The Development of Practice Guidelines for a Palliative Care Multidisciplinary Case Conference

Interdisciplinary Pain Board for Managing Patients with Palliative Care Needs and Substance Use Disorder: A Pilot Study

Context: Patients with cancer-related pain and concurrent substance use disorder (SUD) present a unique set of challenges for palliative care clinicians. A structured forum for interdisciplinary collaboration is needed to effectively manage this complex population. Objectives: Describe the feasibility and acceptability of a palliative care Complex Pain Board (CPB), an interdisciplinary team meeting to provide concrete care recommendations for patients with cancer-related pain and concurrent SUD and/or psychosocial complexity. Methods: We conducted a retrospective analysis of cases presented at CPB between May 2021 and June 2022 and a cross-sectional analysis of CBP participant surveys. Results: Among 28 cases included for analysis, gastrointestinal cancers (n = 7, 25.9%) and multiple myeloma (n = 5, 18.5%) were the most frequent cancer diagnoses. Primary reasons for referral were SUD (n = 22, 78.6%) and provider/team distress (n = 13, 46.4%). The most frequent recommendations made at CBP were encouraging interdisciplinary collaboration (n = 18, 64.3%), maintaining healthy boundaries (n = 15, 53.6%), and SUD management (n = 13, 46.4%). Of 14 scheduled meetings, most meetings involved the presentation of ≥1 cases (n = 12, 86%). Among 40 CBP participant surveys, most attendees (n = 38, 95%) were likely or highly likely to continue to attend. Conclusion: CPB is a feasible and acceptable intervention that allows for palliative care clinicians to collaborate and receive interdisciplinary team feedback and peer support on the management of patients with cancer-related pain and concurrent SUD and/or psychosocial complexity in the ambulatory care setting. Key Message: A regular, interdisciplinary team meeting (CPB) is a feasible and acceptable intervention to help palliative care clinicians manage challenging cases involving patients with cancer and concurrent SUD and/or psychosocial complexity.

'I tried to get into their shoes and their culture'. Care worker experiences in cultural end-of-life care: Interpretative phenomenological analysis

AIM

What are care workers' lived experiences caring for people of culturally and linguistically diverse backgrounds during end-of-life care?

DESIGN

Interpretative phenomenological analysis METHODS: The lived experiences of 11 care workers within the Australian Capital Territory and region who have cared for someone of a culturally and linguistically diverse background during end-of-life care were captured. Each care worker was interviewed individually and answered a series of semi-structured open-ended questions.

RESULTS

Using interpretative phenomenological analysis, three group experiential themes were derived: (i) navigating cultural shock and death, (ii) the hard work of communication and (iii) searching for deeper connections with client and self. Within these were key elements: Care workers worked hard to embrace cultural diversity, but struggled to meet cultural needs, particularly in relation to the unpredictable timeline of dying. Care workers relied on themselves and their improvisation, but experienced self-blame for inadequate care and unexpected challenges in communication. Blurred boundaries in relation to therapeutic relationships were apparent, and care workers felt alone with emotional burden, but also found belonging and joy in their work.

CONCLUSION

Care workers' experiences are vital to understanding the barriers and challenges in providing culturally appropriate end-of-life care. Care workers repeatedly experienced an emotional burden and vicarious trauma throughout their work in this field. Care workers were self-reliant in all aspects of care including communication and consistently desired education, training, resources and support. There remains inadequate research on care workers and their role within the Australian healthcare context.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Care workers need access to support and resources including professional translators to provide culturally appropriate end-of-life care. Workplaces and registered nurses should facilitate training and provide guidance to care workers. A person-centred approach is required during all client encounters while maintaining appropriate therapeutic relationships including therapeutic use of self and professional boundaries.

REPORTING METHOD

COREQ Checklist.

PATIENT OR PUBLIC CONTRIBUTION

During this study, care workers were interviewed on their experiences caring for people of culturally and linguistically diverse backgrounds during end-of-life care. Patients were not directly involved within this study, but their views may have been expressed through the care workers' experience.

