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Meehan CP, White E, CVitan A, Jiang L, Wu WC, Wice M, Stafford J, Rudolph JL. Factors Associated With Early Palliative Care Among Patients With Heart Failure. J Palliat Med 2024; 27:1001-1008. [PMID: 38608234 DOI: 10.1089/jpm.2023.0539] [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: 04/14/2024] Open
Abstract
Background: Heart failure (HF) is a progressive, life-limiting illness for which palliative care (PC) is considered standard of care. Among patients that do receive PC, consultation tends to occur late in the illness course. Objective: Our primary aim was to examine patient factors associated with receiving PC in HF. Secondarily, we sought to determine factors associated with early PC encounters. Design: This was a retrospective cohort study of U.S. Veterans with prior hospitalization who died between January 1, 2011 and December 31, 2020. Setting/Subjects: Subjects were Veterans with HF who died with a prior admission to a Veterans Affairs hospital in the United States. Measurements: We calculated the time from PC encounter to death. We characterized HF patients who died without PC, with late PC (≤90 days before death), and with early PC (>90 days before death). Results: We identified 232,079 Veterans with a mean age of (76.5 ± 10.7) years. Within the cohort, 56.5% (n = 131,122) of Veterans died with no PC, 22.5% (n = 52,114) had PC <90 days before death, and 21.0% (n = 48,843) had PC >90 days before death. Veterans who died without PC tended to be younger with fewer comorbidities. Conclusions: While more than 20% of HF patients in our cohort had PC well in advance of death, more than half died without PC. PC involvement seemed to be driven by comorbidities rather than HF. Effective collaboration with Cardiology is needed to identify patients who would benefit from earlier PC involvement.
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Affiliation(s)
- Caroline P Meehan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Emily White
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Alexander CVitan
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
| | - Lan Jiang
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Wen-Chih Wu
- Department of Medicine, Rhode Island Hospital and Lifespan Health System, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mitchell Wice
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Geriatrics and Extended Care, Providence VA Healthcare System, Providence, Rhode Island, USA
| | - Jensy Stafford
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - James L Rudolph
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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2
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Han HJ, Pilgrim CR, Buss MK. Integrating palliative care into the evolving landscape of oncology. Curr Probl Cancer 2023; 47:101013. [PMID: 37714795 DOI: 10.1016/j.currproblcancer.2023.101013] [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: 06/16/2023] [Accepted: 08/10/2023] [Indexed: 09/17/2023]
Abstract
Patients with cancer have many palliative care needs. Robust evidence supports the early integration of palliative care into the care of patients with advanced cancer. International organizations, such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), have recommended early, longitudinal integration of palliative care into oncology care throughout the cancer trajectory. In this review, we pose a series of clinical questions related to the current state of early palliative care integration into oncology. We review the evidence to address each of these questions and highlight areas for further investigation. As cancer care continues to evolve, incorporating new treatment modalities and improving patient outcomes, we reflect on how to apply the existing evidence supporting early palliative care-oncology integration into this ever-changing therapeutic landscape and how specialty palliative care might adapt to meet the evolving needs of patients, caregivers, and the multidisciplinary oncology team.
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Affiliation(s)
- Harry J Han
- Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA.
| | - Carol R Pilgrim
- Division of Palliative Care, Tufts Medical Center, Boston, MA
| | - Mary K Buss
- Division of Palliative Care, Tufts Medical Center, Boston, MA
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3
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Rizvi F, Wilding HE, Rankin NM, Le Gautier R, Gurren L, Sundararajan V, Bellingham K, Chua J, Crawford GB, Nowak AK, Le B, Mitchell G, McLachlan SA, Sousa TV, Hudson R, IJzerman M, Collins A, Philip J. An evidence-base for the implementation of hospital-based palliative care programs in routine cancer practice: A systematic review. Palliat Med 2023; 37:1326-1344. [PMID: 37421156 PMCID: PMC10548767 DOI: 10.1177/02692163231186177] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/09/2023]
Abstract
BACKGROUND Despite global support, there remain gaps in the integration of early palliative care into cancer care. The methods of implementation whereby evidence of benefits of palliative care is translated into practice deserve attention. AIM To identify implementation frameworks utilised in integrated palliative care in hospital-based oncology services and to describe the associated enablers and barriers to service integration. DESIGN Systematic review with a narrative synthesis including qualitative, mixed methods, pre-post and quasi experimental designs following the guidance by the Centre for Reviews and Dissemination (PROSPERO registration CRD42021252092). DATA SOURCES Six databases searched in 2021: EMBASE, EMCARE, APA PsycINFO, CINAHL, Cochrane Library and Ovid MEDLINE searched in 2023. Included were qualitative or quantitative studies, in English language, involving adults >18 years, and implementing hospital-based palliative care into cancer care. Critical appraisal tools were used to assess the quality and rigour. RESULTS Seven of the 16 studies explicitly cited the use of frameworks including those based on RE-AIM, Medical Research Council evaluation of complex interventions and WHO constructs of health service evaluation. Enablers included an existing supportive culture, clear introduction to the programme across services, adequate funding, human resources and identification of advocates. Barriers included a lack of communication with the patients, caregivers, physicians and palliative care team about programme goals, stigma around the term 'palliative', a lack of robust training, or awareness of guidelines and undefined staff roles. CONCLUSIONS Implementation science frameworks provide a method to underpin programme development and evaluation as palliative care is integrated within the oncology setting.
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Affiliation(s)
- Farwa Rizvi
- Palliative Medicine, University of Melbourne, Parkville, Victoria, Australia
| | | | - Nicole M Rankin
- Evaluation and Implementation Science Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia
| | | | | | - Vijaya Sundararajan
- La Trobe University, Melbourne, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital, Melbourne Medical School, Fitzroy, Victoria, Australia
| | - Kylee Bellingham
- Palliative Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Joyce Chua
- Research Nurse Palliative Medicine, St Vincent’s Hospital Melbourne, Fitzroy, Victoria, Australia
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Gregory B Crawford
- Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
- Northern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Anna K Nowak
- Medical School, University of Western Australia, Perth, Western Australia, Australia
| | - Brian Le
- Deparment of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Deparment of Palliative Care, Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- University of Melbourne, Parkville, Victoria, Australia
| | - Geoff Mitchell
- General Practice Clinical Unit, University of Queensland, Brisbane, Queensland, Australia
| | - Sue-Anne McLachlan
- Oncology and Cancer Services, St Vincent’s Hospital, University of Melbourne, Parkville, Victoria, Australia
| | | | - Robyn Hudson
- Safer Care Victoria, Melbourne, Victoria, Australia
| | - Maarten IJzerman
- Cancer Health Services Research, University of Melbourne, Parkville, Victoria, Australia
| | - Anna Collins
- Department of Medicine, St Vincent’s Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Jennifer Philip
- Palliative Medicine, University of Melbourne, Parkville, Victoria, Australia
- Deparment of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Deparment of Palliative Care, Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Palliative Medicine, Department of Medicine, St Vincent’s Hospital Melbourne, Victoria, Australia
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4
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Chen Y, Qiao C, Zhang X, Li W, Yang H. The Effect of Tele-palliative Care on Patient and Caregiver Outcomes: A Systematic Review. Am J Hosp Palliat Care 2023; 40:907-925. [PMID: 36113129 DOI: 10.1177/10499091221123566] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023] Open
Abstract
Objectives: To describe the use of tele-palliative care in patients with advanced disease and assess its effectiveness on quality of life (QOL), symptom burden and other outcomes for patients and their caregivers. Methods: We searched for randomised controlled trials to assess the outcomes of tele-palliative care on patients with advanced disease and their caregivers. Eight databases were searched for studies published in Chinese or English from inception to November 27, 2021. Data from the included trials were extracted independently by 2 reviewers and evaluated independently for methodological quality using the Cochrane Collaboration's tool. A narrative synthesis of the results of all trials was performed. Results: Thirty trials were included ultimately with more than one half of the studies were moderate to high quality, including, which involved 19 665 patients and 1153 caregivers. Results from 10/15 included trials (reporting patient QOL), 5/14 trials (reporting patient symptoms), 1/3 trials (reporting survival), 8/13 trials (reporting patient mood), 3/6 trials (reporting ACP related indicators), 3/7 trials (reporting resource utilization) showed statistically significant between tele-palliative care and control care groups. Of 30 trials, 8 measured caregiver outcomes, 1/4 trials (reporting caregiver QOL) showed statistically significant, and results from 3/3 trials (reporting caregiver mood), 3/4 trials (reporting caregiver burden) showed benefit in at least 1 domain at 1 or more time points. Conclusions: This systematic review suggests that although tele-palliative care can improve patient physical, patient and caregiver psychological health outcomes to some extent, there is still a lack of sufficient evidence to substantiate its application effects. Moreever, regional and cultural characteristics should also be taken into account when tele-palliative care interventions are carried out.
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Affiliation(s)
- Yiping Chen
- School of nursing, Shanxi Medical University, Shanxi Province, China
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Caihong Qiao
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Xianhui Zhang
- School of nursing, Shanxi Medical University, Shanxi Province, China
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
| | - Wei Li
- International Medical Department, Peking Union Medical College Hospital, Beijing, China
| | - Hui Yang
- School of nursing, Shanxi Medical University, Shanxi Province, China
- Department of Neurology, First Hospital of Shanxi Medical University, Shanxi Province, China
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5
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Tanzi S, Martucci G. Doing palliative care research on hematologic cancer patients: A realist synthesis of literature and experts’ opinion on what works, for whom and in what circumstances. Front Oncol 2023; 13:991791. [PMID: 37051541 PMCID: PMC10083487 DOI: 10.3389/fonc.2023.991791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 03/13/2023] [Indexed: 03/29/2023] Open
Abstract
BackgroundResearch in PC (Palliative Care) is frequently challenging for patient’s frailty, study design, professional misconceptions, and so on. Little is known about specificity in PC research on Hematologic cancer patients, who have distinct characteristics that might influence the enrollment process.AimsWhat works, how and for whom, in increasing enrollment in studies in PC on patients with hematologic malignancies?MethodsRealist review: a qualitative review whose goal is to identify and explain the interaction between Contexts, Mechanisms, and Outcomes (CMOs). The theory was informed by a narrative, theory-based literature research, including an initialsystematic research, and the addition of papers suggested by experts of the field. We also used 7 interviews with experts in PC about patients with hematologic malignancies research and our own experience from a PC pilot study on patients with hematologic malignancies to refine the initial theory.ResultsIn our initial theory we hypothesize that: - Access to palliative care could be beneficial to hematologic patients, even in early stages - Hematologists tend to under-use palliative care services in general, due to unpredictable disease trajectories and cultural barriers. - These factors may negatively impact the patients’ enrollment in PC researchWe included secondary literature as narrative reviews, if they presented interesting propositions useful for our theoretical construction. 23 papers met our inclusion criteria.We also searched for relevant CMOs impacting referral in palliative care, and we selected a list of CMOs that could be relevant also in hematology. We accordingly theorized a group of interventions that could increase the enrollment in PC research and presented them using “social exchange theory” (SET) as a theoretical framework.Prominent researchers in PC in hematologic malignancies were interviewed on their opinion on our results, and additional CMOs.ConclusionsBefore conducting research in PC on patients with hematologic malignancies, it’s probably advisable to assess: - The perception of the different actors (physicians, nurses, other professionals involved), in particular the hematologists, in terms of pros and cons of referral to PC and enrollment in PC trials - The existing relationship between PC and the Hematology departmentAccordingly, it’s possible to tailor different interventions on the various actors and choose a model of trial to increase the perception of benefits from PC and, consequently, enrollment.
