Patient-Reported Quality Measures for Palliative Care: The Time is now

Quality of Care during the COVID-19 Pandemic: A Qualitative Exploration of Bereaved Caregivers' Experiences at a Hospice Residence

Background: An essential component of residential hospice care is the provision of high quality palliative care. The perspectives of quality of care from palliative care patients and bereaved caregivers have increasingly been studied to guide quality improvements. Aim: The study aimed to explore the experiences and perceptions of bereaved caregivers of patients who died in residential hospice during the coronavirus disease-19 (COVID-19) pandemic to determine perceptions of quality of care, caregiver grief and bereavement, and the impact of the COVID-19 pandemic. Design: Qualitative exploratory study using secure, web-based semistructured interviews. Data were analyzed using thematic analysis. Setting/Participants: A total of 15 bereaved caregiver participants were recruited from two residential hospice sites in Ottawa, Ontario. Results: Participants identified several factors that impacted the quality of care in residential hospice, including the impact of the COVID-19 pandemic itself. The findings are presented in three main themes: (1) quality of residential hospice end-of-life care; (2) caregiver perceptions of their grief and bereavement; and (3) impact of the COVID-19 pandemic on hospice quality of care and caregiver bereavement. Conclusions: The COVID-19 pandemic had a significant impact on the patient and caregivers experience of hospice, including perception of quality of care and caregiver experience of grief and bereavement.

Association Between Intensity and Timing of Specialty Palliative Care and Hospice Exposure With Quality of End-of-Life Care

Background: Gaps remain in our understanding of the intensity and timing of specialty palliative care (SPC) exposure on end-of-life (EOL) outcomes. Objective: Examine the association between intensity and timing of SPC and hospice (HO) exposure on EOL care outcomes. Design, Settings, Participants: Data for this cohort study were drawn from 2021 adult decedents from Kaiser Permanente Southern California and Colorado (n = 26,251). Caregivers of a decedent subgroup completed a postdeath care experience survey from July to August 2022 (n = 424). Measurements: SPC intensity (inpatient, outpatient, and home-based) and HO exposure in the five years before death were categorized as: (1) No SPC or HO; (2) SPC-only; (3) HO-only; and (4) SPC-HO. Timing of SPC exposure (<90 or 90+ days) before death was stratified by HO enrollment. Death in the hospital and potentially burdensome treatments in the last 14 days of life were extracted from electronic medical records (EMRs) and claims. EOL care experience was obtained from the caregiver survey. Results: Among the EMR cohort, exposure to SPC and HO were: No SPC or HO (38%), SPC-only (14%; of whom, 55% received inpatient SPC only), HO-only (20%), and SPC-HO (28%). For decedents who did not enroll in HO, exposure to SPC 90+ days versus <90 days before death was associated with lower risk of receiving potentially burdensome treatments (adjusted relative risk, aRR: 0.69 [95% confidence interval, CI: 0.62-0.76], p < 0.001) and 23% lower risk of dying in the hospital (aRR: 0.77 [95% CI: 0.73-0.81], p < 0.001). Caregivers of patients in the HO-only (aRR: 1.27 [95% CI: 0.98-1.63], p = 0.07) and SPC-HO cohorts (aRR: 1.19 [95% CI: 0.93-1.52], p = 0.18) tended to report more positive care experience compared to the no SPC or HO cohort. Conclusion: Earlier exposure to SPC was important in reducing potentially burdensome treatments and death in the hospital for decedents who did not enroll in HO. Increasing availability and access to community-based SPC is needed.

TAVR in Older Adults: Moving Toward a Comprehensive Geriatric Assessment and Away From Chronological Age: JACC Family Series

Calcific aortic stenosis can be considered a model for geriatric cardiovascular conditions due to a confluence of factors. The remarkable technological development of transcatheter aortic valve replacement was studied initially on older adult populations with prohibitive or high-risk for surgical valve replacement. Through these trials, the cardiovascular community has recognized that stratification of these chronologically older adults can be improved incrementally by invoking the concept of frailty and other geriatric risks. Given the complexity of the aging process, stratification by chronological age should only be the initial step but is no longer sufficient to optimally quantify cardiovascular and noncardiovascular risk. In this review, we employ a geriatric cardiology lens to focus on the diagnosis and the comprehensive management of aortic stenosis in older adults to enhance shared decision-making with patients and their families and optimize patient-centered outcomes. Finally, we highlight knowledge gaps that are critical for future areas of study.

