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Müller E, Müller MJ, Boehlke C, Schäfer H, Quante M, Becker G. Screening for Palliative Care Need in Oncology: Validation of Patient-Reported Outcome Measures. J Pain Symptom Manage 2024; 67:279-289.e6. [PMID: 38154625 DOI: 10.1016/j.jpainsymman.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 12/30/2023]
Abstract
CONTEXT Leading oncology societies recommend monitoring symptoms and support needs through patient-reported outcome measures (PROMs), but their use for assessing specialist palliative care (SPC) need has not yet been explored. Research on SPC integration has focused on staff-assessed screening tools, which are time-consuming. OBJECTIVES This study aimed to assess the diagnostic validity of the Integrated Palliative Outcome Scale (IPOS) and NCCN Distress Thermometer (NCCN DT) in identifying need for SPC in patients with incurable cancer. METHODS In a cross-sectional study, patients with incurable cancer (prognosis <2 years) completed PROMs. In an independent process, the palliative care consultation service (PCCS) assessed the need for SPC in each patient through multiprofessional case review, and this was used as the reference standard. ROC analyses were employed to determine diagnostic validity. RESULTS Of the 208 participants, 71 (34.1 %) were classified as having SPC need by the PCCS. Aiming for a minimum sensitivity of 80%, a cut-off of ≥2 items with high/very high burden in the IPOS resulted in a 90.2% sensitivity (specificity = 50; AUC = 0.791; CI 95%= 0.724-0.858). A cut-off of ≥5 resulted in a sensitivity of 80 % for NCCN DT (specificity = 49.5 %; AUC = 0.687; CI 95% = 0.596-0.777). CONCLUSION PROMs are useful for identifying SPC need in cancer patients. Their implementation might facilitate timely integration of SPC. Future research should focus on an integrated assessment approach with PROMs that combines the requirements of the different specialties to save patient and staff resources.
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Affiliation(s)
- Evelyn Müller
- Department of Palliative Medicine (E.M., M.J.M., G.B.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Josef Müller
- Department of Palliative Medicine (E.M., M.J.M., G.B.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Christopher Boehlke
- Department of Palliative Care (C.B.), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Henning Schäfer
- Department of Radiation Oncology (H.S.), Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ) Heidelberg, Freiburg, Germany
| | - Michael Quante
- Clinic for Internal Medicine II (M.Q.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerhild Becker
- Department of Palliative Medicine (E.M., M.J.M., G.B.), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Müller E, Müller MJ, Seibel K, Boehlke C, Schäfer H, Klein C, Heckel M, Simon ST, Becker G. Interrater agreement of multi-professional case review as reference standard for specialist palliative care need: a mixed-methods study. BMC Palliat Care 2023; 22:181. [PMID: 37974104 PMCID: PMC10652431 DOI: 10.1186/s12904-023-01281-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/11/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND A wide variety of screening tools for the need for specialist palliative care (SPC) have been proposed for the use in oncology. However, as there is no established reference standard for SPC need to compare their results with, their sensitivity and specificity have not yet been determined. The aim of the study was to explore whether SPC need assessment by means of multi-professional case review has sufficient interrater agreement to be employed as a reference standard. METHODS Comprehensive case descriptions were prepared for 20 inpatients with advanced oncologic disease at the University Hospital Freiburg (Germany). All cases were presented to the palliative care teams of three different hospitals in independent, multi-professional case review sessions. The teams assessed whether patients had support needs in nine categories and subsequently concluded SPC need (yes / no). Interrater agreement regarding SPC need was determined by calculating Fleiss' Kappa. RESULTS In 17 out of 20 cases the three teams agreed regarding their appraisal of SPC need (substantial interrater agreement: Fleiss' Kappa κ = 0.80 (95% CI: 0.55-1.0; p < 0.001)). The number of support needs was significantly lower for patients who all teams agreed had no SPC need than for those with agreed SPC need. CONCLUSIONS The proposed expert case review process shows sufficient reliability to be used as a reference standard. Key elements of the case review process (e.g. clear definition of SPC need, standardized review of the patients' support needs) and possible modifications to simplify the process are discussed. TRIAL REGISTRATION German Clinical Trials Register, DRKS00021686, registered 17.12.2020.