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Affiliation(s)
- Silvia Tanzi
- Palliative Care Unit, Azienda USL-IRCCS Reggio Emilia, Reggio Emilia, Italy
| | - Gianfranco Martucci
- Palliative Care Local Program, Local Health Unit of Modena, Modena, Italy
- *Correspondence: Gianfranco Martucci,
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6
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Borelli E, Bigi S, Potenza L, Eliardo S, Artioli F, Mucciarini C, Cottafavi L, Cagossi K, Razzini G, Cruciani M, Pietramaggiori A, Fantuzzi V, Lombardo L, Ferrari U, Ganfi V, Lui F, Odejide O, Cacciari C, Porro CA, Zimmermann C, Efficace F, Bruera E, Luppi M, Bandieri E. Changes in Cancer Patients' and Caregivers' Disease Perceptions While Receiving Early Palliative Care: A Qualitative and Quantitative Analysis. Oncologist 2021; 26:e2274-e2287. [PMID: 34510624 PMCID: PMC8649024 DOI: 10.1002/onco.13974] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 08/18/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Little is known about the underlying mechanisms through which early palliative care (EPC) improves multiple outcomes in patients with cancer and their caregivers. The aim of this study was to qualitatively and quantitatively analyze patients' and caregivers' thoughts and emotional and cognitive perceptions about the disease prior to and during the EPC intervention, and in the end of life, following the exposure to EPC. MATERIALS AND METHODS Seventy-seven patients with advanced cancer and 48 caregivers from two cancer centers participated in semistructured interviews. Their reports were qualitatively and quantitatively analyzed by the means of the grounded theory and a text-analysis program. RESULTS Participants reported their past as overwhelmed by unmanaged symptoms, with detrimental physical and psychosocial consequences. The EPC intervention allowed a prompt resolution of symptoms and of their consequences and empowerment, an appreciation of its multidimensional approach, its focus on the person and its environment, and the need for EPC for oncologic populations. Patients reported that conversations with the EPC team increased their acceptance of end of life and their expectation of a painless future. Quantitative analysis revealed higher use of Negative Affects (p < .001) and Biological Processes words (p < .001) when discussing the past; Agency words when discussing the present (p < .001); Positive Affects (p < .001), Optimism (p = .002), and Insight Thinking words (p < .001) when discussing the present and the future; and Anxiety (p = .002) and Sadness words (p = .003) when discussing the future. CONCLUSION Overall, participants perceived EPC to be beneficial. Our findings suggest that emotional and cognitive processes centered on communication underlie the benefits experienced by participants on EPC. IMPLICATIONS FOR PRACTICE By qualitative and quantitative analyses of the emotional and cognitive perceptions of cancer patients and their caregivers about their experiences before and during EPC interventions, this study may help physicians/nurses to focus on the disease perception by patients/caregivers and the benefits of EPC, as a standard practice. The analysis of words used by patients/caregivers provides a proxy for their psychological condition and support in tailoring an EPC intervention, based on individual needs. This study highlights that the relationship of the triad EPC team/patients/caregivers may rise as a therapeutic tool, allowing increasing awareness and progressive acceptance of the idea of death.
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Affiliation(s)
- Eleonora Borelli
- Department of Medical and Surgical Sciences, University of Modena and Reggio EmiliaModenaItaly
| | - Sarah Bigi
- Department of Linguistic Sciences and Foreign Literatures, Catholic University of the Sacred HeartMilanItaly
| | - Leonardo Potenza
- Department of Medical and Surgical Sciences, University of Modena and Reggio EmiliaModenaItaly
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di ModenaModenaItaly
| | - Sonia Eliardo
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | - Fabrizio Artioli
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | | | - Luca Cottafavi
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | - Katia Cagossi
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | - Giorgia Razzini
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | | | | | - Valeria Fantuzzi
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | - Laura Lombardo
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | - Umberto Ferrari
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
| | - Vittorio Ganfi
- Department of Medical and Surgical Sciences, University of Modena and Reggio EmiliaModenaItaly
| | - Fausta Lui
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio EmiliaModenaItaly
- Center for Neuroscience and Neurotechnology, University of Modena and Reggio EmiliaModenaItaly
| | - Oreofe Odejide
- Department of Medical Oncology, Dana‐Farber Cancer InstituteBostonMassachusettsUSA
| | - Cristina Cacciari
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio EmiliaModenaItaly
- Center for Neuroscience and Neurotechnology, University of Modena and Reggio EmiliaModenaItaly
| | - Carlo Adolfo Porro
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio EmiliaModenaItaly
- Center for Neuroscience and Neurotechnology, University of Modena and Reggio EmiliaModenaItaly
| | - Camilla Zimmermann
- Princess Margaret Cancer Centre, University Health NetworkTorontoOntarioCanada
- University of TorontoTorontoOntarioCanada
| | - Fabio Efficace
- Health Outcomes Research Unit, Italian Group for Adult Hematologic Diseases (GIMEMA)RomeItaly
| | - Eduardo Bruera
- Palliative Care & Rehabilitation Medicine, UT MD Anderson Cancer CenterHoustonTexasUSA
| | - Mario Luppi
- Department of Medical and Surgical Sciences, University of Modena and Reggio EmiliaModenaItaly
- Hematology Unit and Chair, Azienda Ospedaliera Universitaria di ModenaModenaItaly
| | - Elena Bandieri
- Oncology and Palliative Care Units, Civil Hospital Carpi, USLCarpiItaly
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Wu H, Lin P, Yang S, Zhang W, Tao W. Cost-utility analysis of palliative care in patients with advanced cancer: a retrospective study. BMC Palliat Care 2021; 20:126. [PMID: 34380461 PMCID: PMC8359093 DOI: 10.1186/s12904-021-00816-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/15/2021] [Indexed: 02/08/2023] Open
Abstract
Background Aging population and other factors have led to a rapid rise in cancer incidence in China. However, under the influence of traditional perception of diseases, deaths and economic factors, many patients who are unresponsive to radical treatment are still adherent to excessive and unnecessary treatment, which may lead to poor quality of life (QoL) and increase unnecessary medical burden. Aim Compare the difference of the quality of life and cost-utility value between patients who received palliative care (PC) and patients who were adherent to conventional anticancer treatment (CAT) and provides empirical evidence of clinical and economic value for hospital-based PC. Methods Chinese Quality of Life Questionnaire (CQLQ) Scale was used to collect advanced cancer patients’ QoL on admission and discharge days. Paired and independent samples’ statistical analysis were used to compare inter- and intra- QoL between PC and CAT group. Delphi and Analytic Hierarchy Process were used to weight QoL scores and converted the QoL to quality-adjusted life years (QALYs). Propensity Score Matching (PSM) for 1:1 was used to compare average hospitalization expenses between two groups. The expense per QALYs was used for Cost-Utility analysis between the two treatments. Results A total of 248 hospitalized patients diagnosed with metastatic disease at stage IV were recruited from West China Fourth Hospital between January 2018 and August 2018, including 128 patients receiving PC and 120 patients receiving CAT. Although both treatments had positive effects on improving QoL for patients, the QoL in the PC group were significantly higher than that in the CAT group (55.90 ± 18.80 vs 24.00 ± 8.60, t = 7.51, p < 0.05). The QALY (days) of pre- and post- treatment increased by 55.9 and 24.0 days in PC and CAT group respectively. Compared average hospitalization expense in 613 pairs of advanced cancer inpatients after PSM 1:1, the per capita expense of PC group was higher (13,743.5 ± 11,574.1 vs 11,689.0 ± 8876.8, t = 3.44, p < 0.05), while each unit of QALYs paid by PC group was only 50% of that paid by those receiving CAT. Conclusions PC played a positive role in improving the QoL for patients diagnosed with advanced cancer and alleviating economic burdens of both patient families and the society from the viewpoint of cost-utility. Our findings imply that PC should be recognized as a proactive care model in China that helps patients with some terminal diseases.
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Affiliation(s)
- Hao Wu
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Ping Lin
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Shujuan Yang
- West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Wei Zhang
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Wenjuan Tao
- Institute of Hospital Management, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
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Tewes M, Baumann F, Teufel M, Ostgathe C. Symptoms During Outpatient Cancer Treatment and Options for Their Management. DEUTSCHES ARZTEBLATT INTERNATIONAL 2021; 118:arztebl.m2021.0028. [PMID: 33531117 DOI: 10.3238/arztebl.m2021.0028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Cancer patients account for a large segment of the German healthcare system, with a 5-year prevalence of around 1.7 million persons. Advances in oncological treatment, now frequently performed on an outpatient basis, are granting many of these individuals a longer life span. At the same time, cancer patients often suffer disease-related symptoms and adverse effects from their tumor treatment, which may strongly impair their quality of life despite the improved techniques for management of side effects. METHODS This review is based on a selective literature search of the PubMed and Cochrane Library databases carried out in December 2019 and January 2020. Special attention was paid to guidelines, expert opinions, and recommendations from professional societies. RESULTS Alongside decreased well-being, cancer patients often suffer from fatigue (70-100%), loss of appetite (6-53%), pain (30-80 %), and dyspnea (10-70%). The prevalence and severity of the symptoms varies depending on the tumor entity and the patient's sex. A meta-analysis showed that besides causal treatment, physical activity achieves moderately strong effects in tumor-associated fatigue syndrome (Cohen's d = 0.30 [0.25; 0.36]). The WHO recommends early use of opioids in tumor-associated pain. A meta-analysis of randomized trials described symptom relief by means of opioids also in dyspnea (standardized mean difference: -0.32 [-0.53; -0.10]). Increasingly, guidelines are recommending regular palliative medical symptom screening. CONCLUSION Regular documentation of symptoms in outpatients offers the opportunity for targeted management of symptoms during treatment with the involvement of various disciplines such as palliative medicine, exercise therapy, and psychotherapy.
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9
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Oluyase AO, Higginson IJ, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FEM, Bajwah S. Hospital-based specialist palliative care compared with usual care for adults with advanced illness and their caregivers: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Most deaths still take place in hospital; cost-effective commissioning of end-of-life resources is a priority. This review provides clarity on the effectiveness of hospital-based specialist palliative care.
Objectives
The objectives were to assess the effectiveness and cost-effectiveness of hospital-based specialist palliative care.
Population
Adult patients with advanced illnesses and their unpaid caregivers.
Intervention
Hospital-based specialist palliative care.
Comparators
Inpatient or outpatient hospital care without specialist palliative care input at the point of entry to the study, or community care or hospice care provided outside the hospital setting (usual care).
Primary outcomes
Patient health-related quality of life and symptom burden.
Data sources
Six databases (The Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and CareSearch), clinical trial registers, reference lists and systematic reviews were searched to August 2019.
Review methods
Two independent reviewers screened, data extracted and assessed methodological quality. Meta-analysis was carried out using RevMan (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark), with separate synthesis of qualitative data.
