (B.M.S.), University of Pennsylvania Health System, Lancaster, Pennsylvania, USA; Division of Hematology and Oncology, Department of Medicine (C.B.S.), Icahn School of Medicine at Mount Sinai, New York, New York, USA
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13
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Frydman JL, Aldridge M, Moreno J, Singer J, Zeng L, Chai E, Morrison RS, Gelfman LP. Access to Palliative Care Consultation for Hospitalized Adults with COVID-19 in an Urban Health System: Were There Disparities at the Peak of the Pandemic? J Palliat Med 2022; 25:124-129. [PMID: 34637349 PMCID: PMC8721492 DOI: 10.1089/jpm.2021.0313] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Palliative care (PC) services expanded rapidly to meet the needs of coronavirus disease 2019 (COVID-19) patients, yet little is known about which patients were referred for PC consultation during the pandemic. Objective: Examine factors predictive of PC consultation for COVID-19 patients. Design: Retrospective cohort study of COVID-19 patients discharged from four hospitals (March 1-June 30, 2020). Exposures: Patient demographic, socioeconomic, and clinical factors and hospital-level characteristics. Outcome Measurement: Inpatient PC consultation. Results: Of 4319 hospitalized COVID-19 patients, 581 (14%) received PC consultation. Increasing age, serious illness (cancer, chronic obstructive pulmonary disease, and dementia), greater illness severity, and admission to the quaternary hospital were associated with receipt of PC consultation. There was no association between PC consultation and race/ethnicity, household crowding, insurance status, or hospital-factors, including inpatient, emergency department, and intensive care unit census. Conclusions: Although site variation existed, the highest acuity patients were most likely to receive PC consultation without racial/ethnic or socioeconomic disparities.
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Affiliation(s)
- Julia L. Frydman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Address correspondence to: Julia L. Frydman, MD, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1070, New York, NY 10029, USA
| | - Melissa Aldridge
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Jaison Moreno
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua Singer
- Enterprise Reporting, Mount Sinai Health System, New York, New York, USA
| | - Li Zeng
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
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14
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Anandarajah G, Roseman J, Mennillo LG, Kelley B. Spirituality in Primary Palliative Care and Beyond: A 20-Year Longitudinal Qualitative Study of Interacting Factors Impacting Physicians' Spiritual Care Provision Over Time. J Pain Symptom Manage 2021; 62:1216-1228. [PMID: 34051292 DOI: 10.1016/j.jpainsymman.2021.05.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/15/2021] [Accepted: 05/20/2021] [Indexed: 12/25/2022]
Abstract
CONTEXT Spiritual care (SC) is central to palliative care. However, a mismatch between patients' desire for SC and physicians' SC provision remains. The shortage of specialty-trained palliative physicians, necessitates that all physicians provide primary palliative care, including SC. Although several quantitative studies explore physicians' barriers to SC, few qualitative studies and no longitudinal studies exist. OBJECTIVE To gain in-depth understanding of factors influencing physicians' ability to provide SC over time. METHODS A 20-year longitudinal, individual interview study. In study year-1, we interviewed all residents in a USA primary care residency (full study-group) regarding SC beliefs, experiences and skills. The longitudinal study-group (PGY1 subgroup) was interviewed again in study-years 3, 11, and 20. Interviews were audio-recorded and transcribed. Four researchers analyzed transcripts using a grounded theory approach. IRB approval was obtained. RESULTS We analyzed 66 interviews from 34 physicians. Physicians had diverse personal spiritual beliefs. Seven themes emerged from both groups (response rate 89%): patients' needs; practice setting; beliefs regarding physician's role; personal spiritual beliefs; SC training; life experiences (professional, personal); self-care and reflection. Longitudinal interviews revealed thematic evolution and interactions over 20-years: patients' needs and physicians' belief in whole-person care remained primary motivators; cross-cultural SC communication training diminished impact of personal spiritual beliefs and worries; life experiences enhanced SC skills; work environment helped or hindered SC provision; and spiritual self-care/reflection fostered patient-centered, compassionate SC. CONCLUSION Facilitating SC provision by nonpalliative care specialists is complex and may require both individual and systems level interventions fostering motivation, SC skill development, and supportive work environments.