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Affiliation(s)
- Evelyn Müller
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Michael Josef Müller
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
| | - Katharina Seibel
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
| | - Christopher Boehlke
- Department of Palliative Care, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland
| | - Henning Schäfer
- Department of Radiation Oncology, Medical Center, Faculty of Medicine, University of Freiburg, German Cancer Consortium (DKTK) Partner Site Freiburg, German Cancer Research Center (DKFZ), Heidelberg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
| | - Carsten Klein
- Department of Palliative Medicine, University Hospital Erlangen-EMN, Comprehensive Cancer Center CCC Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine, University Hospital Erlangen-EMN, Comprehensive Cancer Center CCC Erlangen, Friedrich-Alexander-University Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Steffen T Simon
- Department of Palliative Medicine and Center for Integrated Oncology Aachen Bonn Cologne Dusseldorf (CIO ABCD), University Hospital of Cologne, Faculty of Medicine and University Hospital, Kerpener Str. 62, 50937, Cologne, Germany
| | - Gerhild Becker
- Department of Palliative Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Robert-Koch-Straße 3, 79106, Freiburg, Germany
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Sedhom R, Shulman LN, Parikh RB. Precision Palliative Care as a Pragmatic Solution for a Care Delivery Problem. J Clin Oncol 2023; 41:2888-2892. [PMID: 37084327 PMCID: PMC10414742 DOI: 10.1200/jco.22.02532] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/01/2023] [Accepted: 03/23/2023] [Indexed: 04/23/2023] Open
Affiliation(s)
- Ramy Sedhom
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | - Lawrence N. Shulman
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | - Ravi B. Parikh
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
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Pigni A, Alfieri S, Caraceni AT, Zecca E, Fusetti V, Tallarita A, Brunelli C. Development of the palliative care referral system: proposal of a tool for the referral of cancer patients to specialized palliative care. BMC Palliat Care 2022; 21:209. [PMID: 36443700 PMCID: PMC9816370 DOI: 10.1186/s12904-022-01094-0] [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: 04/14/2022] [Accepted: 11/02/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Early palliative care (PC) has shown beneficial effects for advanced cancer patients. However, it is still debated what criteria to use to identify patients for PC referral. AIM To document the initial steps of the development of the Palliative Care Referral System (PCRS), a tool to be used by oncologists in clinical practice. METHODS A multiprofessional working group developed the PCRS based on the results of a scoping literature review on PC referral criteria. PCRS criteria were evaluated by experts via a nominal group technique (NGT). Descriptive statistics were used to summarize expert scores on relevance, appropriateness and perceived feasibility of the criteria proposed. Quotations of participants during the discussion were also reported. RESULTS Sixteen studies, including PC referral criteria/tools, emerged from the scoping review. Severe symptoms, poor performance status, comorbidities and prognosis were the most commonly used criteria. The PCRS included nine major criteria and nine assessment methods; a scoring procedure was also proposed. Answers to the questionnaire during the NGT showed that five criteria reached full agreement on all items, while four did not, and were then discussed within the group. Participants agreed on the relevance of all criteria and on the appropriateness of methods proposed to assess most of them, while issues were raised about potential feasibility of the overall assessment of the PCRS in clinical practice. CONCLUSION The PCRS has been developed as an help for oncologists to timely identify patients for specialized PC referral. Since feasibility emerged as the main concern, implementation strategies have to be tested in subsequent studies.