Advocating for Training in End-Of-Life Conversations With Seriously Ill Patients During Residency

According to section IV.B.1.e of common residency program requirements from the Accreditation Council for Graduate Medical Education (ACGME), "[r]esidents must learn to communicate with patients and families to partner with them to assess their care goals, including, when appropriate, end-of-care [EOL] goals". EOL conversations are frequently appropriate for patients suffering from serious, life-threatening diseases (ie, terminal illness) or otherwise chronic health conditions with poor disease trajectories. These conversations are often followed with services and care from palliative medicine or hospice specialists depending on patients' projected prognoses (ie, 6 months or less). The focus of this patient-centered care, then, is on relieving patient and caregiver suffering, establishing clear treatment goals, and managing the physical, psychosocial, and spiritual burdens of disease. Although palliative medicine and hospice care have been shown to reduce health care costs and improve the overall care of patients who require these services, recent literature still suggests a gap in training programs being able to provide effective, educational strategies to their trainees regarding the appropriate and competent delivery of EOL conversations. Herein, this commentary will provide a discussion on what EOL is, palliative vs hospice care indications, and address current literature regarding EOL exposure within training programs while offering our personal insight and advocacy on the manner.

The Impact of Hospice Care Structures on Care Processes: A Retrospective Cohort Study

Background: Palliative care is subject to substantial variations in care, which may be shaped through adapting the organisational structures through which care is provided. Whilst the goal of these structures is to improve patient care, there is a lack of evidence regarding their effect on care processes and patient outcomes. Aims: This study aims to describe the relationship between care structures and the quantity and domains of care processes in hospice care. Design: Retrospective cohort study. Settings/Participants: Data were collected from Dutch hospice patient's clinical records and hospice surveys, detailing hospice structures, patient clinical characteristics and care processes. Results: 662 patients were included from 42 hospices, mean age 76.1 years. Hospices were categorised according to their care structures - structured clinical documentation and multidisciplinary meetings. Patients receiving care in hospices with structured multidisciplinary meetings had an increased quantity of documented care processes per patient on admission through identification (median 4 vs 3, P < .001), medication (2 vs 1, P = .004) and non-medication (1 vs 0, P < .001) interventions, monitoring (2 vs 1, P < .001) and evaluation (0 vs 0, P = .014), and prior to death. Similar increases were identified for patients who received care in hospices with structured documentation upon admission, but these changes were not consistent prior to death. Conclusions: This study details that the care structures of documentation and multidisciplinary meetings are associated with increased quantity and breadth of documentation of care processes in hospice care. Employing these existing structures may result in improvements in the documentation of patient care processes, and thus better communication around patient care.

A shared decision-making model in pediatric palliative care: a qualitative study of healthcare providers

BACKGROUND

Pediatric shared decision-making (SDM) is a fundamental part of family-centered care. Pediatric palliative care (PPC) is one of the more difficult fields for healthcare providers when choosing to utilize SDM. However, to our knowledge, there are still few structured approaches of SDM in PPC. We aimed to build a model of SDM in PPC that achieves better care and outcomes for children and their family members.

METHODS

This study is a descriptive phenomenology study. Participants included physicians, nurses, and social workers in the PPC team. Participants were individually interviewed face-to-face or via an online meeting software. Data were collected in semi-structured interviews and analyzed using a thematic framework analysis.

RESULTS

In total, 27 healthcare providers were interviewed. The model of SDM in PPC identified three themes, including the participants, the principle and the process of SDM. Decision participants involved the children, parents, the PPC team and others. The decision principle had three sub-themes including type, standard and precondition. The decision process describes the fundamental process of SDM and provides suggestions for mobilizing patients and parents to engage in decision-making and seeking conflict resolution.

CONCLUSIONS

This is the first study to develop a SDM model in PPC. This model can provide guidance to PPC teams on SDM practices. In addition, the model contributes to the existing body of knowledge by providing a conceptual model for SDM in the context of PPC.

Contextualizing the results of an integrative review on the characteristics of dementia-friendly hospitals: a workshop with professional dementia experts

BACKGROUND

To become a dementia-friendly hospital (DFH) is increasingly being discussed in health care practice, research, politics and society. In our previous integrative review, we identified six characteristics of DFHs. To thoroughly discuss and contextualize these characteristics in relation to hospitals in Germany, we involved professional dementia experts in our review process.

METHODS

At the end of our review process, we involved professional dementia experts at the 'contributing' level of the ACTIVE framework to discuss and reflect on the six DFH characteristics we identified. We conducted a group process in the form of a one-day workshop. The workshop consisted of four steps: 1. presentation of review results (input), 2. modification of DFH characteristics and rating of their relevance in smaller working groups, 3. discussion of group results in plenary and 4. questionnaire for prioritization and rating of feasibility. The data were analyzed in MAXQDA using content analysis and descriptive statistics.