Results
Forty-two randomised controlled trials involving 7779 participants (6678 patients and 1101 unpaid caregivers) were included. Diagnoses of participants were as follows: cancer, 21 studies; non-cancer, 14 studies; and mixed cancer and non-cancer, seven studies. Hospital-based specialist palliative care was offered in the following models: ward based (one study), inpatient consult (10 studies), outpatient (six studies), hospital at home or hospital outreach (five studies) and multiple settings that included hospital (20 studies). Meta-analyses demonstrated significant improvement favouring hospital-based specialist palliative care over usual care in patient health-related quality of life (10 studies, standardised mean difference 0.26, 95% confidence interval 0.15 to 0.37; I
2 = 3%) and patient satisfaction with care (two studies, standardised mean difference 0.36, 95% confidence interval 0.14 to 0.57; I
2 = 0%), a significant reduction in patient symptom burden (six studies, standardised mean difference –0.26, 95% confidence interval –0.41 to –0.12; I
2 = 0%) and patient depression (eight studies, standardised mean difference –0.22, 95% confidence interval –0.34 to –0.10; I
2 = 0%), and a significant increase in the chances of patients dying in their preferred place (measured by number of patients with home death) (seven studies, odds ratio 1.63, 95% confidence interval 1.23 to 2.16; I
2 = 0%). There were non-significant improvements in pain (four studies, standardised mean difference –0.16, 95% confidence interval –0.33 to 0.01; I
2 = 0%) and patient anxiety (five studies, mean difference –0.63, 95% confidence interval –2.22 to 0.96; I
2 = 76%). Hospital-based specialist palliative care showed no evidence of causing serious harm. The evidence on mortality/survival and cost-effectiveness was inconclusive. Qualitative studies (10 studies, 322 participants) suggested that hospital-based specialist palliative care was beneficial as it ensured personalised and holistic care for patients and their families, while also fostering open communication, shared decision-making and respectful and compassionate care.
Limitation
In almost half of the included randomised controlled trials, there was palliative care involvement in the control group.
Conclusions
Hospital-based specialist palliative care may offer benefits for person-centred outcomes including health-related quality of life, symptom burden, patient depression and satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death) with little evidence of harm.
Future work
More studies are needed of populations with non-malignant diseases, different models of hospital-based specialist palliative care, and cost-effectiveness.
Study registration
This study is registered as PROSPERO CRD42017083205.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Massimo Costantini
- Palliative Care Unit, Azienda Unità Sanitaria Locale – Istituto di Ricovero e Cura a Carattere Scientifico (USL-IRCCS), Reggio Emilia, Italy
| | - Fliss EM Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
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10
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Umaretiya PJ, Rubin JP, Snaman JM, Ullrich C, Feraco AM, Dussel V, Wolfe J, Waldman E. Are we undermining the value of palliative care through advanced cancer clinical trial consent language? Cancer 2021; 127:1954-1956. [PMID: 33689176 DOI: 10.1002/cncr.33482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Revised: 01/15/2021] [Accepted: 01/22/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Puja J Umaretiya
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Jennifer P Rubin
- Department of Pediatric Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer M Snaman
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Christina Ullrich
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Angela M Feraco
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts.,Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts
| | - Veronica Dussel
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts.,Centro de Investigación e Implementación en Cuidados Paliativos, Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina
| | - Joanne Wolfe
- Division of Pediatric Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts.,Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Elisha Waldman
- Division of Palliative Care, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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11
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Laabar TD, Saunders C, Auret K, Johnson CE. Palliative care needs among patients with advanced illnesses in Bhutan. BMC Palliat Care 2021; 20:8. [PMID: 33422058 PMCID: PMC7797114 DOI: 10.1186/s12904-020-00697-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 12/15/2020] [Indexed: 02/08/2023] Open
Abstract
Background Palliative care improves the quality of lives of patients and families affected by advanced illnesses through the prevention and relief of suffering. While palliative care is well established in developed countries, it is inadequate or non-existent in most developing countries. Palliative care is an emerging concept in Bhutan, a tiny Himalayan Kingdom. A small community palliative care service is available in the national referral hospital with three dedicated inpatient palliative care beds. This study explored the needs for palliative care among patients diagnosed with advanced illnesses and is a component of a larger project aimed to inform a suitable palliative care model for the country. Methods This is a cross-sectional descriptive study. A survey, using a structured questionnaire including the EORTC QLQ-C30, was carried out among patients with advanced illness in hospitals, primary care units and communities across the country. Purposeful and snowball sampling strategies were used to recruit study participants. Results Seventy (76%), out of 93 eligible patients, agreed to participate in the survey. Participants reported low to moderate scores on physical, role, emotional, cognitive and social functioning, a moderate score for the global health/ quality of life scale and moderately high (worse) scores in symptoms including fatigue, pain, insomnia, loss of appetite and the financial impact from the disease. Conclusions The symptom burden experienced by patients affected by advanced illnesses demonstrates the need for palliative care in Bhutan. These findings will help inform the development of a public health-focused palliative care model, modified to the Bhutanese context, as recommended by the World Health Organization.
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Affiliation(s)
- Tara Devi Laabar
- Medical School, The University of Western Australia, 35 Stirling Highway, 6009, Perth, Western Australia, Australia. .,Department of Nursing, Faculty of Nursing and Public Health, Khesar Gyalpo University of Medical Sciences of Bhutan, Thimphu, Bhutan.
| | - Christobel Saunders
- Medical School, Surgery Division, The University of Western Australia, 35 Stirling Highway, 6009, Perth, Western Australia, Australia
| | - Kirsten Auret
- Rural Clinical School of Western Australia, The University of Western Australia, Science Building M701, 35 Stirling Terrace, 6330, Albany, Western Australia, Australia
| | - Claire E Johnson
- Medical School, The University of Western Australia, 35 Stirling Highway, 6009, Perth, Western Australia, Australia.,Monash Nursing and Midwifery, Monash University, 10 Chancellors Walk, Wellington Road, 3800, Clayton, Victoria, Australia.,Australian Health Services Research Institute (AHSRI), University of Wollongong, Building 234, Innovation Campus, 2522, Sydney, NSW, Australia
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12
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Parajuli J, Hupcey JE. A Systematic Review on Barriers to Palliative Care in Oncology. Am J Hosp Palliat Care 2021; 38:1361-1377. [PMID: 33412898 DOI: 10.1177/1049909120983283] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The number of people with cancer and the need for palliative care among this population is increasing in the United States. Despite this growing need, several barriers exist to the utilization of palliative care in oncology. The purpose of this study was to synthesize the evidence on the barriers to palliative care utilization in an oncology population. A systematic review of literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, CINAHL, and Psych Info databases were used for the literature search. Articles were included if they: 1) focused on cancer, (2) examined and discussed barriers to palliative care, and c) were peer reviewed, published in English, and had an accessible full text. A total of 29 studies (8 quantitative, 18 qualitative, and 3 mixed-methods) were identified and synthesized for this review. The sample size of the included studies ranged from 10 participants to 313 participants. The barriers to palliative care were categorized into barriers related to the patient and family, b) barriers related to providers, and c) barriers related to the healthcare system or policy. The factors identified in this review provide guidance for intervention development to mitigate the existing barriers and facilitate the use palliative care in individuals with cancer.
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Affiliation(s)
| | - Judith E Hupcey
- 311285The Pennsylvania State University, University Park, PA, USA
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13
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ALMouaalamy N, AlMarwani K, AlMehmadi A, AlNakhli AA, AlGhamdi Y, Zarkan A, Althubaiti A. Referral Time of Advance Cancer Patients to Palliative Care Services and Its Predictors in Specialized Cancer Center. Cureus 2020; 12:e12300. [PMID: 33403189 PMCID: PMC7773523 DOI: 10.7759/cureus.12300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/26/2020] [Indexed: 12/21/2022] Open
Abstract
Background and aim Globally, there is a discrepancy in whether terminal cancer patients are early referred to palliative care service (PCS) or not. A late referral can lead to a delay in treating and palliating those patients in need. The aim of this study is to investigate the referral time patterns of advanced cancer patients to PCS in Princess Noorah Oncology Center (PNOC) at King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia. In addition, this study evaluates the factors that influence referral time to the palliative care unit (PCU), along with the overall survival rate. Methods This was a retrospective cross-sectional study (chart review) conducted at the inpatient unit in PNOC and included all patients referred to PCS between January 1st, 2016, and December 31, 2016. In total, 153 patients met the inclusion criteria, and their data were collected and analyzed. Results The median length of stay (LOS) was five days (95% CI: 3.85-6.15). Among the 153 patients, 22 (14.4%) died within 24 hours of enrollment to PCU. Patients who were referred to the PCU with non-metastasis disease had a median LOS of nine days, which is significantly longer than the median LOS in patients with metastatic disease (95% CI: 0.35-0.82, p=0.004), which indicates that they referred relatively earlier to PCU. The hazard ratio for death in patients with non-metastatic cancer stage was 0.54 (95% CI: 0.35-0.82, p=0.004). Conclusion Referral of advanced cancer patients to palliative care services occurs late in their disease course in our institution, like other institutions, with variation in LOS, which shorten their stay at palliative, as well as, affects their quality of life (QOL) and ability to plan or make a decision regarding their care. Education of the public and, most importantly, the medical community is needed.
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Affiliation(s)
- Nabil ALMouaalamy
- Princess Noorah Oncology Center/Palliative Care Service, King Abdulaziz Medical City, National Guard Health Affairs, Jeddah, SAU
- Research, King Abdullah International Medical Research Center, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Khaled AlMarwani
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Abdulmajeed AlMehmadi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Ahmed A AlNakhli
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Yasser AlGhamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Abdullah Zarkan
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
| | - Alaa Althubaiti
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Research, King Abdullah International Medical Research Center, Jeddah, SAU
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14
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Booker R, Dunn S, Earp MA, Sinnarajah A, Biondo PD, Simon JE. Perspectives of hematology oncology clinicians about integrating palliative care in oncology. Curr Oncol 2020; 27:313-320. [PMID: 33380863 PMCID: PMC7755435 DOI: 10.3747/co.27.6305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Patients with hematologic malignancies receive palliative care (pc) less frequently and later than patients with solid tumours. We compared survey responses of hematology oncology clinicians with other oncology clinicians to better understand their challenges with providing primary pc or using secondary pc. Patients' negative perceptions of pc and limited time or competing priorities were challenges for all clinicians. Compared with other oncology clinicians, more hematology oncology clinicians perceived pc referral criteria as too restrictive (40% vs. 22%, p = 0.021) and anticipated that integrating pc supports into their practice would require substantial change (53% vs. 28%, p = 0.014). This study highlights barriers that may need targeted interventions to better integrate pc into the care of patients with hematologic malignancies.