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Affiliation(s)
- Alessandra Pigni
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Sara Alfieri
- grid.417893.00000 0001 0807 2568Clinical Psychology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Augusto Tommaso Caraceni
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy ,grid.4708.b0000 0004 1757 2822Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Ernesto Zecca
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Viviana Fusetti
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy ,grid.6530.00000 0001 2300 0941Università degli Studi di Roma “Tor Vergata”, Rome, Italy
| | - Antonino Tallarita
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Cinzia Brunelli
- grid.417893.00000 0001 0807 2568Palliative care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Brunelli C, Zecca E, Pigni A, Bracchi P, Caputo M, Lo Dico S, Fusetti V, Tallarita A, Bergamini C, Brambilla M, Raimondi A, Niger M, Provenzano S, Sepe P, Alfieri S, Tinè G, De Braud F, Caraceni AT. Outpatient palliative care referral system (PCRS) for patients with advanced cancer: an impact evaluation protocol. BMJ Open 2022; 12:e059410. [PMID: 36307164 PMCID: PMC9621186 DOI: 10.1136/bmjopen-2021-059410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Early palliative care (PC) in the clinical pathway of advanced cancer patients improves symptom control, quality of life and has a positive impact on overall quality of care. At present, standardised criteria for appropriate referral for early PC in oncology care are lacking. The aim of this project is to develop a set of standardised referral criteria and procedures to implement appropriate early PC for advanced cancer patients (the palliative care referral system, PCRS) and test its impact on user perception of quality of care received, on patient quality of life and on the use of healthcare resources. SETTING Selected oncology clinics and PC outpatient clinic. METHODS AND ANALYSIS A scoping literature review and an expert consultation through a nominal group technique will be used to revise existing referral tools and to develop a new one, the PCRS. 25 patients will be enrolled in a pilot study to assess feasibility of the implementation of PCRS; 10 interviews with patients and healthcare professionals will be carried out to evaluate applicability.A pretest-post-test quasiexperimental study involving 150 patients before implementation of the PCRS and 150 patients after implementation will be carried out.Patient satisfaction with care received, quality of life and use of resources, and caregiver satisfaction with care will also be assessed to explore the impact of the intervention. ETHICS AND DISSEMINATION Ethical approval for the study has been granted by the Institutional Review board of the Fondazione IRCCS Istituto Nazionale Tumori; approval reference INT201/19.Results will be disseminated through open access publications and through scientific communication presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04936568.
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Affiliation(s)
- Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Ernesto Zecca
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Alessandra Pigni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Paola Bracchi
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Mariangela Caputo
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Silvia Lo Dico
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Viviana Fusetti
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Roma Tor Vergata, Roma, Lazio, Italy
| | - Antonino Tallarita
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Cristiana Bergamini
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Marta Brambilla
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Alessandra Raimondi
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Monica Niger
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Salvatore Provenzano
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Pierangela Sepe
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Sara Alfieri
- Clinical Psychology Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Gabriele Tinè
- Unit of Clinical Epidemiology and Trial Organisation, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Filippo De Braud
- Medical Oncology Department, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Milano, Milano, Italy
| | - Augusto Tommaso Caraceni
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
- Università degli Studi di Milano, Milano, Italy
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6
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Testing a Pediatric Palliative Care Education Workplace Intervention. J Hosp Palliat Nurs 2022; 24:E166-E171. [PMID: 35470315 DOI: 10.1097/njh.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric palliative care is aimed at pain and symptom management, reducing hospitalization, promoting psychosocial care, and improving quality of life for children with serious illness. As a professional caregiver, nurses play an essential role in the provision of appropriate pediatric palliative care in clinical care settings. The purpose of this quality improvement study was to improve pediatric nurses' awareness and perceptions of palliative care. A 1-group pretest-posttest design was used in the study. A 20-minute education video was used as an intervention to enhance nurses' awareness and perception about pediatric palliative care. Twenty-one pediatric medical-surgical nurses participated in the intervention. Posttest results indicated raised awareness about palliative care, more nurses were able to define palliative care correctly, and nurses were more likely to encourage a palliative care consult. Future studies are needed using larger sample sizes with robust measures to further evaluate the effectiveness of the intervention on enhancing pediatric palliative care awareness among nurses.