The Evolving Roles and Expectations of Inpatient Palliative Care Through COVID-19: a Systematic Review and Meta-synthesis

BACKGROUND

Palliative care performed a central role in responding to the systemic suffering incurred by the COVID-19 pandemic. Yet, few studies have elucidated the inpatient palliative care specialists' experiences and perceptions.

OBJECTIVE

Systematically review and synthesize the evolving roles and expectations of inpatient palliative care specialists in response to COVID-19.

DESIGN

A systematic review and meta-synthesis informed by Thomas and Harden's framework and Pozzar et al.'s approach was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

DATA SOURCES

MEDLINE, EMBASE, CINAHL, and PubMed were systematically searched for articles published between December 2019 and March 2023. We included all peer-reviewed qualitative and mixed-method literature studying the roles and expectations of inpatient palliative care specialists. A mixed-method appraisal tool was used for quality assessment.

RESULTS

Of 3869 unique articles, 52 were included. Studies represented North American (n = 23), European (n = 16), South American (n = 4), Oceanic (n = 2), Asian (n = 2), West African (n = 1), Middle Eastern (n = 1), and inter-continental settings (n = 3). Most were reported in English (n = 50), conducted in 2020 (n = 28), and focused on the perspectives of inpatient palliative care clinicians (n = 28). Three descriptive themes captured the roles and expectations of inpatient palliative care specialists: shifting foundations, reorienting to relationships, and evolving identity. Two analytical themes were synthesized: palliative care propagates compassion through a healing presence, and palliative care enhances the systemic response to suffering through nimble leadership.

CONCLUSION

Inpatient palliative care specialists responded to the COVID-19 pandemic by establishing their healing presence and leading with their adaptability. To develop institutionally tailored and collaborative responses to future pandemics, future studies are needed to understand how inpatient palliative care clinicians are recognized and valued within their institutions.

Effects of early exposure to palliative care on end-of-life outcomes in patients with cancer in a community setting

OBJECTIVE

Although prior studies show that exposure to early outpatient palliative care (OPC) versus no exposure is associated with improved outcomes at the end of life (EoL) for patients with cancer, few examined the impact of exposure to OPC prior to home-based palliative care (HBPC) on EoL outcomes. This study compares the effect of OPC prior to HBPC versus HBPC alone on EoL outcomes in patients with cancer.

METHODS

A secondary analysis of data from a trial comparing two models of HBPC was performed on patients with primary cancer diagnoses. Adjusted negative binomial and logistic regression models were used to compare days in acute care and intensive care unit stays in the last 30 days, chemotherapy administration in the last 14 days and in-hospital deaths between patients who received standard-dose (4+ encounters) and low-dose (<4 encounters) OPC plus HBPC versus HBPC alone.

RESULTS

A total of 1187 patients, 483 (40.1%) of whom had OPC+HBPC and 704 (59.3%) who had HBPC alone were included in the analyses. Compared with patients who had HBPC alone, patients who had standard-dose OPC spent fewer days in acute care (4.29 vs 4.19, p=0.04) and fewer days inpatient (3.45 vs 3.09, p=0.03) in the last 30 days of life. No difference was seen in EoL outcomes in patients exposed to low-dose OPC compared with those with HBPC alone. Receipt of hospice after HBPC was strongly associated with improved EoL outcomes.

CONCLUSION

Future research is needed to examine the modality, timing and intensity of palliative care necessary to effect EoL outcomes.

Perspectives of inpatients with palliative care needs, their families, clinicians and key stakeholders on measuring quality of hospital care via patient experience measures: A qualitative study

BACKGROUND

Globally there are high numbers of patients with palliative care needs receiving care in hospitals. Patient reported experience measures (PREMs) provide useful data to guide improvement work. How to implement PREMs within palliative care populations is unclear.