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Affiliation(s)
- R Booker
- Department of Psychosocial Oncology, Tom Baker Cancer Centre, Calgary, AB
| | - S Dunn
- Department of Community Health Sciences, University of Calgary, Calgary, AB
| | - M A Earp
- Department of Oncology, University of Calgary, Calgary, AB
| | - A Sinnarajah
- Department of Community Health Sciences, University of Calgary, Calgary, AB
- Department of Oncology, University of Calgary, Calgary, AB
- Department of Family Medicine, University of Calgary, Calgary, AB
| | - P D Biondo
- Department of Oncology, University of Calgary, Calgary, AB
| | - J E Simon
- Department of Community Health Sciences, University of Calgary, Calgary, AB
- Department of Oncology, University of Calgary, Calgary, AB
- Department of Medicine, University of Calgary, Calgary, AB
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15
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Dhollander N, Smets T, De Vleminck A, Lapeire L, Pardon K, Deliens L. Is early integration of palliative home care in oncology treatment feasible and acceptable for advanced cancer patients and their health care providers? A phase 2 mixed-methods study. BMC Palliat Care 2020; 19:174. [PMID: 33228662 PMCID: PMC7685643 DOI: 10.1186/s12904-020-00673-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 10/19/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND To support the early integration of palliative home care (PHC) in cancer treatment, we developed the EPHECT intervention and pilot tested it with 30 advanced cancer patients in Belgium using a pre post design with no control group. We aim to determine the feasibility, acceptability and perceived effectiveness of the EPHECT intervention. METHODS Interviews with patients (n = 16 of which 11 dyadic with family caregivers), oncologists and GPs (n = 11) and a focus group with the PHC team. We further analyzed the study materials and logbooks of the PHC team (n = 8). Preliminary effectiveness was assessed with questionnaires EORTC QLQ C-30, HADS and FAMCARE and were filled in at baseline and 12, 18 and 24 weeks. RESULTS In the interviews after the intervention period, patients reported feelings of safety and control and an optimized quality of life. The PHC team could focus on more than symptom management because they were introduced earlier in the trajectory of the patient. Telephone-based contact appeared to be insufficient to support interprofessional collaboration. Furthermore, some family caregivers reported that the nurse of the PHC team was focused little on them. CONCLUSION Nurses of PHC teams are able to deliver early palliative care to advanced cancer patients. However, more attention needs to be given to family caregivers as caregiver and client. Furthermore, the home visits by the PHC team have to be further evaluated and adapted. Lastly, professionals have to find a more efficient way to discuss future care.
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Affiliation(s)
- Naomi Dhollander
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Corneel Heymanslaan 10, 6K3, room 009, 9000, Brussels, Belgium.
| | - Tinne Smets
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Corneel Heymanslaan 10, 6K3, room 009, 9000, Brussels, Belgium
| | - Aline De Vleminck
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Corneel Heymanslaan 10, 6K3, room 009, 9000, Brussels, Belgium
| | - Lore Lapeire
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
- Cancer Research Institute Ghent (CRIG), Ghent University Hospital, Ghent, Belgium
| | - Koen Pardon
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Corneel Heymanslaan 10, 6K3, room 009, 9000, Brussels, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Corneel Heymanslaan 10, 6K3, room 009, 9000, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University Hospital, Ghent, Belgium
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16
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Salins N, Ghoshal A, Hughes S, Preston N. How views of oncologists and haematologists impacts palliative care referral: a systematic review. BMC Palliat Care 2020; 19:175. [PMID: 33228651 PMCID: PMC7686696 DOI: 10.1186/s12904-020-00671-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/14/2020] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Worldwide, many patients with cancer, are infrequently referred to palliative care or are referred late. Oncologists and haematologists may act as gatekeepers, and their views may facilitate or hinder referrals to palliative care. This review aimed to identify, explore and synthesise their views on referrals systematically. METHODS Databases of MEDLINE, CINAHL, PsycINFO, EMBASE, Scopus, Web of Science and Cochrane were searched for articles from 01/01/1990 to 31/12/2019. All studies were scored for their methodological rigour using Hawker's tool. Findings were synthesised using Popay's narrative synthesis method and interpreted using a critical realist lens and social exchange theory. RESULTS Out of 9336 initial database citations, 23 studies were included for synthesis. Five themes were developed during synthesis. 1. Presuppositions of oncologists and haematologists about palliative care referral: Role conflict, abandonment, rupture of therapeutic alliance and loss of hope were some of the presuppositions that hindered palliative care referral. Negative emotions and perception of self-efficacy to manage palliative care need also hindered referral. 2. Power relationships and trust issues: Oncologists and haematologists preferred to gatekeep the referral process and wished to control and coordinate the care process. They had diminished trust in the competency of palliative care providers. 3. Making a palliative care referral: A daunting task: The stigma associated with palliative care, navigating illness and treatment associated factors, addressing patient and family attitudes, and overcoming organisational challenges made referral a daunting task. Lack of referral criteria and limited palliative care resources made the referral process challenging. 4. Cost-benefit of palliative care referral: Pain and symptom management and psychosocial support were the perceived benefits, whereas inconsistencies in communication and curtailment of care were some of the costs associated with palliative care referral. 5. Strategies to facilitate palliative care referral: Developing an integrated model of care, renaming and augmenting palliative care resources were some of the strategies that could facilitate a referral. CONCLUSION Presuppositions, power relationships, trust issues and the challenges associated with the task of referrals hindered palliative care referral. Oncologists and haematologists appraised the cost-benefit of making a palliative care referral. They felt that an integrated model of care, changing the name of palliative care and augmenting palliative care resources might facilitate a referral.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Arunangshu Ghoshal
- Department of Palliative Medicine, Tata Memorial Centre, MB-G-75, DR E Borges Road, Parel, Mumbai, 400012, India
| | - Sean Hughes
- Division of Health Research, Faculty of Health and Medicine, Furness College, Lancaster University, C051, C - Floor, Bailrigg, LA1 4YW, UK
| | - Nancy Preston
- Division of Health Research, Faculty of Health and Medicine, Furness College, Lancaster University, C051, C - Floor, Bailrigg, LA1 4YW, UK.
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17
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Bajwah S, Oluyase AO, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FE, Higginson IJ. The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2020; 9:CD012780. [PMID: 32996586 PMCID: PMC8428758 DOI: 10.1002/14651858.cd012780.pub2] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously. OBJECTIVES To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families. SEARCH METHODS We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available. MAIN RESULTS We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I2 = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I2 = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I2 = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I2 = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I2 = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision. AUTHORS' CONCLUSIONS Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.
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Affiliation(s)
- Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Fliss E Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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18
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Palumbo K, Koncicki ML. Pediatric Palliative Care and the PICU: Where We Have Been and Where We Are Going. CURRENT PEDIATRICS REPORTS 2020. [DOI: 10.1007/s40124-020-00230-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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19
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20
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Iyer AS, Dionne-Odom JN, Khateeb DM, O'Hare L, Tucker RO, Brown CJ, Dransfield MT, Bakitas MA. A Qualitative Study of Pulmonary and Palliative Care Clinician Perspectives on Early Palliative Care in Chronic Obstructive Pulmonary Disease. J Palliat Med 2020; 23:513-526. [PMID: 31657654 PMCID: PMC7104897 DOI: 10.1089/jpm.2019.0355] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2019] [Indexed: 12/25/2022] Open
Abstract
Background: Guidelines recommend that pulmonary clinicians involve palliative care in chronic obstructive pulmonary disease (COPD); however, integration before advanced stage, that is, early palliative care, is rare. Objective: To explore and compare pulmonary and palliative care clinician perspectives on barriers, facilitators, and potential referral criteria for early palliative care in COPD. Design: Qualitative descriptive formative evaluation study. Setting/Subjects: Pulmonary and palliative care clinicians at a tertiary academic medical center. Measurements: Transcribed interviews were thematically analyzed by specialty to identify within- and across-specialty perspectives on barriers, facilitators, and referral criteria. Results: Twelve clinicians (n = 6 pulmonary, n = 6 palliative care) participated. Clinicians from both specialties agreed that early palliative care could add value to disease-focused COPD care. Perspectives on many barriers and facilitators were shared between specialties along broad educational, clinical, and operational categories. Pulmonary and palliative care clinicians shared concerns about the misconception that palliative care was synonymous to end-of-life care. Pulmonologists were particularly concerned about the potential risks of opioids and benzodiazepines in COPD. Both specialties stressed the need for clearly defined roles, consensus referral criteria, and novel delivery models. Although no single referral criterion was discussed by all, frequent hospitalizations and emotional symptoms were raised by most across disciplines. Multimorbidity and poor prognosis were discussed only by palliative care clinicians, whereas medication adherence was discussed only by pulmonary clinicians. Conclusions: Pulmonary and palliative care clinicians supported early palliative care in COPD. Continued needs include addressing pulmonologists' misconceptions of palliative care, establishing consensus referral criteria, and implementing novel early palliative care models.
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Affiliation(s)
- Anand S. Iyer
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Center for Outcomes and Effectiveness Research and Education, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - James Nicholas Dionne-Odom
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
| | - Dina M. Khateeb
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lanier O'Hare
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rodney O. Tucker
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cynthia J. Brown
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Mark T. Dransfield
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Lung Health Center, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Marie A. Bakitas
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
- Department of Medicine, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
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Patel P, Lyons L. Examining the Knowledge, Awareness, and Perceptions of Palliative Care in the General Public Over Time: A Scoping Literature Review. Am J Hosp Palliat Care 2019; 37:481-487. [PMID: 31690088 DOI: 10.1177/1049909119885899] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The field of palliative care (PC) is growing as the world population ages and burden of chronic diseases increases. Thus, it is important that the general public is knowledgeable about PC and the benefits PC provides. OBJECTIVE The aim of this study is to describe the public's knowledge, awareness, and perceptions of PC and determine whether these have changed over time. METHODS A scoping literature review was conducted from 1968 to May 2019 using PubMed, EMBASE, and MEDLINE databases. RESULTS Thirteen studies met inclusion criteria that originated from the United States, Canada, Scotland, Italy, New Zealand, Ireland, United Kingdom, Korea, and Sweden between years 2003 and 2019. Participants were adults and mostly younger than 64 years, women, and Caucasian. The majority of studies reported the public having poor knowledge (7/9 articles) and awareness (4/6 articles) of PC over the past 16 years. Top characteristics associated with increased levels of knowledge and/or awareness of PC included women (6/8 articles), age 40+ (6/8 articles), experience with a close friend and/or relative requiring PC (4/8 articles), and working in health-care and/or PC (4/8 articles). The most common perceptions of PC were associated with patients who have terminal illnesses and end-of-life care. Participants commonly received information about PC from the media, having a close friend or relative requiring PC, and working in a health-care setting. CONCLUSIONS The public has poor knowledge and awareness about PC and several misperceptions exist. These findings have remained constant over time despite growth in the field of PC, which highlights the strong need for focused educational interventions.