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Timely Palliative Care: Personalizing the Process of Referral. Cancers (Basel) 2022; 14:cancers14041047. [PMID: 35205793 PMCID: PMC8870673 DOI: 10.3390/cancers14041047] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/13/2022] [Accepted: 02/15/2022] [Indexed: 02/01/2023] Open
Abstract
Timely palliative care is a systematic process to identify patients with high supportive care needs and to refer these individuals to specialist palliative care in a timely manner based on standardized referral criteria. It requires four components: (1) routine screening of supportive care needs at oncology clinics, (2) establishment of institution-specific consensual criteria for referral, (3) a system in place to trigger a referral when patients meet criteria, and (4) availability of outpatient palliative care resources to deliver personalized, timely patient-centered care aimed at improving patient and caregiver outcomes. In this review, we discuss the conceptual underpinnings, rationale, barriers and facilitators for timely palliative care referral. Timely palliative care provides a more rational use of the scarce palliative care resource and maximizes the impact on patients who are offered the intervention. Several sets of referral criteria have been proposed to date for outpatient palliative care referral. Studies examining the use of these referral criteria consistently found that timely palliative care can lead to a greater number of referrals and earlier palliative care access than routine referral. Implementation of timely palliative care at each institution requires oncology leadership support, adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria.
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Telles AC, Bento PADSS, Chagas MC, Queiroz ABAD, Bittencourt NCCDM, Silva MMD. Transition to exclusive palliative care for women with breast cancer. Rev Bras Enferm 2021; 74:e20201325. [PMID: 34320155 DOI: 10.1590/0034-7167-2020-1325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/02/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to analyze the perspectives that affect the transition to exclusive palliative care for women with breast cancer. METHODS qualitative, descriptive study, carried out in a public health institution in Rio de Janeiro, Brazil, between December 2018 and May 2019. 28 health professionals were interviewed. Content analysis was used in the thematic modality. RESULTS the operational difficulties were linked to the fragmented physical structure, the late and unplanned nature of the referral, the ineffective communication, and the deficit of human resources. In general, women and family members resist referral because they do not know palliative care. There is no consensus among oncologists on the most appropriate time to stop systemic therapy for disease control. FINAL CONSIDERATIONS the perceived difficulties configure an abrupt referral, accompanied by false hopes and, often, limited to end-of-life care.
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Affiliation(s)
| | - Paulo Alexandre de Souza São Bento
- Fundação Oswaldo Cruz, Instituto Nacional de Saúde da Mulher, da Criança e do Adolescente Fernandes Figueira. Rio de Janeiro, Rio de Janeiro, Brazil
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9
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Crooms RC, Lin HM, Neifert S, Deiner SG, Brallier JW, Goldstein NE, Gal JS, Gelfman LP. Palliative Care Consultation for Hospitalized Patients with Primary and Secondary Brain Tumors at a Single Academic Center. J Palliat Med 2021; 24:1550-1554. [PMID: 34166114 DOI: 10.1089/jpm.2021.0088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Studies addressing palliative care delivery in neuro-oncology are limited. Objectives: To compare inpatients with brain tumors who received palliative care (through referral or trigger) with those receiving usual care. Design: Retrospective cohort study. Setting/Subjects: Inpatients with primary or secondary brain tumors who did or did not receive palliative care at a U.S. medical center. Measurements: Sociodemographic, clinical, and utilization characteristics were compared. Results: Of 1669 brain tumor patients, 386 (23.1%) received palliative care [nontrigger: 246 (14.7%); trigger: 140 (8.4%)] and 1283 (76.9%) received usual care. Nontrigger patients were oldest (mean age 65.0 years; trigger: 61.1 years; usual care: 55.5 years; p < 0.001); sickest at baseline (mean Elixhauser comorbidity index 3.76; trigger: 3.49; usual care: 1.84; p < 0.001); and had highest in-hospital death [34 (13.8%), trigger: 10 (7.1%), usual care: 7 (0.5%); p < 0.001] and hospice discharge [54 (22.0%), trigger: 18 (12.9%), usual care: 14 (1.1%); p < 0.001]. Conclusions: Trigger criteria may promote earlier palliative care referral, yet criteria tailored for neuro-oncology are undeveloped.