RESULTS

A total of 16 professional dementia experts working in hospitals participated in the workshop. All the previously identified characteristics of a DFH were rated as relevant or very relevant for patients with dementia, their relatives and health care professionals from the professional dementia experts' perspective. They made a few modifications of the six characteristics at the level of subcategories, aspects, and descriptions. The feasibility of the characteristics in hospitals was critically discussed regarding resources, hospital structures and processes, the role of nurses, and the current care situation of people with dementia in hospitals. More than half of the subcategories of the characteristics were considered very difficult or difficult to implement by most professional dementia experts.

CONCLUSION

The involvement of professional dementia experts helped us contextualize our review findings within the German hospital setting. These results highlight the need to consider resources, funding options, influencing factors, and the current situation and culture of care provided by hospitals before implementing DFH characteristics. Beside the involvement of professional dementia experts and various health care professionals, the involvement of other stakeholders, such as people with dementia and their relatives, is necessary in future research for the development of a DFH.

Palliative Care Delivery Systems and Integration With Palliative Care Teams

Radiotherapy (RT) plays a critical role in the palliation of symptoms in patients with advanced or metastatic cancer. To address the growing need for these services, multiple dedicated palliative RT programs have been established. This article serves to highlight the novel ways in which palliative RT delivery systems support patients with advanced cancer. Through early integration of multidisciplinary palliative supportive services, rapid access programs facilitate best practices for oncologic patients at the end of life.

Implementation of a Palliative Oncology Tumor Board

CONTEXT

The integration of palliative care into standard oncologic care has been shown to improve multiple outcomes in patients with advanced cancer. Ideal methods for integrating these disciplines is an ongoing area of discussion. One method of integration is a palliative oncology tumor board (POTB).

OBJECTIVES

To describe the implementation of a POTB in a community cancer center as a method of integrating oncology and palliative care by providing a forum for multidisciplinary discussion of complex cases.

METHODS

During development of the POTB, multiple influencing factors and barriers were considered including the setting of implementation, culture prior to implementation, design elements, engagement of stakeholders, and evaluation of implementation. The focus of this POTB was to address the identified communication gap between inpatient and outpatient care teams. Two complex hospitalized oncology patients were selected to be discussed weekly.

RESULTS

Conferences were attended by an average of 23 individuals. The highest proportion of attendees were members of oncology support services (including nurse navigators, social workers, chaplains, dietitians, financial counselors; OSS; 31%), followed by medical oncology (25%). The most common theme of discussion was methods of communication with patient and/or family (68% of cases). Thirty days after presentation, a total of 50 new referrals were placed to inpatient palliative care, OSS, and outpatient palliative care and 11 new advance care plans were documented in the electronic medical record.

CONCLUSION

This paper describes a sustainable method to implement a POTB in a community cancer center setting, which is one method of integrating palliative care into standard oncologic care.

Multidisciplinary team meetings in palliative care: an ethnographic study

OBJECTIVES

Multidisciplinary team meetings are a regular feature in the provision of palliative care, involving a range of professionals. Yet, their purpose and best format are not necessarily well understood or documented. This article describes how hospital and community-based palliative care multidisciplinary team meetings operate to elucidate some of their main values and offer an opportunity to share examples of good practice.

METHODS

Ethnographic observations of over 70 multidisciplinary team meetings between May 2018 and January 2020 in hospital and community palliative care settings in intercity London. These observations were part of a larger study examining palliative care processes. Fieldnotes were thematically analysed.

RESULTS

This article analyses how the meetings operated in terms of their setup, participants and general order of business. Meetings provided a space where patients, families and professionals could be cared for through regular discussions of service provision.

CONCLUSIONS

Meetings served a variety of functions. Alongside discussing the more technical, clinical and practical aspects that are formally recognised aspects of the meetings, an additional core value was enabling affectual aspects of dealing with people who are dying to be acknowledged and processed collectively. Insight into how the meetings are structured and operate offer input for future practice.