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Affiliation(s)
- Priya Patel
- Department of Family Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
| | - Laura Lyons
- Department of Family Medicine, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
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The Perceived Facilitators and Challenges of Translating a Lung Cancer Palliative Care Intervention Into Community-Based Settings. J Hosp Palliat Nurs 2019; 20:407-415. [PMID: 30063635 DOI: 10.1097/njh.0000000000000470] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite significant progress in implementing palliative care interventions for patients with cancer, few intervention studies seek health care clinicians' input before implementation of these into the community. The purpose of this study was to explore palliative care and oncology clinicians' perspectives on the perceived facilitators and challenges in meeting the quality-of-life needs of patients with lung cancer and family caregivers in community-based settings. The Reach Effectiveness Adoption Implementation Maintenance model for implementation research was used as a framework. This was a multisite qualitative study using focus group and key informant interviews. Nineteen clinicians addressed useful practices and challenges in the following areas: (a) early palliative care, (b) interdisciplinary care planning, (c) symptom management, (d) addressing psychological and social needs, and (e) providing culturally respectful care, including spiritual care. In preparation for the intervention, specific education needs and organizational challenges were revealed. Challenges included timing and staffing constraints, the need for clinician education on palliative care services to increase organizational buy-in, and education in providing spiritual support for patients and family caregivers. This research allowed investigators to understand perceptions of clinicians as they prepared to integrate palliative care in their settings. Hospice and palliative care nurses can be instrumental in implementing palliative care into community practice.
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Ellis EM, Orehek E, Ferrer RA. Patient-provider care goal concordance: implications for palliative care decisions. Psychol Health 2019; 34:983-998. [DOI: 10.1080/08870446.2019.1584672] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Erin M. Ellis
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, National Cancer Institute, Rockville, MD, USA
| | - Edward Orehek
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rebecca A. Ferrer
- Basic Biobehavioral and Psychological Sciences Branch, Behavioral Research Program, National Cancer Institute, Rockville, MD, USA
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Abstract
The integration of palliative care and hospice into standard gynecologic oncology care is associated with cost-savings, longer survival, lower symptom burden, and better quality of life for patients and caregivers. Consequently, this comprehensive approach is formally recognized and endorsed by the Society of Gynecologic Oncology, the National Comprehensive Cancer Network, and the American Society of Clinical Oncology. This article reviews the background, benefits, barriers, and most practical delivery models of palliative care. It also discusses management of common symptoms experienced by gynecologic oncology patients.
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Affiliation(s)
- Mary M Mullen
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, 660 South Euclid Avenue, Mail Stop 8064-37-905, St Louis, MO 63110, USA
| | - James C Cripe
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, 660 South Euclid Avenue, Mail Stop 8064-37-905, St Louis, MO 63110, USA
| | - Premal H Thaker
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Washington University School of Medicine, Alvin J. Siteman Cancer Center, 660 South Euclid Avenue, Mail Stop 8064-37-905, St Louis, MO 63110, USA.
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Dhollander N, De Vleminck A, Deliens L, Van Belle S, Pardon K. Barriers to the early integration of palliative home care into the disease trajectory of advanced cancer patients: A focus group study with palliative home care teams. Eur J Cancer Care (Engl) 2019; 28:e13024. [DOI: 10.1111/ecc.13024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 11/21/2018] [Accepted: 01/17/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Naomi Dhollander
- End‐of‐Life Care Research Group Vrije Universiteit Brussel & Ghent University Brussels Belgium
| | - Aline De Vleminck
- End‐of‐Life Care Research Group Vrije Universiteit Brussel & Ghent University Brussels Belgium
| | - Luc Deliens
- End‐of‐Life Care Research Group Vrije Universiteit Brussel & Ghent University Brussels Belgium
- Department of Medical Oncology Ghent University Hospital Ghent Belgium
| | - Simon Van Belle
- End‐of‐Life Care Research Group Vrije Universiteit Brussel & Ghent University Brussels Belgium
- Department of Medical Oncology Ghent University Hospital Ghent Belgium
- Palliative Care Team Ghent University Hospital Ghent Belgium
| | - Koen Pardon
- End‐of‐Life Care Research Group Vrije Universiteit Brussel & Ghent University Brussels Belgium
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Rubens M, Ramamoorthy V, Saxena A, Das S, Appunni S, Rana S, Puebla B, Suarez DT, Khawand-Azoulai M, Medina S, Viamonte-Ros A. Palliative Care Consultation Trends Among Hospitalized Patients With Advanced Cancer in the United States, 2005 to 2014. Am J Hosp Palliat Care 2018; 36:294-301. [DOI: 10.1177/1049909118809975] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Although palliative care services are increasing in the United States, disparities exist in access and utilization. Hence, we explored these factors in hospitalized patients with advanced cancers using the National Inpatient Sample (NIS). Methods: This was a retrospective analysis of NIS data, 2005 to 2014, and included patients ≥18 years with advanced cancers with and without palliative care consultations. Both χ2 and independent t tests were used for categorical and continuous variables. Multivariate logistic regressions were used for identifying factors associated with palliative care consultations. Results: Palliative care consultations were recorded in 9.9% of 4 732 172 weighted advanced cancer hospitalizations and increased from 3.0% to 15.5% during 2005 to 2014 (relative increase, 172.2%, Ptrend < .01). Factors associated with higher palliative care consultations were increasing age, ≥80 years (odds ratio [OR]: 1.47; 95% confidence interval [CI]: 1.38-1.56); black race (OR: 1.21; 95% CI: 1.14-1.28); private insurance coverage (OR: 1.10; 95% CI: 1.02-1.18); West region (OR: 1.15; 95% CI: 1.01-1.33); large hospitals (OR: 1.19; 95% CI: 1.02-1.34); high income (OR: 1.08; 95% CI: 1.08-1.17); do-not-resuscitate (dying patients) status (OR: 10.55; 95% CI: 10.14-10.99); and in-hospital radiotherapy (OR: 1.13; 95% CI: 1.06-1.21). Palliative care consultations were lower in patients with chemotherapy (OR: 0.71; 95% CI: 0.60-0.84). Conclusion: Many demographic, socioeconomic, health-care, and geographic disparities were identified in palliative care consultations. Additionally, palliative care resources were underutilized by hospitalized patients with advanced cancers and commonly utilized by patients who are dying. Health-care providers and policy makers should focus on these disparities in order to improve palliative care use.
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Affiliation(s)
- Muni Rubens
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | | | - Anshul Saxena
- Center for Healthcare Advancement and Outcomes, Baptist Health South Florida, Miami, FL, USA
| | - Sankalp Das
- Employee Health and Wellness Advantage, Baptist Health South Florida, Miami, FL, USA
| | - Sandeep Appunni
- Malabar Medical College Hospital and Research Center, Kerala, India
| | - Sagar Rana
- Department of Biometrics, Chiltern Inc, Reston, VA, USA
| | - Brittany Puebla
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Deborah T. Suarez
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | | | - Suleyki Medina
- Miami Cancer Institute, Baptist Health South Florida, Miami, FL, USA
| | - Ana Viamonte-Ros
- Bioethics and Palliative Care, Baptist Health South Florida, Miami, FL, USA
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Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-e653. [DOI: 10.1016/s1470-2045(18)30415-7] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
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Hui D, Hannon B, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care. CA Cancer J Clin 2018; 68:356-376. [PMID: 30277572 PMCID: PMC6179926 DOI: 10.3322/caac.21490] [Citation(s) in RCA: 218] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state-of-the-science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team-based, timely, and targeted palliative care. Team-based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse-led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00-00. 2018 American Cancer Society, Inc.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Ferrer RA, Orehek E, Padgett LS. Goal conflict when making decisions for others. JOURNAL OF EXPERIMENTAL SOCIAL PSYCHOLOGY 2018. [DOI: 10.1016/j.jesp.2018.05.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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30
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Tewes M, Rettler T, Wolf N, Hense J, Schuler M, Teufel M, Beckmann M. Predictors of outpatients' request for palliative care service at a medical oncology clinic of a German comprehensive cancer center. Support Care Cancer 2018; 26:3641-3647. [PMID: 29730713 DOI: 10.1007/s00520-018-4245-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Accepted: 04/30/2018] [Indexed: 01/28/2023]
Abstract
PURPOSE Early integration of palliative care (PC) is recommended. The determination of predictors for patients' request for PC may guide implementation in clinical practice. Toward this end, we analyzed the symptom burden and distress of cancer patients in outpatient care and examined their need and request for PC. METHODS Between October 2013 and March 2016, 705 patients receiving outpatient cancer treatment took part in the survey. We used the new MInimal DOcumentation System to detect symptom clusters. Additionally, patients' request for palliative and psychosocial support was assessed. Groups of patients with PC request were compared to patients without PC request regarding their symptom clusters. Logistic regression analysis was applied to discover significant predictors for the requested inclusion of PC. RESULTS A total of 159 patients (25.5%) requested additional support by PC. Moderate and severe tiredness (40.3%), weakness (37.9%), pain (25.0%), loss of appetite (22.3%), and dyspnea (19.1%) were the most frequent symptoms. The group of patients requesting PC differed significantly in terms of pain, nausea, dyspnea, constipation, weakness, loss of appetite, tiredness, depression, and anxiety from patients without request for PC (p < .01). The perceived need for PC was identified by the significant predictors "depression," "anxiety," and "weakness" with an explained variance of 22%. CONCLUSION Combining a standardized screening questionnaire and the assessment of patients' request for PC allows systematic monitoring for patients' need for PC in a large Medical Oncology clinic. Depression, anxiety, and weakness are predictors of requesting PC service by patients receiving outpatient cancer treatment.
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Affiliation(s)
- Mitra Tewes
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, 45122, Essen, Germany.
| | - Teresa Rettler
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, 45122, Essen, Germany
| | - Nathalie Wolf
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, 45122, Essen, Germany
| | - Jörg Hense
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, 45122, Essen, Germany
| | - Martin Schuler
- West German Cancer Center, Department of Medical Oncology, University Hospital Essen, 45122, Essen, Germany.,German Cancer Consortium (DKTK), Partner Site University Hospital Essen, 45122, Essen, Germany
| | - Martin Teufel
- Department of Psychosomatic Medicine and Psychotherapy, University of Duisburg Essen, LVR-Klinikum Essen, 45122, Essen, Germany
| | - Mingo Beckmann
- Department of Psychosomatic Medicine and Psychotherapy, University of Duisburg Essen, LVR-Klinikum Essen, 45122, Essen, Germany
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31
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Szymczak JE, Schall T, Hill DL, Walter JK, Parikh S, DiDomenico C, Feudtner C. Pediatric Oncology Providers' Perceptions of a Palliative Care Service: The Influence of Emotional Esteem and Emotional Labor. J Pain Symptom Manage 2018; 55:1260-1268. [PMID: 29425881 PMCID: PMC5908218 DOI: 10.1016/j.jpainsymman.2018.01.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/28/2018] [Accepted: 01/30/2018] [Indexed: 11/30/2022]
Abstract
CONTEXT Pediatric palliative care consults for children with cancer often occur late in the course of disease and close to death, when earlier involvement would reduce suffering. The perceptions that pediatric oncology providers hold about the pediatric palliative care service (PPCS) may shape referral patterns. OBJECTIVES To explore how pediatric oncology providers at one institution perceived the hospital's PPCS and the way these perceptions may influence the timing of consultation. METHODS We conducted semistructured qualitative interviews with pediatric oncology providers at a large children's hospital. Interviews were audio-recorded, transcribed, and analyzed by two coders using a modified grounded theory approach. RESULTS We interviewed 16 providers (10 physicians, one nurse practitioner, two social workers, two psychologists, and one child life specialist). Three core perceptions emerged: 1) the PPCS offers a diverse range of valuable contributions to the care of children with advancing cancer; 2) providers held favorable opinions about the PPCS owing to positive interactions with individual palliative care specialists deemed extraordinarily emotionally skilled; and 3) there is considerable emotional labor involved in calling a PPCS consult that serves as a barrier to early initiation. CONCLUSION The pediatric oncology providers in our study held a highly favorable opinion about their institution's PPCS and agreed that early consultation is ideal. However, they also described that formally consulting PPCS is extremely difficult because of what the PPCS symbolizes to families and the emotional labor that the provider must manage in introducing them. Interventions to encourage the early initiation of palliative care in this population may benefit from a focus on the emotional experiences of providers.