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Affiliation(s)
- Gowri Anandarajah
- Warren Alpert Medical School, Brown University (G.A.,B.K.), Providence, Rhode Island; Hope Hospice and Palliative Care Rhode Island (G.A.), Providence, Rhode Island.
| | - Janet Roseman
- Nova Southeastern College of Osteopathic Medicine (J.R.), Florida
| | | | - Brendan Kelley
- Warren Alpert Medical School, Brown University (G.A.,B.K.), Providence, Rhode Island
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15
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Catalisano G, Ippolito M, Marino C, Giarratano A, Cortegiani A. Palliative Care Principles and Anesthesiology Clinical Practice: Current Perspectives. J Multidiscip Healthc 2021; 14:2719-2730. [PMID: 34611408 PMCID: PMC8486274 DOI: 10.2147/jmdh.s240563] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Palliative care is a person-centered approach aiming to relieve patient’s health-related suffering and it is often needed when caring for critically ill patients to manage symptoms and identify goals of care. Aim To describe the integration of palliative care principles in anesthesiology clinical practice, within and outside the ICU and to analyze the additional challenges that COVID-19 pandemic is posing in this context. Methods For the purpose of this review, PubMed database was searched for studies concerning palliative care and end of life care, in contexts involving anesthesiologists and intensivists, published in the last 5 years. Results Anesthesiologists and intensivists integrate palliative care within their daily practice providing symptoms management as well as family counseling. High-quality communicational skills are fundamental for anesthesiologists and intensivists especially when interfacing with surrogate decision makers in the ICU or with patients in the preoperative setting while discussing goals of care. Coronavirus disease 2019 (COVID-19) pandemic has challenged many aspects of palliative care delivery: reduced family presence within the ICU, communication with families through phone calls or video calls, patient–physician relationship mediated by bulky personal protective equipment and healthcare workers physical and psychological distress due to the increased workload and limitations in resources are some of the most evident. Conclusion Anesthesiologists and intensivists are increasingly facing challenging clinical situations where principles and practice of palliative care have to be applied. In this sense, increasing knowledge on palliative care and providing specific training would allow to deliver high-quality symptom management, family counseling and end of life guidance in critical care settings. COVID-19 pandemic sets additional difficulties to palliative care delivery.
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Affiliation(s)
- Giulia Catalisano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Mariachiara Ippolito
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Claudia Marino
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), University of Palermo, Palermo, Italy.,Department of Anesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Palermo, Italy
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16
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Sinha S, Subramoney K, Fraser M, Howard J, Sadowski J, Azar J, Kara A. Using a Modified Surprise Question as a Tool to Improve Primary Palliative Care in a Neurocritical Care Unit. Jt Comm J Qual Patient Saf 2021; 47:228-233. [PMID: 33451896 DOI: 10.1016/j.jcjq.2020.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 11/13/2020] [Accepted: 11/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Specialty palliative care is a limited resource. The surprise question ("Would you be surprised if this patient died within the next 12 months?") is a screening tool for clinicians to identify people nearing the end of life. The researchers used a modified surprise question (MSQ) to improve primary palliative care in a neurocritical care unit. METHODS A palliative care physician attended interdisciplinary rounds up to three days a week and asked the primary neurocritical care team, for each patient admitted in the previous 24 hours, the MSQ: "Would you be surprised if this patient died during this hospital stay?" If the response was "No," the unit social worker identified the patient's surrogate decision maker (SDM), and the primary team was encouraged to conduct a goals of care (GOC) conversation. The frequency of SDM documentation, occurrence and timing of GOC conversations, and palliative care and hospice consultations were measured for the baseline six months before the intervention, and six months after. RESULTS Among 350 patients admitted to the neurocritical care unit during the study, the age, gender, prehospitalization presence of advance directives, and mortality were comparable between the baseline (n = 173) and intervention (n = 177) periods. Compared to the baseline period, there was a higher frequency during the intervention period of documentation of SDM (31.8% vs. 54.2%, p = 0.00002), all GOC conversations (35.3% vs. 53.1%, p = 0.008), GOC conversations conducted by the primary team (27.2% vs. 47.5%, p = 0.00009), palliative care consultations (11.6% vs. 23.2%, p = 0.004), and hospice consultations (2.3% vs. 9.6%, p = 0.004). CONCLUSION The MSQ can be used as a tool to identify the risk of mortality, facilitate palliative care delivered by the primary team, and improve end-of-life care.