Facilitating Advance Care Planning for Patients With Severe COPD: A Qualitative Study of Experiences and Perceptions of Community Physicians, Nurses, and Allied Health Professionals

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity worldwide. Patients with severe COPD often fail to receive adequate palliative care and are subject to undesired hospital transfers and cardiopulmonary resuscitation. Although promoting advance care planning (ACP) in the community can help ensure the optimal delivery of palliative care for patients with COPD, the key challenges to routinely implementing ACP are not known. The aim of this study was to identify the perception of healthcare professionals with regard to ACP for adults living with severe COPD and the challenges to facilitating ACP. A multicenter qualitative study design was used. In-depth semistructured interviews were held involving 38 healthcare professionals from 19 institutions in Japan. Text data were analyzed by content analysis. Five main themes capturing the challenges to routine implementation of ACP were identified: daily decision-making; sense of ethical decision-making; in-depth interviewing skills; collaborative information sharing among team members; and knowledge dissemination regarding ACP. The model demonstrates the complexity inherent in ACP facilitation for community-dwelling adults with severe COPD, with all the elements required for successful ACP implementation. We recommend an approach that recognizes the importance of stakeholder education, particularly educating professionals to develop the knowledge, attitudes, and skills required for ACP facilitation: in-depth interviewing, collaborative information sharing, and ethical analysis, focusing on decision-making concerning everyday life support.

Barriers and enablers to the implementation of multidisciplinary team meetings: a qualitative study using the theoretical domains framework

Background

Evidence-based clinical practice guidelines recommend discussion by a multidisciplinary team (MDT) to review and plan the management of patients for a variety of cancers. However, not all patients diagnosed with cancer are presented at an MDT.

Objectives

(1) To identify the factors (barriers and enablers) influencing presentation of all patients to, and the perceived value of, MDT meetings in the management of patients with pancreatic cancer and; (2) to identify potential interventions that could overcome modifiable barriers and enhance enablers using the theoretical domains framework (TDF).

Methods

Semistructured interviews were conducted with radiologists, surgeons, medical and radiation oncologists, gastroenterologists, palliative care specialists and nurse specialists based in New South Wales and Victoria, Australia. Interviews were conducted either in person or via videoconferencing. All interviews were recorded, transcribed verbatim, deidentified and data were thematically coded according to the 12 domains explored within the TDF. Common belief statements were generated to compare the variation between participant responses.

Results

In total, 29 specialists were interviewed over a 4-month period. Twenty-two themes and 40 belief statements relevant to all the TDF domains were generated. Key enablers influencing MDT practices included a strong organisational focus (social/professional role and identity), beliefs about the benefits of an MDT discussion (beliefs about consequences), the use of technology, for example, videoconferencing (environmental context and resources), the motivation to provide good quality care (motivation and goals) and collegiality (social influences). Barriers included: absence of palliative care representation (skills), the number of MDT meetings (environmental context and resources), the cumulative cost of staff time (beliefs about consequences), the lack of capacity to discuss all patients within the allotted time (beliefs about capabilities) and reduced confidence to participate in discussions (social influences).

Conclusions

The internal and external organisational structures surrounding MDT meetings ideally need to be strengthened with the development of agreed evidence-based protocols and referral pathways, a focus on resource allocation and capabilities, and a culture that fosters widespread collaboration for all stages of pancreatic cancer.

Interprofessional case conferences to bridge perception gaps regarding ethical dilemmas in home-based end-of-life care: a qualitative study

Objective: The aim of this study was to examine the effectiveness and efficiency of interprofessional case conferences on home-based end-of-life care to bridge perceptions gaps regarding ethical dilemmas among different healthcare professionals and analyze essential issues extracted the interprofessional discussions. Patients and Methods: The participants could spend only a limited amount of time after their working hours. Therefore, we shortened and simplified each of three case scenarios so that the discussions do not last longer than 90 minutes. For the case conferences, we selected 3 cases, which entailed the following ethical dilemmas pertaining to home-based end-of-life care: refusal of hospital admission, passive euthanasia, and emergency transport. Participant responses were audio-recorded, transcribed, and analyzed using qualitative content analysis and Jonsen's four topics approach. Results: A total of 136 healthcare professionals (11 physicians, 35 nurses, and 90 care workers) participated in the case conferences. The physicians, nurses, and care workers differed in their perceptions of and attitudes toward each case, but there were no interprofessional conflicts. Despite the short duration of each case conference (90 minutes), the participants were able to discuss a wide range of medical ethical issues that were related to the provision of appropriate home-based end-of-life care to older adults. These issues included discrimination against older adults (ageism), self-determination, an unmet desire for caregiver-patient communication, insufficient end-of-life care skills and education, healthcare costs, and legal issues. Conclusion: The physicians, nurses, and care workers differed in their perceptions of and attitudes toward each case, but there were no interprofessional conflicts.