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Affiliation(s)
- Julia E Szymczak
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Theodore Schall
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Douglas L Hill
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jennifer K Walter
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Shefali Parikh
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Concetta DiDomenico
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Chris Feudtner
- Department of Medical Ethics, Pediatric Advanced Care Team, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Pifer PM, Farrugia MK, Mattes MD. Comparative Analysis of the Views of Oncologic Subspecialists and Palliative/Supportive Care Physicians Regarding Advanced Care Planning and End-of-Life Care. Am J Hosp Palliat Care 2018. [PMID: 29514487 DOI: 10.1177/1049909118763592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Early palliative/supportive care (PSC) consultation and advance care planning (ACP) improve outcomes for patients with incurable cancer. However, PSC is underutilized in the United States. OBJECTIVE To examine philosophical differences among PSC, radiation oncology (RO), and medical oncology (MO) physicians in order to understand barriers to early PSC referral. DESIGN An electronic survey collected views of a nationwide cohort of health-care professionals regarding ACP and end-of-life care. Setting/Participants/Measurements: A subgroup analysis compared the responses from all 51 PSC, 178 RO, and 81 MO physician participants (12% response rate), using Pearson χ2 and Mann-Whitney U tests for categorical and ordinal data, respectively. RESULTS More statistically significant differences were observed between RO-PSC (12 questions) and MO-PSC (12 questions) than RO-MO (4 questions). Both RO and MO were more likely than PSC physicians to believe doctors adequately care for emotional ( P < .001) and physical ( P < .001) needs of patients with an incurable illness. Both RO and MO were also less likely to believe that PSC physicians were helpful at addressing these needs ( P = .002 and <.001, respectively) or that patients' awareness of their life expectancy leads to better medical ( P = .007 and .002, respectively) and personal ( P = .001 for each) decisions. Palliative/supportive care physicians felt that doctors are generally less successful at explaining/clarifying advanced life-sustaining treatments than RO ( P < .001) or MO ( P = .004). MO favored later initiation of ACP than either RO ( P = .006) or PSC physicians ( P = .004). CONCLUSIONS Differences in perception of appropriate end-of-life care exist between oncologists and PSC physicians, suggesting a need for improved education and communication between these groups.
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Affiliation(s)
- Phillip M Pifer
- 1 Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Mark K Farrugia
- 1 Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA
| | - Malcolm D Mattes
- 1 Department of Radiation Oncology, West Virginia University, Morgantown, WV, USA
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Physician Perceptions Regarding Antimicrobial Use in End-of-Life Care. Infect Control Hosp Epidemiol 2018; 39:383-390. [PMID: 29428002 DOI: 10.1017/ice.2018.6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The decision to utilize antimicrobials in end-of-life situations is complex. Understanding the reasons why physicians prescribe antimicrobials in this patient population is important for informing the design of antimicrobial stewardship interventions. METHODS A 51-item survey containing both closed and open-ended questions on end-of-life antimicrobial use was administered to physicians affiliated with the University of Pennsylvania and Children's Hospital of Philadelphia from January through April 2017. A mixed-methods approach was used to analyze responses. RESULTS Of 637 physicians surveyed, 283 responses (44.4%) were received. Most (86.2%) physicians believed that respecting a patient's wish to continue antimicrobials was important. Approximately half of physicians (49.8%) believed that antimicrobial use at the end of life contributes to resistance. A higher proportion of pediatricians would often or always continue antimicrobial treatment for active infections and for hospice patients whose death was imminent compared to adult physicians (P<.001). Analysis of free-text responses revealed additional reasons why physicians may continue antimicrobials at end of life, including meeting family expectations, wanting to avoid the perception of "giving up," uncertainty about prognosis, and reducing patient pain or discomfort. CONCLUSIONS Physician decision making concerning antimicrobial use in patients at the end of life is multifactorial. Clinicians may overweigh the benefits of antimicrobial therapy in end-of-life situations and view the importance of adhering to stewardship policies differently. Pediatric and adult clinicians have different approaches to this patient population. Better understanding of the complex decision making that occurs in the end-of-life patient population can help guide antimicrobial stewardship policies and improve patient care. Infect Control Hosp Epidemiol 2018;39:383-390.
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Mollica MA, Kent EE, Castro KM, Ellis EM, Ferrer RA, Falisi AL, Gaysynsky A, Huang GC, Palan MA, Chou WYS. Perspectives on Palliative Care in Cancer Clinical Trials: Diverse Meanings from Multidisciplinary Cancer Care Providers. J Palliat Med 2018; 21:616-621. [PMID: 29389224 DOI: 10.1089/jpm.2017.0445] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Palliative care (PC) is often misunderstood as exclusively pertaining to end-of-life care, which may be consequential for its delivery. There is little research on how PC is operationalized and delivered to cancer patients enrolled in clinical trials. OBJECTIVE We sought to understand the diverse perspectives of multidisciplinary oncology care providers caring for such patients in a teaching hospital. METHODS We conducted qualitative semistructured interviews with 19 key informants, including clinical trial principal investigators, oncology fellows, research nurses, inpatient and outpatient nurses, spiritual care providers, and PC fellows. Questions elicited information about the meaning providers assigned to the term "palliative care," as well as their experiences with the delivery of PC in the clinical trial context. Using grounded theory, a team-based coding method was employed to identify major themes. RESULTS Four main themes emerged regarding the meaning of PC: (1) the holistic nature of PC, (2) the importance of symptom care, (3) conflict between PC and curative care, and (4) conflation between PC and end-of-life care. Three key themes emerged with regard to the delivery of PC: (1) dynamics among providers, (2) discussing PC with patients and family, and (3) the timing of PC delivery. CONCLUSION There was great variability in personal meanings of PC, conflation with hospice/end-of-life care, and appropriateness of PC delivery and timing, particularly within cancer clinical trials. A standard and acceptable model for integrating PC concurrently with treatment in clinical trials is needed.
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Affiliation(s)
- Michelle A Mollica
- 1 Division of Cancer Control and Population Sciences, National Cancer Institute , NIH, Bethesda, Maryland
| | - Erin E Kent
- 1 Division of Cancer Control and Population Sciences, National Cancer Institute , NIH, Bethesda, Maryland.,2 ICF International, Inc. , Rockville, Maryland
| | - Kathleen M Castro
- 1 Division of Cancer Control and Population Sciences, National Cancer Institute , NIH, Bethesda, Maryland
| | - Erin M Ellis
- 1 Division of Cancer Control and Population Sciences, National Cancer Institute , NIH, Bethesda, Maryland
| | - Rebecca A Ferrer
- 1 Division of Cancer Control and Population Sciences, National Cancer Institute , NIH, Bethesda, Maryland
| | - Angela L Falisi
- 1 Division of Cancer Control and Population Sciences, National Cancer Institute , NIH, Bethesda, Maryland
| | | | | | | | - Wen-Ying Sylvia Chou
- 1 Division of Cancer Control and Population Sciences, National Cancer Institute , NIH, Bethesda, Maryland
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Patient-Reported-Outcome-Messung (PROM) psychosozialer Belastung und Symptome für ambulante Patienten unter kurativer oder palliativer Tumortherapie. ONKOLOGE 2018. [DOI: 10.1007/s00761-017-0324-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Costantini M, Apolone G, Tanzi S, Falco F, Rondini E, Guberti M, Fanello S, Cavuto S, Savoldi L, Piro R, Mecugni D, Di Leo S. Is early integration of palliative care feasible and acceptable for advanced respiratory and gastrointestinal cancer patients? A phase 2 mixed-methods study. Palliat Med 2018; 32:46-58. [PMID: 28952881 DOI: 10.1177/0269216317731571] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND There is evidence that early integration of palliative care improves quality of life, lowers spending and helps clarify preferences and goals for advanced cancer patients. Little is known about the feasibility and acceptability of early integration. AIM Assessing feasibility of early integration of palliative care, and exploring concerns perceived and problems encountered by patients, relatives and oncologists. DESIGN A phase 2 mixed-methods study ( ClinicalTrials.Gov :NCT02078700). METHODS Oncologists of two outpatient clinics offered a specialised palliative care intervention integrated with standard oncological care to all consecutive newly diagnosed metastatic respiratory/gastrointestinal cancer patients. We interviewed samples of patients, relatives and oncologists to explore strengths and weaknesses of the intervention. RESULTS The intervention was proposed to 44/54 eligible patients (81.5%), 40 (90.1%) accepted, 38 (95.0%) attended the first palliative care visit. The intervention was completed for 32 patients (80.0%). It did not start for three (7.5%) and was interrupted for three patients who refused (7.5%). The Palliative Care Unit performed 274 visits in 38 patients (median per patient 4.5), and 24 family meetings with relatives of 16 patients. All patients and most relatives referred to the usefulness of the intervention, specifically for symptoms management, information and support to strategies for coping. Oncologists highlighted their difficulties in informing patients on palliative intervention, sharing information and coordinating patient's care with the palliative care team. CONCLUSION Early integration of palliative care in oncological setting seems feasible and well accepted by patients, relatives and, to a lesser extent, oncologists. Some difficulties emerged concerning patient information and inter-professional communication.