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17
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Elk R, Gazaway S. Engaging Social Justice Methods to Create Palliative Care Programs That Reflect the Cultural Values of African American Patients with Serious Illness and Their Families: A Path Towards Health Equity. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2021; 49:222-230. [PMID: 34924058 DOI: 10.1017/jme.2021.32] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Cultural values influence how people understand illness and dying, and impact their responses to diagnosis and treatment, yet end-of-life care is rooted in white, middle class values. Faith, hope, and belief in God's healing power are central to most African Americans, yet life-preserving care is considered "aggressive" by the healthcare system, and families are pressured to cease it.
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18
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Webber C, Chan R, Scott M, Brown C, Spruin S, Hsu AT, Bush SH, Isenberg SR, Quinn K, Scott J, Tanuseputro P. Delivery of Palliative Care in Acute Care Hospitals: A Population-Based Retrospective Cohort Study Describing the Level of Involvement and Timing of Inpatient Palliative Care in the Last Year of Life. J Palliat Med 2020; 24:1000-1010. [PMID: 33337265 DOI: 10.1089/jpm.2020.0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Background: Much end-of-life care is provided in hospital, yet little is known about the delivery of palliative care during end-of-life hospitalizations. Objectives: To characterize the level of palliative care involvement across hospitalizations in the last year of life. Methods: A population-based retrospective cohort study of adults in Ontario, Canada, who died between April 1, 2012, and March 31, 2017, and had at least one acute care hospitalization in their last year of life. Using linked administrative health data, we developed a hierarchy of inpatient palliative care involvement reflecting the degree to which care was delivered with palliative intent. This hierarchy was based on palliative care diagnosis and service provider codes on hospitalization records and physician claims. We examined variations in the level of palliative care involvement across key patient characteristics. Results: In the last year of life, 65.1% of hospitalizations had no indication of palliative care involvement, 16.7% had a low level of involvement, 13.5% had a medium level of involvement, and 4.7% had a high level of involvement. Most hospitalizations with palliative care involvement (85.6%) occurred in the two months before death. Compared to patients who received no inpatient palliative care, patients who received a high level of palliative care involvement tended to be younger, died of cancer, resided in urban or lower income neighborhoods, and had fewer chronic conditions. Discussion: While many hospitalizations occurred in the last year of life, the majority did not involve palliative care, and very few had a high level of palliative care involvement.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Raphael Chan
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Catherine Brown
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Spruin
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Department of Family and Community Medicine and University of Toronto, Toronto, Ontario, Canada
| | - Kieran Quinn
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Scott
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
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Educational intervention to improve palliative care knowledge among informal caregivers of cognitively impaired older adults. Palliat Support Care 2020; 19:515-523. [PMID: 33234188 DOI: 10.1017/s1478951520001200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Lack of palliative care knowledge among caregivers may pose an access barrier for cognitively impaired older adults, who may benefit from the specialized care. Therefore, this study aims to examine the effectiveness of an educational intervention in improving palliative care knowledge among informal caregivers of cognitively impaired older adults. METHOD Using a one-group, pre- and post-test intervention design, this study implemented an individual, face-to-face educational intervention with an informational brochure for 43 informal caregivers of chronically or seriously ill older adults (50+) with cognitive impairment, recruited from communities in West Alabama. Their level of knowledge about palliative care was assessed by the Palliative Care Knowledge Scale (PaCKS). The pre- and post-test scores were compared by the Wilcoxon signed-ranks test, and the racial subgroup (Whites vs. Blacks) comparison was made by the Mann-Whitney U test. RESULTS There was a statistically significant difference between the pre- and post-test scores (z = 5.38, p < 0.001), indicating a statistically