AIM

To explore the perspectives of inpatients with palliative care needs, their family members, and the clinical team regarding the use of a generic PREM as compared with a PREM designed for people with palliative care needs and related implementation factors.

DESIGN

A qualitative study was undertaken using semi-structured interviews and focus groups and integrated thematic analysis.

SETTING/PARTICIPANTS

Inpatients with palliative care needs, their family members, and clinical team members were recruited from three wards in an Australian metropolitan hospital.

RESULTS

Twenty-seven interviews and three focus groups were conducted. Six themes emerged: (1) PREMs for people with palliative care needs ought to be tailored to the needs of this population; (2) PREMs should appraise whether the needs of families have been met in addition to those of patients; (3) PREMs for inpatients with palliative care needs ought to be easy to use, brief and incorporate space for free text alongside each question; (4) Implementation of PREMs for people with palliative care needs ought to consider who administers these, when and how often; (5) PREM data need to be specific enough to inform process change and/or care provision; (6) Patients and families require meaningful feedback to encourage PREM completion.

CONCLUSIONS

This study provides practical guidance for PREM selection and implementation to inform improvements to care for inpatients with palliative care needs.

Evaluating the pragmatic characteristics of advance care planning outcome measures in dementia clinical trials: A scoping review

BACKGROUND

Advance care planning (ACP) is a process that involves discussing a person's goals, values, and preferences; it is particularly important for persons living with dementia (PLWD) given that dementia is incurable and progressive. To ensure results that will impact real-world practices, ACP outcome measures must be psychometrically strong, meaningful to key partners, and pragmatic to collect. Therefore, we conducted a scoping review of outcome measures utilized in ACP randomized controlled clinical trials (RCTs) enrolling PLWD or their care partners and evaluated their pragmatic characteristics.

METHODS

We searched MEDLINE/PubMed, EMBASE, CINAHL, PsycINFO, and Web of Science for peer-reviewed ACP RCTs enrolling PLWD or their care partners from 2011 to 2021. We abstracted characteristics of primary and secondary outcome measures, including pragmatic characteristics using an adapted Psychometric and Pragmatic Evidence Rating Scale and ACP outcome domains using the standardized ACP Outcome Framework (i.e., process, action, healthcare, or quality of care).

RESULTS

We included 21 ACP RCTs. Trials included 103 outcome measures (39 primary and 64 secondary), of which 11% measured process, 14% measured action, 49% measured healthcare, and 26% measured quality of care. Twenty-four (23%) outcome measures were highly pragmatic, the majority of which (67%) reflected healthcare outcome measures. Sixty-one (59%) outcomes were assessed as highly relevant to PLWD or their care partners. Only 20% (n = 21) of outcome measures were embedded into clinical practice. Most (62%) RCTs were conducted in nursing homes, and 33% were focused PLWD with advanced stage disease.

CONCLUSIONS

In RCTs testing ACP interventions to support PLWD, only 23% of outcome measures were highly pragmatic, and most of these measured healthcare utilizations. Outcome assessments were rarely integrated into the EHR during routine clinical care. New outcome measures that address the lived experience of PLWD and their care partners plus have high pragmatic characteristics are needed for embedded pragmatic clinical trials.

Best Practices for Providing Patient-Centered Tele-Palliative Care to Cancer Patients

Cancer patients receiving palliative care may face significant challenges in attending outpatient appointments. Patients on controlled substances such as opioids require frequent visits and often rely on assistive devices and/or a caregiver to accompany them to these visits. In addition, pain, fatigue, and shortness of breath may magnify the challenges associated with in-person visits. The rapid adoption of telemedicine in response to the COVID-19 pandemic has proven to be highly beneficial for advanced cancer patients and caregivers. The hurried COVID-19-related implementation of telemedicine is now evolving into a permanent platform for providing palliative care. This review will focus on the best practices and recommendations to deliver high-quality, interdisciplinary tele-palliative care.