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Affiliation(s)
| | | | - Silvia Tanzi
- 3 Palliative Care Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Francesco Falco
- 4 Pulmonology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Ermanno Rondini
- 5 Oncology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Monica Guberti
- 6 Department of Health Professions, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Silvia Fanello
- 5 Oncology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Silvio Cavuto
- 7 Department Infrastructure Research and Statistics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Luisa Savoldi
- 7 Department Infrastructure Research and Statistics, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Roberto Piro
- 4 Pulmonology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Daniela Mecugni
- 8 Surgical, Medical and Dental Department of Morphological Sciences related to Transplant, Oncology and Regenerative Medicine, Università degli Studi di Modena e Reggio Emilia, Modena, Italy
| | - Silvia Di Leo
- 9 Psycho-Oncology Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
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Protocol and pilot testing: The feasibility and acceptability of a nurse-led telephone-based palliative care intervention for patients newly diagnosed with lung cancer. Contemp Clin Trials 2017; 64:30-34. [PMID: 29175560 DOI: 10.1016/j.cct.2017.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 11/21/2017] [Accepted: 11/22/2017] [Indexed: 12/18/2022]
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Haun MW, Estel S, Rücker G, Friederich H, Villalobos M, Thomas M, Hartmann M. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev 2017; 6:CD011129. [PMID: 28603881 PMCID: PMC6481832 DOI: 10.1002/14651858.cd011129.pub2] [Citation(s) in RCA: 258] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Incurable cancer, which often constitutes an enormous challenge for patients, their families, and medical professionals, profoundly affects the patient's physical and psychosocial well-being. In standard cancer care, palliative measures generally are initiated when it is evident that disease-modifying treatments have been unsuccessful, no treatments can be offered, or death is anticipated. In contrast, early palliative care is initiated much earlier in the disease trajectory and closer to the diagnosis of incurable cancer. OBJECTIVES To compare effects of early palliative care interventions versus treatment as usual/standard cancer care on health-related quality of life, depression, symptom intensity, and survival among adults with a diagnosis of advanced cancer. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, OpenGrey (a database for grey literature), and three clinical trial registers to October 2016. We checked reference lists, searched citations, and contacted study authors to identify additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and cluster-randomised controlled trials (cRCTs) on professional palliative care services that provided or co-ordinated comprehensive care for adults at early advanced stages of cancer. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. We assessed risk of bias, extracted data, and collected information on adverse events. For quantitative synthesis, we combined respective results on our primary outcomes of health-related quality of life, survival (death hazard ratio), depression, and symptom intensity across studies in meta-analyses using an inverse variance random-effects model. We expressed pooled effects as standardised mean differences (SMDs, or Hedges' adjusted g). We assessed certainty of evidence at the outcome level using GRADE (Grading of Recommendations Assessment, Development, and Evaluation) and created a 'Summary of findings' table. MAIN RESULTS We included seven randomised and cluster-randomised controlled trials that together recruited 1614 participants. Four studies evaluated interventions delivered by specialised palliative care teams, and the remaining studies assessed models of co-ordinated care. Overall, risk of bias at the study level was mostly low, apart from possible selection bias in three studies and attrition bias in one study, along with insufficient information on blinding of participants and outcome assessment in six studies.Compared with usual/standard cancer care alone, early palliative care significantly improved health-related quality of life at a small effect size (SMD 0.27, 95% confidence interval (CI) 0.15 to 0.38; participants analysed at post treatment = 1028; evidence of low certainty). As re-expressed in natural units (absolute change in Functional Assessment of Cancer Therapy-General (FACT-G) score), health-related quality of life scores increased on average by 4.59 (95% CI 2.55 to 6.46) points more among participants given early palliative care than among control participants. Data on survival, available from four studies enrolling a total of 800 participants, did not indicate differences in efficacy (death hazard ratio 0.85, 95% CI 0.56 to 1.28; evidence of very low certainty). Levels of depressive symptoms among those receiving early palliative care did not differ significantly from levels among those receiving usual/standard cancer care (five studies; SMD -0.11, 95% CI -0.26 to 0.03; participants analysed at post treatment = 762; evidence of very low certainty). Results from seven studies that analysed 1054 participants post treatment suggest a small effect for significantly lower symptom intensity in early palliative care compared with the control condition (SMD -0.23, 95% CI -0.35 to -0.10; evidence of low certainty). The type of model used to provide early palliative care did not affect study results. One RCT reported potential adverse events of early palliative care, such as a higher percentage of participants with severe scores for pain and poor appetite; the remaining six studies did not report adverse events in study publications. For these six studies, principal investigators stated upon request that they had not observed any adverse events. AUTHORS' CONCLUSIONS This systematic review of a small number of trials indicates that early palliative care interventions may have more beneficial effects on quality of life and symptom intensity among patients with advanced cancer than among those given usual/standard cancer care alone. Although we found only small effect sizes, these may be clinically relevant at an advanced disease stage with limited prognosis, at which time further decline in quality of life is very common. At this point, effects on mortality and depression are uncertain. We have to interpret current results with caution owing to very low to low certainty of current evidence and between-study differences regarding participant populations, interventions, and methods. Additional research now under way will present a clearer picture of the effect and specific indication of early palliative care. Upcoming results from several ongoing studies (N = 20) and studies awaiting assessment (N = 10) may increase the certainty of study results and may lead to improved decision making. In perspective, early palliative care is a newly emerging field, and well-conducted studies are needed to explicitly describe the components of early palliative care and control treatments, after blinding of participants and outcome assessors, and to report on possible adverse events.
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Affiliation(s)
- Markus W Haun
- Im Neuenheimer Feld 410, Heidelberg University HospitalDepartment of General Internal Medicine and PsychosomaticsHeidelbergGermanyD‐69120
| | - Stephanie Estel
- Im Neuenheimer Feld 410, Heidelberg University HospitalDepartment of General Internal Medicine and PsychosomaticsHeidelbergGermanyD‐69120
| | - Gerta Rücker
- Faculty of Medicine and Medical Center – University of FreiburgInstitute for Medical Biometry and StatisticsStefan‐Meier‐Str. 26FreiburgGermany79104
| | - Hans‐Christoph Friederich
- University Hospital DüsseldorfPsychosomatic Medicine and PsychotherapyMoorenstrasse 5DüsseldorfGermany40225
| | - Matthias Villalobos
- Thoraxklinik at Heidelberg University HospitalDepartment of Thoracic OncologyHeidelbergGermanyD‐69120
| | - Michael Thomas
- Thoraxklinik at Heidelberg University HospitalDepartment of Thoracic OncologyHeidelbergGermanyD‐69120
| | - Mechthild Hartmann
- Im Neuenheimer Feld 410, Heidelberg University HospitalDepartment of General Internal Medicine and PsychosomaticsHeidelbergGermanyD‐69120
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Hannon B, Swami N, Rodin G, Pope A, Zimmermann C. Experiences of patients and caregivers with early palliative care: A qualitative study. Palliat Med 2017; 31:72-81. [PMID: 27495814 DOI: 10.1177/0269216316649126] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Early palliative care improves quality of life and satisfaction with care and is increasingly endorsed for patients with advanced cancer. However, little is known about the experience of receiving early palliative care from a patient and caregiver perspective. AIM The aim of this qualitative study was to determine, from a participant perspective, the experience of receiving early palliative care and elements of that care. DESIGN Qualitative grounded theory study using individual interviews. SETTING/PARTICIPANTS The study took place at a comprehensive cancer centre. Patients ( n = 26) and caregivers ( n = 14) from the intervention arm of a cluster-randomised controlled trial of early palliative care versus standard oncology care participated in qualitative interviews. Participants were asked to comment on their quality of life, the quality of care provided over the intervention period and their experiences with the palliative care team. RESULTS Participants described feeling supported and guided in their illness experience and in their navigation of the healthcare system. Specific elements of early palliative care included prompt, personalised symptom management; holistic support for patients and caregivers; guidance in decision-making; and preparation for the future. Patients with symptoms particularly valued prompt attention to their physical concerns, while those without symptoms valued other elements of care. Although three patients were ambivalent about their current need for palliative care, no distress was reported as a consequence of the intervention. CONCLUSION The elements of care described by participants may be used to develop, support and refine models of early palliative care for patients with cancer.
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Affiliation(s)
- Breffni Hannon
- 1 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Nadia Swami
- 2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Gary Rodin
- 2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,4 Campbell Family Cancer Research Institute, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Ashley Pope
- 2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Camilla Zimmermann
- 1 Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, ON, Canada.,2 Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada.,3 Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,4 Campbell Family Cancer Research Institute, Ontario Cancer Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
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Gidwani R, Nevedal A, Patel M, Blayney DW, Timko C, Ramchandran K, Kelly PA, Asch SM. The Appropriate Provision of Primary versus Specialist Palliative Care to Cancer Patients: Oncologists' Perspectives. J Palliat Med 2016; 20:395-403. [PMID: 27997278 DOI: 10.1089/jpm.2016.0399] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Many cancer patients do not receive recommended palliative care (PC). Oncologists' perspectives about PC have not been adequately described qualitatively and may explain some of the gaps in the delivery of PC. OBJECTIVE To characterize U.S. oncologists' perceptions of: primary and specialist PC; experiences interacting with PC specialists; and the optimal interface of PC and oncology in providing PC. DESIGN In-depth interviews with practicing oncologists. SETTING/SUBJECTS Oncologists working in: the general community, academic medical centers (AMC), and Veterans Health Administration. MEASUREMENTS Semistructured telephone interviews with 31 oncologists analyzed using matrix and thematic approaches. RESULTS Seven major themes emerged: PC was perceived as appropriate throughout the disease trajectory but due to resource constraints was largely provided at end of life; oncologists had three schools of thought on primary versus specialist PC; there was an under-availability of outpatient PC; poor communication about prognosis and care plans created tension between providers; PC was perceived as a "team of outsiders"; PC had too narrow a focus of care; and AMC-based PC evidence did not generalize to community practices. Oncologists noted three ways to improve the interface between oncologists and PC providers: a clear division of responsibility, in-person collaboration, and sharing of nonphysician palliative team members. CONCLUSIONS Oncologists in our sample were supportive of PC, but they reported obstacles related to care coordination and inpatient PC. Inpatient PC posed some unique challenges with respect to conflicting prognoses and care practices that would be mitigated through the increased availability and use of outpatient PC.
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Affiliation(s)
- Risha Gidwani
- 1 Health Economics Resource Center (HERC) , VA Palo Alto Health Care System, Palo Alto, California.,2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California.,3 Division of General Medical Disciplines, Stanford University , Stanford, California
| | - Andrea Nevedal
- 2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California
| | - Manali Patel
- 4 Division of Medical Oncology, Stanford University , Stanford, California.,5 VA Palo Alto Health Care System , Palo Alto, California
| | - Douglas W Blayney
- 4 Division of Medical Oncology, Stanford University , Stanford, California
| | - Christine Timko
- 2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California.,6 Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine , Stanford, California
| | | | - P Adam Kelly
- 7 Southeast Louisiana Veterans Health Care System , New Orleans, Louisiana.,8 Tulane University School of Medicine , New Orleans, Louisiana
| | - Steven M Asch
- 2 Center for Innovation to Implementation (Ci2i) , VA Palo Alto Health Care System, Palo Alto, California.,3 Division of General Medical Disciplines, Stanford University , Stanford, California
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Hannon B, Swami N, Pope A, Leighl N, Rodin G, Krzyzanowska M, Zimmermann C. Early Palliative Care and Its Role in Oncology: A Qualitative Study. Oncologist 2016; 21:1387-1395. [PMID: 27449522 DOI: 10.1634/theoncologist.2016-0176] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 06/16/2016] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Early integration of palliative care alongside oncology is being increasingly recommended, although the strategies and models for integration remain poorly defined. We solicited the opinions of patients and caregivers who participated in a randomized trial of early palliative care versus standard oncology care, regarding the respective roles of their oncologist (both groups) and palliative care physician (early palliative care group). MATERIALS AND METHODS The study was performed at a comprehensive cancer center. Forty-eight patients (26 intervention, 22 control) and 23 caregivers (14 intervention, 9 control) were recruited purposefully at trial end. One-on-one, semistructured qualitative interviews were conducted and analyzed using grounded theory. RESULTS The themes resulting from the analysis fell into three categories: the focus of care, the model of care delivery, and the complementarity between teams. The focus of care in oncology was perceived to be disease-centered, with emphasis on controlling disease, directing cancer treatment, and increasing survival; palliative care was perceived to be more holistic and person-focused, with an emphasis on symptom management. Oncology visits were seen as following a structured, physician-led, time-constrained model in contrast to the more fluid, patient-led, flexible model experienced in the palliative care clinic. No differences were found in the descriptions of oncology between participants in the intervention and control groups. Participants in the intervention group explicitly described the roles of their oncologist and their palliative care physician as distinct and complementary. CONCLUSION Participants perceived the respective roles of their oncologist and palliative care physician as discrete, important, and complementary for the provision of excellent cancer care. IMPLICATIONS FOR PRACTICE Patients and their caregivers who experienced early palliative care described the roles of their oncologists and palliative care physicians as being discrete and complementary, with both specialties contributing to excellent patient care. The findings of the present research support an integrated approach to care for patients with advanced cancer, which involves early collaborative care in the ambulatory setting by experts in both oncology and palliative medicine. This can be achieved by more widespread establishment of ambulatory palliative care clinics, encouragement of timely outpatient referral to palliative care, and education of oncologists in palliative care.