significant effect of the educational intervention in improving palliative care knowledge among participants. There was a significant difference (U = 143, p < 0.05) between Whites and Blacks in the pre-test, which, however, disappeared in the post-test (U = 173.50, p > 0.05), suggesting that the amount of increased PaCKS scores were significantly greater for Blacks (Mdn = 9.50) than for Whites (Mdn = 4.00, U = 130.50, p < 0.05). SIGNIFICANCE OF RESULTS This study demonstrated that a one-time educational intervention can improve the level of palliative care knowledge among informal caregivers of chronically or seriously ill older adults with cognitive impairment, particularly among Black caregivers. Therefore, further educational efforts can be made to promote palliative care knowledge and reduce racial disparities in palliative care knowledge and its use.
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Online End-of-Life Nursing Education Consortium Core Curriculum for Staff Nurses: An Education Strategy to Improve Clinical Practice. J Hosp Palliat Nurs 2020; 21:531-539. [PMID: 31568109 DOI: 10.1097/njh.0000000000000593] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Because of the growing population of patients with serious illness, the demand for specialty palliative care exceeds the resources available. Nurses must be prepared to provide primary palliative care to fill the gap in the availability of specialized palliative care providers. However, meeting the educational needs of a vast number of practicing nurses poses a significant challenge. Often, institutions are limited in the financial and staffing support that they can contribute for continuing nursing education, especially when the training requires staff to spend substantial time away from work. In order to address this issue, one large medical center conducted a study to examine the educational and clinical practice outcomes of offering an online version of the End-of-Life Nursing Education Consortium Core Curriculum to nearly 100 nurses. The participants were divided into 2 groups. Group 1 received online education only, whereas the other group received the online education plus a 3-hour face-to-face training session. Both groups reported statistically significant improvements in symptom management and communication skills, with no significant difference between the pedagogical approaches. Most importantly, the education resulted in a statistically significant impact on the nurses' clinical practice. The results of this study demonstrate that online education can be used as an effective and efficient strategy to provide primary palliative care education to a large number of nurses.
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Starr LT, Ulrich CM, Appel SM, Junker P, O'Connor NR, Meghani SH. Goals-of-Care Consultations Are Associated with Lower Costs and Less Acute Care Use among Propensity-Matched Cohorts of African Americans and Whites with Serious Illness. J Palliat Med 2020; 23:1204-1213. [PMID: 32345109 PMCID: PMC7469692 DOI: 10.1089/jpm.2019.0522] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2020] [Indexed: 01/20/2023] Open
Abstract
Background: African Americans receive more aggressive end-of-life care than Whites. Little is known about how palliative care consultation to discuss goals-of-care ("PCC") is associated with acute care utilization and costs by race. Objective: To compare future acute care costs and utilization between propensity-matched cohorts of African Americans with and without PCC, and Whites with and without PCC. Design: Secondary analysis of a retrospective cohort study. Setting/Subjects: Thirty-five thousand one hundred and fifty-four African Americans and Whites age 18+ admitted for conditions other than childbirth or rehabilitation, who were not hospitalized at the end of the study, and did not die during index hospitalization (hospitalization during which the first PCC occurred). Measurements: Accumulated mean acute care costs and utilization (30-day readmissions, future hospital days, future intensive care unit [ICU] admission, future number of ICU days) after discharge from index hospitalization. Results: No significant difference between African Americans with or without PCC in mean future acute care costs ($11,651 vs. $15,050, p = 0.09), 30-day readmissions (p = 0.58), future hospital days (p = 0.34), future ICU admission (p = 0.25), or future ICU days (p = 0.30). There were significant differences between Whites with PCC and those without PCC in mean future acute care costs ($8,095 vs. $16,799, p < 0.001), 30-day readmissions (10.2% vs. 16.7%, p < 0.0001), and future days hospitalized (3.7 vs. 6.3 days, p < 0.0001). Conclusions: PCC decreases future acute care costs and utilization in Whites and, directionally but not significantly, in African Americans. Research is needed to explain why utilization and cost disparities persist among African Americans despite PCC.