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Affiliation(s)
- Rita C Crooms
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hung-Mo Lin
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sean Neifert
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stacie G Deiner
- Dartmouth Hitchcock and Geisel School of Medicine, Lebanon, New Hampshire, USA
| | - Jess W Brallier
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Nathan E Goldstein
- 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
| | - Jonathan S Gal
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, 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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10
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Hui D, Bohlke K, Bao T, Campbell TC, Coyne PJ, Currow DC, Gupta A, Leiser AL, Mori M, Nava S, Reinke LF, Roeland EJ, Seigel C, Walsh D, Campbell ML. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol 2021; 39:1389-1411. [DOI: 10.1200/jco.20.03465] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer. METHODS ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020. RESULTS The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea. RECOMMENDATIONS A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .
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Affiliation(s)
- David Hui
- MD Anderson Cancer Center, Houston, TX
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Ting Bao
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Arjun Gupta
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Aliza L. Leiser
- Rutgers RWJ Cancer Institute of New Jersey, New Brunswick, NJ
| | - Masanori Mori
- Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Stefano Nava
- IRCCS Azienda Ospedaliera University of Bologna, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy
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11
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Mo L, Geng Y, Chang YK, Philip J, Collins A, Hui D. Referral criteria to specialist palliative care for patients with dementia: A systematic review. J Am Geriatr Soc 2021; 69:1659-1669. [PMID: 33655535 DOI: 10.1111/jgs.17070] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 01/19/2021] [Accepted: 01/26/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Patients with dementia often have significant symptom burden and a progressive course of functional deterioration. Specialist palliative care referral may be helpful, but it is unclear who and when patients should be referred. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with dementia. METHODS We searched Ovid MEDLINE, Ovid Embase, Ovid PsycInfo, Cochrane Library, PubMed, and CINAHL databases for articles from inception to December 3, 2019, related to specialist palliative care referral for dementia. Two investigators independently reviewed the citations for inclusion, extracted the referral criteria, and categorized them thematically. RESULTS Of the 1788 citations, 59 articles were included in the final sample. We identified 13 categories of referral criteria, including 6 disease-based and 7 needs-based criteria. The most commonly discussed criterion was "dementia stage" (n = 43, 73%), followed by "new diagnosis of dementia" (n = 17, 29%), "medical complications of dementia" (n = 12, 20%), "prognosis" (n = 11, 19%), and "physical symptoms" (n = 11, 19%). Under dementia stage, 37/44 (84%) articles recommended a palliative care referral for advanced dementia. Pneumonia (n = 6, 10%), fall/fracture (n = 4, 7%), and decubitus ulcers (n = 4, 7%) were most commonly discussed complications to trigger a referral. Under prognosis, the time frame for referral varied from <2 years of life expectancy to <6 months. 3 (5%) of articles recommended "surprise question" as a potential trigger. CONCLUSIONS This systematic review highlighted the lack of consensus regarding referral criteria for palliative care in patients with dementia and the need to identify timely triggers to standardize referral.
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Affiliation(s)
- Li Mo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,The Center of Gerontology and Geriatrics, National Clinical Research Center of Geriatrics, Sichuan University West China Hospital, Chengdu, China
| | - Yimin Geng
- Research Medical Library, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Yuchieh Kathryn Chang
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Philip
- Department of Medicine, University of Melbourne, Fitzroy, Australia.,Palliative Care Service, St Vincent's Hospital, Fitzroy, Australia.,Palliative Care Service, Royal Melbourne Hospital, Parkville, Australia
| | - Anna Collins
- Department of Medicine, University of Melbourne, Fitzroy, Australia
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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