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Affiliation(s)
- Breffni Hannon
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Nadia Swami
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Ashley Pope
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Natasha Leighl
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Monika Krzyzanowska
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Division of Medical Oncology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Campbell Family Cancer Research Institute, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
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Duska LR. Early Integration of Palliative Care in the Care of Women with Advanced Epithelial Ovarian Cancer: The Time Is Now. Front Oncol 2016; 6:83. [PMID: 27148475 PMCID: PMC4826869 DOI: 10.3389/fonc.2016.00083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2016] [Accepted: 03/24/2016] [Indexed: 12/25/2022] Open
Affiliation(s)
- Linda Rosenbaum Duska
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Virginia , Charlottesville, VA , USA
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Gaertner J, Siemens W, Antes G, Meerpohl JJ, Xander C, Schwarzer G, Stock S, Becker G. Specialist palliative care services for adults with advanced, incurable illness in hospital, hospice, or community settings--protocol for a systematic review. Syst Rev 2015; 4:123. [PMID: 26407847 PMCID: PMC4583160 DOI: 10.1186/s13643-015-0121-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 09/17/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Specialist palliative care (SPC) interventions aim to relieve and prevent suffering in the physical, psychological, social, and spiritual domain. Therefore, SPC is carried out by a multi-professional team with different occupations (e.g., physician, nurse, psychologist, and social worker). Remaining skepticism concerning the need for SPC may be based on the scarcity of high-quality evaluations about the external evidence for SPC. Therefore, we will conduct a systematic review according to Cochrane standards to examine the effects of SPC for adults with advanced illness. METHODS/DESIGN The comprehensive systematic literature search will include randomized controlled trials (RCTs) and cluster RCTs. We will search the databases MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and PsycINFO. Patients must be adults suffering from life-limiting diseases. Proxy and caregiver outcomes will not be assessed in order to ensure a clear and well-defined research question for this review. Interventions may be in an in- or outpatient setting, e.g., consulting service, palliative care ward, and palliative outpatient clinic. In line with the multi-dimensional scope of palliative care, the primary outcome is quality of life (QoL). Key secondary outcomes are patients' symptom burden, place of death and survival, and health economic aspects. Subgroup analysis will assess results according to cancer type, age, early vs not early SPC, site of care, and setting. Analysis will be performed with the current RevMan software. We will use the Cochrane Collaboration risk of bias assessment tool. The quality of evidence will be judged according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. DISCUSSION The available evidence will be summarized and discussed to provide a basis for decision-making among health care professionals and policy makers. For SPC, we believe that multi-professional care is of utmost importance. Therefore, single-profession interventions such as physician consultations will not be included. Based on the multi-dimensional scope of palliative care, we chose QoL as the primary outcome, despite an expected heterogeneity among the QoL outcomes. We consider unidimensional endpoints such as "pain" for the physical domain to be inadequate for capturing the true scope of (S)PC (i.e., QoL) as defined by the World Health Organization. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015020674.
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Affiliation(s)
- Jan Gaertner
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Waldemar Siemens
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Gerd Antes
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany.
| | - Joerg J Meerpohl
- German Cochrane Centre, Medical Center, University of Freiburg, Freiburg, Germany.
| | - Carola Xander
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
| | - Guido Schwarzer
- Institute of Medical Biometry and Informatics, Medical Center, University of Freiburg, Freiburg, Germany.
| | - Stephanie Stock
- Institute for Health Economics and Clinical Epidemiology, Cologne University Hospital, Cologne, Germany.
| | - Gerhild Becker
- Department of Palliative Care, University Medical Center, Robert-Koch-Straße 3, 79106, Freiburg, Germany.
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Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, Dionne-Odom JN, Frost J, Dragnev KH, Hegel MT, Azuero A, Ahles TA. Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial. J Clin Oncol 2015; 33:1438-45. [PMID: 25800768 PMCID: PMC4404422 DOI: 10.1200/jco.2014.58.6362] [Citation(s) in RCA: 766] [Impact Index Per Article: 85.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Randomized controlled trials have supported integrated oncology and palliative care (PC); however, optimal timing has not been evaluated. We investigated the effect of early versus delayed PC on quality of life (QOL), symptom impact, mood, 1-year survival, and resource use. PATIENTS AND METHODS Between October 2010 and March 2013, 207 patients with advanced cancer at a National Cancer Institute cancer center, a Veterans Affairs Medical Center, and community outreach clinics were randomly assigned to receive an in-person PC consultation, structured PC telehealth nurse coaching sessions (once per week for six sessions), and monthly follow-up either early after enrollment or 3 months later. Outcomes were QOL, symptom impact, mood, 1-year survival, and resource use (hospital/intensive care unit days, emergency room visits, chemotherapy in last 14 days, and death location). RESULTS Overall patient-reported outcomes were not statistically significant after enrollment (QOL, P = .34; symptom impact, P = .09; mood, P = .33) or before death (QOL, P = .73; symptom impact, P = .30; mood, P = .82). Kaplan-Meier 1-year survival rates were 63% in the early group and 48% in the delayed group (difference, 15%; P = .038). Relative rates of early to delayed decedents' resource use were similar for hospital days (0.73; 95% CI, 0.41 to 1.27; P = .26), intensive care unit days (0.68; 95% CI, 0.23 to 2.02; P = .49), emergency room visits (0.73; 95% CI, 0.45 to 1.19; P = .21), chemotherapy in last 14 days (1.57; 95% CI, 0.37 to 6.7; P = .27), and home death (27 [54%] v 28 [47%]; P = .60). CONCLUSION Early-entry participants' patient-reported outcomes and resource use were not statistically different; however, their survival 1-year after enrollment was improved compared with those who began 3 months later. Understanding the complex mechanisms whereby PC may improve survival remains an important research priority.
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Affiliation(s)
- Marie A Bakitas
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY.
| | - Tor D Tosteson
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Zhigang Li
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kathleen D Lyons
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jay G Hull
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Zhongze Li
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - J Nicholas Dionne-Odom
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jennifer Frost
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Konstantin H Dragnev
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mark T Hegel
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Andres Azuero
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Tim A Ahles
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
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Dionne-Odom JN, Kono A, Frost J, Jackson L, Ellis D, Ahmed A, Azuero A, Bakitas M. Translating and testing the ENABLE: CHF-PC concurrent palliative care model for older adults with heart failure and their family caregivers. J Palliat Med 2014; 17:995-1004. [PMID: 25072240 DOI: 10.1089/jpm.2013.0680] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Heart failure (HF) and palliative care (PC) organizations recommend early PC to improve the quality of life of patients living with HF. OBJECTIVE We conducted a two-phase formative evaluation study to translate a cancer-focused concurrent PC intervention into one that would be appropriate for rural-dwelling adults with New York Heart Association Class III-IV HF and their primary caregivers. METHODS Phase I: We tailored the intervention for an HF population via literature review, expert consultation, and clinician (N=15) small group interviews. Phase II: We enrolled 11 patient/caregiver dyads to assess intervention feasibility and satisfaction. We assessed participants' experiences and satisfaction after session/week three and session/week six via digitally recorded interviews. Clinician and participant interviews were transcribed and content analyzed. Outcome measures were evaluated for completion rates and effect sizes. RESULTS Phase I: Clinicians described barriers to initiating PC in HF, triggers for initiating PC, and suggestions for intervention improvement. Phase II: Participants were able to complete the majority of study sessions, measures, and interviews. Satisfaction interviews revealed the content to be relevant and comprehensive in addressing HF patient and caregiver primary concerns; however, participants unanimously suggested making the intervention available earlier in the illness trajectory. Efficacy measures demonstrated small to medium effect sizes. CONCLUSIONS We tailored and demonstrated feasibility of providing an early, concurrent palliative care intervention to patients with advanced HF and their caregivers. Based on this experience we are now conducting an efficacy trial in a racially diverse sample.
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Abstract
The provision of comprehensive cancer care in an increasingly complex landscape necessitates that oncology providers familiarize themselves with the application of palliative care. Palliative care is a learnable skill. Recent endeavors in this arena have demonstrated that providing palliative care is part and parcel with providing compassionate and high-quality cancer care, specifically as it pertains to physical and emotional outcomes for patients and their caregivers alike. The basic tenets of providing palliative care emphasize: frequent and honest communication, routine and systematic symptom assessment, integration of spiritual assessments, and early integration of specialized hospice and palliative care resources as a patient's circumstances evolve. This article will endeavor to review and synthesize recent developments in the palliative care literature, specifically as they pertain to the oncologist as a primary palliative care provider.
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Affiliation(s)
- Mark T. Hughes
- General Internal Medicine and Berman Institute of Bioethics, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-0941;
| | - Thomas J. Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-0005;
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Granek L, Krzyzanowska MK, Tozer R, Mazzotta P. Oncologists' strategies and barriers to effective communication about the end of life. J Oncol Pract 2013; 9:e129-35. [PMID: 23942929 DOI: 10.1200/jop.2012.000800] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Communicating about the end of life with patients has been reported as one of the most difficult and stressful part of the work of oncologists. Despite this fact, oncologists receive little training in this area, and many do not communicate effectively with patients. The purpose of this analysis, part of a larger study examining oncologists' experiences of patient loss, was to explore oncologists' communication strategies and communication barriers when discussing end-of-life issues with patients. METHODS Twenty oncologists were interviewed at three hospitals about their communication strategies on end-of-life issues with patients. The data were analyzed using the grounded theory method. RESULTS The findings revealed the strategies to effective communication about the end of life included: being open and honest; having ongoing, early conversations; communicating about modifying treatment goals; and balancing hope and reality. Barriers to implementing these strategies fell broadly into three domains, including physician factors, patient factors, and institutional factors. Physician factors included difficulty with treatment and palliation, personal discomfort with death and dying, diffusion of responsibility among colleagues, using the "death-defying mode," lack of experience, and lack of mentorship. Patient factors included, patients and/or families being reluctant to talk about the end of life, language barriers, and younger age. Institutional factors included stigma around palliative care, lack of protocol about end-of-life issues; and lack of training for oncologists on how to talk with patients about end-of-life issues. CONCLUSION We conclude by drawing implications from our study and suggest that further research and intervention are necessary to aid oncologists in achieving effective communication about end-of-life issues.
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Affiliation(s)
- Leeat Granek
- Ben Gurion University of the Negev, Be'er Sheva, Israel; Princess Margaret Hospital; Sunnybrook Health Sciences Centre; University of Toronto, Toronto; and Juravinski Cancer Centre, Hamilton Ontario, Canada
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