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Affiliation(s)
- Lauren T. Starr
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Bioethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Connie M. Ulrich
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
- Center for Bioethics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott M. Appel
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Paul Junker
- Program for Clinical Effectiveness and Quality Improvement, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Nina R. O'Connor
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Salimah H. Meghani
- Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA
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22
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Goebel JR, Bird MN, Martinez IL. Empowering the Latino Community Related to Palliative Care and Chronic Disease Management through Promotores de Salud (Community Health Workers). J Palliat Med 2020; 24:423-427. [PMID: 32833526 DOI: 10.1089/jpm.2020.0332] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Latinos are the largest minority group in the United States and when compared with non-Latino whites suffer from higher rates of certain chronic diseases. Latino community health workers (promotores de salud) are successful in improving the health of their communities. However, evidence of their effectiveness in increasing awareness of palliative care (PC) is limited. Objective: To evaluate the feasibility of applying a promotores de salud model to improve PC awareness among Latinos within the context of chronic disease management. Methods: Bilingual promotores from Familias en Acción trained 76 southern California promotores on PC and chronic disease management. Promotores agreed to disseminate the information learned to 10+ Latino community members. The strengths of the curriculum and the community's needs were identified during phone interviews six months post-training. Results: In 406 diverse settings, 69 promotores trained 2734 community members. Interviews with promotores at follow-up established four themes: (1) holistic health in chronic disease management; (2) communication with doctors; (3) shared decision making, patients' rights, and control; and (4) need for PC information (awareness, access, and support groups). Conclusion: Promotores proved effective at disseminating information related to PC within chronic disease management to Latino community members. Future training should include information on support groups and where caregivers can seek help while caring for those with a terminal disease.
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Affiliation(s)
- Joy R Goebel
- School of Nursing, College of Health and Human Services, California State University, Long Beach, California, USA
| | - Mara N Bird
- Center for Latino Community Health, Evaluation and Leadership Training, College of Health and Human Services, California State University, Long Beach, California, USA
| | - Iveris L Martinez
- Center for Successful Aging, College of Health and Human Services, California State University, Long Beach, California, USA
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23
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Lee K, Gani F, Canner JK, Johnston FM. Racial Disparities in Utilization of Palliative Care Among Patients Admitted With Advanced Solid Organ Malignancies. Am J Hosp Palliat Care 2020; 38:539-546. [PMID: 32372699 DOI: 10.1177/1049909120922779] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND There is increasing recognition of the importance of early incorporation of palliative care services in the care of patients with advanced cancers. Hospice-based palliative care remains underutilized for black patients with cancer, and there is limited literature on racial disparities in use of non-hospice-based palliative care services for patients with cancer. OBJECTIVE The primary objective of this study is to describe racial differences in the use of inpatient palliative care consultations (IPCC) for patients with advanced cancer who are admitted to a hospital in the United States. DESIGN This retrospective cohort study analyzed 204 175 hospital admissions of patients with advanced cancers between 2012 and 2014. The cohort was identified through the National Inpatient Dataset. International Classification of Disease, Ninth Revision codes were used to identify receipt of a palliative care consultation. RESULTS Of this, 57.7% of those who died received IPCC compared to 10.5% who were discharged alive. In multivariable logistic regression models, black patients discharged from the hospital, were significantly less likely to receive a palliative care consult compared to white patients (odds ratio [OR] black: 0.69, 95% CI: 0.62-0.76). CONCLUSIONS Death during hospitalization was a significant modifier of the relationship between race and receipt of palliative care consultation. There are significant racial disparities in the utilization of IPCC for patients with advanced cancer.
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Affiliation(s)
- Kimberley Lee
- Department of Oncology, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Faiz Gani
- Department of Surgery, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joseph K Canner
- Department of Surgery, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabian M Johnston
- Division of Surgical Oncology, Department of Surgery, 1466Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Torensma M, Suurmond JL, van der Heide A, Onwuteaka-Philipsen BD. Care and Decision-Making at the End of Life for Patients With a Non-Western Migration Background Living in The Netherlands: A Nationwide Mortality Follow-Back Study. J Pain Symptom Manage 2020; 59:990-1000.e5. [PMID: 31837456 DOI: 10.1016/j.jpainsymman.2019.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/30/2022]
Abstract
CONTEXT Migrant populations across Europe are aging and will increasingly need end-of-life care. OBJECTIVE The objectives of this study were to gain insight into end-of-life care and decision-making for patients with a non-western migration background and assess differences compared to patients with a Dutch or western migration background. METHODS A mortality follow-back study was conducted using a stratified sample of death certificates of persons who died between August and December 2015, obtained from the central death registry of Statistics Netherlands. Questionnaires were sent to the attending physician (n = 9351; response 78%). Patients aged ≥18 years who died a nonsudden death were included in this study (n = 5327). RESULTS Patients with a non-western migration background are more likely than patients with a Dutch or western migration background to be admitted to and die in hospital (51.6% vs. 33.9% [OR 1.74; 95% CI 1.26-2.41]; 39.1% vs. 20.1% [OR 1.96; 95% CI 1.39-2.78]); less likely to receive morphine or morphine-like medication and continuous deep sedation (72.8% vs. 80.1% [OR 0.62; 95% CI 0.43-0.89]; 16.8% vs. 25.2% [OR 0.52; 95% CI 0.34-0.80]); and more likely to receive end-of-life care that, according to physicians, is directed at curation for too long (6.8% vs. 1.7% [OR 3.61; 95% CI 1.83-7.12]). End-of-life decisions are made less frequently for patients with a non-western migration background (71.6% vs. 79.2% [OR 0.64; 95% CI 0.45-0.91]). Characteristics of decision-making are similar. CONCLUSION End-of-life care for patients with a non-western migration background focuses more, or longer on maximum, curative treatment and end-of-life decisions are made less often.
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Affiliation(s)
- Marieke Torensma
- Department of Public Health, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
| | - Jeanine L Suurmond
- Department of Public Health, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bregje D Onwuteaka-Philipsen
- Department of Public and Occupational Health, Amsterdam UMC Expertise center for Palliative Care and Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Chuang E, Fiter RJ, Sanon OC, Wang A, Hope AA, Schechter CB, Gong MN. Race and Ethnicity and Satisfaction With Communication in the Intensive Care Unit. Am J Hosp Palliat Care 2020; 37:823-829. [PMID: 32237996 DOI: 10.1177/1049909120916126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Racial and ethnic minority patients receive poorer quality end-of-life (EoL) care compared with white patients. Differences in quality of communication (QOC) with clinicians may contribute to these disparities. We measured differences in satisfaction with communication in the intensive care unit (ICU) by race and ethnicity. MATERIALS AND METHODS This is a cross-sectional survey of family members of patients in ICUs of an academic medical center serving a diverse urban population using The Family Satisfaction with the ICU (FS-ICU) and QOC scales. RESULTS One hundred surveys were completed (18.8% white, non-Hispanic; 34.4% black, non-Hispanic; 31.3% Hispanic; 15.6% other race/ethnicity). Mean FS-ICU score was 84.2 (standard deviation [SD] 20.5) for white patients, 83.3 (SD 16.2) for black patients, 82.7 (SD 17.8) for Hispanic or Latino patients, and 80.9 (SD 18.8) for patients with other race/ethnicity (Kruskal-Wallis, P = .92). Differences remained insignificant when controlling for patient and respondent characteristics. The QOC scale was not scored due to nonresponse levels on questions about EoL communication. CONCLUSIONS Uniformly high ratings may have been influenced by avoidance of EoL discussion. This study is inconclusive regarding whether QOC influences disparities in EoL care since quality of EoL communication was not captured.
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Affiliation(s)
- Elizabeth Chuang
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ryan J Fiter
- Department of Medicine, Icahn School of Medicine at Mount Sinai Hospital, NY, USA
| | - Omar C Sanon
- Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ann Wang
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Aluko A Hope
- Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center, NY, USA
| | - Clyde B Schechter
- Department of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michelle N Gong
- Division of Critical Care, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, USA
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Early for Everyone: Reconceptualizing Palliative Care in the Neonatal Intensive Care Unit. Adv Neonatal Care 2020; 20:109-117. [PMID: 31990696 DOI: 10.1097/anc.0000000000000707] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Palliative care (PC) in the neonatal intensive care unit (NICU) is often provided exclusively to infants expected to die. Standards of care support providing PC early after diagnosis with any condition likely to impact quality of life. PURPOSE To determine the state of early PC practice across populations to derive elements of early PC applicable to neonates and their families and demonstrate their application in practice. SEARCH STRATEGY Multiple literature searches were conducted from 2016 to 2019. Common keywords used were: palliative care; early PC; end of life, neonate; NICU; perinatal PC; pediatric PC; family-centered care; advanced care planning; palliative care consultant; and shared decision-making. FINDINGS Early PC is an emerging practice in adult, pediatric, and perinatal populations that has been shown to be helpful for and recommended by families. Three key elements of early PC in the NICU are shared decision-making, care planning, and coping with distress. A hypothetical case of a 24-week infant is presented to illustrate how findings may be applied. Evidence supports expansion of neonatal PC to include infants and families without terminal diagnoses and initiation earlier in care. IMPLICATIONS FOR PRACTICE Involving parents more fully in care planning activities and decision-making and providing structured support for them to cope with distress despite their child's prognosis are essential to early PC. IMPLICATIONS FOR RESEARCH As early PC is incorporated into practice, strategies should be evaluated for feasibility and efficacy to improve parental and neonatal outcomes. Researchers should consider engaging NICU parent stakeholders in leading early PC program development and research.
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Rodenbach R, Kavalieratos D, Tamber A, Tapper C, Resick J, Arnold R, Childers J. Coaching Palliative Care Conversations: Evaluating the Impact on Resident Preparedness and Goals-of-Care Conversations. J Palliat Med 2019; 23:220-225. [PMID: 31460823 DOI: 10.1089/jpm.2019.0165] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background: There is increasing need for nonspecialty physicians to deliver palliative care (PC) services to meet patient needs, but many physicians feel inadequately prepared. Objective: We aimed to improve the PC skills of resident physicians through a learner-centered, just-in-time coaching intervention. Design: Our quality improvement initiative consisted of two didactics and brief thrice-weekly coaching sessions that focused on real-time PC questions. Upper level internal medicine residents participated during an inpatient hospitalist rotation. Measurements: Residents completed pre/postrotation surveys of their preparedness in discussing PC topics. Electronic medical record data of documentation of goals-of-care (GOC) discussions and Physician Orders for Life-Sustaining Treatment (POLST) completion in at-risk hospitalized patients (age >65 with two or more hospitalizations in the past six months, or age >90) were obtained and compared with before hospitalization. These data were also compared with data from patients on the same resident hospitalist service during the six-month period before the intervention began. Results: During the 14-month intervention period, 42 residents cared for 232 at-risk patients. Among at-risk patients, 12.9% had a documented GOC discussion before hospitalization, which rose to 57.3% before discharge. Among at-risk patients preintervention, these rates were 5.2% and 25.0%, respectively. Residents reported their preparedness increased across many elements of GOC discussions and rated coaching sessions as useful and relevant to their training. Rates of POLST completion did not differ between preintervention and intervention groups. Conclusions: Brief coaching sessions can integrate PC education into a busy clinical service, improve residents' primary PC skills, and improve GOC documentation.
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Affiliation(s)
- Rachel Rodenbach
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anoo Tamber
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Corey Tapper
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith Resick
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives. Support Care Cancer 2019; 27:4733-4744. [PMID: 30972644 DOI: 10.1007/s00520-019-04726-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations. PURPOSE To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer. METHODS Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists. RESULTS Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues. CONCLUSION Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.
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Abedini NC, Chopra V. A Model to Improve Hospital-Based Palliative Care: The Palliative Care Redistribution Integrated System Model (PRISM). J Hosp Med 2018; 13:868-871. [PMID: 30156581 DOI: 10.12788/jhm.3065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Many hospitalized patients have unmet palliative care needs that are exacerbated by gaps in the palliative care subspecialty workforce. Training frontline physicians, including hospitalists, to provide primary palliative care has been proposed as one solution to this problem. However, improving palliative care access requires more than development of the physician workforce. Systemlevel change and interdisciplinary approaches are also needed. Using task shifting as a guiding principle, we propose a new workforce framework (the Palliative care Redistribution Integrated System Model, or PRISM), which utilizes physician and nonphysician providers and resources to their maximum potential. We highlight the central role of hospitalists in this model and provide examples of innovations in screening, workflow, quality, and benchmarking to enable hospitalists to be purveyors of quality palliative care.
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Affiliation(s)
- Nauzley C Abedini
- National Clinician Scholars Program, University of Michigan, Ann Arbor, Michigan, USA.
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vineet Chopra
- Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
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30
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Wells R, Ejem D, Dionne-Odom JN, Bagcivan G, Keebler K, Frost J, Azuero A, Kono A, Swetz KM, Bakitas M. Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study. Heart Lung 2018; 47:533-538. [PMID: 30143363 DOI: 10.1016/j.hrtlng.2018.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF). OBJECTIVES To describe evaluation practices and treatment recommendations made during protocol-driven OPCCs for advanced HF. METHODS We performed content analysis of OPCCs completed as part of ENABLE CHF-PC, an early palliative care HF intervention, conducted at sites in the Northeast and Southeast. T-tests, Fisher's exact, and Chi-square tests were used to evaluate sociodemographic, outcome measures, and site content differences. RESULTS Of 61 ENABLE CHF-PC participants, 39 (64%) had an OPCC (Northeast, n=27; Southeast, n=12). Social and medical history assessed most were close relationships (n=35, 90%), family support (n=33, 85%), advance directive status (n=33, 85%), functional status (n=30, 77%); and symptoms were mood (n= 35, 90%), breathlessness (n=28, 72%), and chest pain (n=24, 62%). Treatment recommendations focused on care coordination (n=13, 33%) and specialty referrals (n=12, 31%). Between-site OPCC differences included assessment of family support (Northeast vs. Southeast: 100% vs. 50%), code status (96% vs. 58%), goals of care discussions (89% vs. 41.7%), and prognosis understanding (85% vs. 33%). CONCLUSION OPCCs for HF focused on evaluating medical and social history, along with goals of care and code status discussions. Symptom evaluation commonly included mood disorders, pain, dyspnea, and fatigue. Notable regional differences were found in topics evaluated and OPCC completion rates.
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Affiliation(s)
- Rachel Wells
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA.
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Gulcan Bagcivan
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Konda Keebler
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Jennifer Frost
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Alan Kono
- Cardiology, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine at Dartmouth, Heart and Vascular Center DHMC, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Keith M Swetz
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB Center for Palliative & Supportive Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-0012, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA; Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB Center for Palliative & Supportive Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-0012, USA
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