Palliative Care Research in Latin America: Results of a Survey within the Scope of the Declaration of Venice

Developing research priorities for palliative care in Colombia: a priority setting partnership approach

BACKGROUND

A recent Lancet commission called for more research on palliative care in low- and middle-income (LMIC) countries such as Colombia. A research priority setting approach has been recommended by The Global Forum for Health Research to address the huge gap in research output between LMIC and high-income countries, with influential health service bodies recommending the active involvement of non-research expert stakeholders in establishing research priorities to address service user needs.

METHOD

Priority setting partnership (PSP) following the four stages of the James Lind Alliance methodology; establishing the partnership, identifying evidence uncertainties, refining questions and uncertainties, and prioritization. Data from MS forms were analysed using descriptive statistics.

RESULTS

A total of 33 stakeholders attended an online PSP workshop and completed the Mentimeter exercise in Microsoft Teams. A total of 48 attended the subsequent in person prioritisation exercise in urban Bogota (n = 22) and rural Popayan (n = 25). The stakeholders were a diverse group of health professionals (physicians, medical students, nurses, dentists, physiotherapists, nutritionist, occupational and speech therapists), financial and administrative staff and patients with life-limiting illness and caregivers. Top research priorities included patient and caregiver needs, service provider education and training, and better integration of palliative care with cancer and non-cancer services. The key challenges included a lack of interest in palliative care research, along with funding, time and resource constraints. Key solutions included collaboration across disciplines and settings, highlighting benefits of palliative research to help secure adequate resources, and multicentre, mixed method research, with patient involvement from the research development stage.

CONCLUSION

The findings of this PSP should be disseminated among palliative care associations worldwide to inform international multicentre studies, and among governmental and nongovernmental organisations that promote research in Colombia. A focus on patient and family caregiver palliative care needs in Colombia should be prioritised.

A Global Collaboration to Develop and Pilot Test a Mobile Application to Improve Cancer Pain Management in Nepal

Introduction

Quality palliative care, which prioritizes comfort and symptom control, can reduce global suffering from non-communicable diseases, such as cancer. To address this need, the Nepalese Association of Palliative Care (NAPCare) created pain management guidelines (PMG) to support healthcare providers in assessing and treating serious pain. The NAPCare PMG are grounded in World Health Organization best practices but adapted for the cultural and resource context of Nepal. Wider adoption of the NAPCare PMG has been limited due to distribution of the guidelines as paper booklets.

Methods

Building on a long-standing partnership between clinicians and researchers in the US and Nepal, the NAPCare PMG mobile application (“app”) was collaboratively designed. Healthcare providers in Nepal were recruited to pilot test the app using patient case studies. Then, participants completed a Qualtrics survey to evaluate the app which included the System Usability Scale (SUS) and selected items from the Mobile App Rating Scale (MARS). Descriptive and summary statistics were calculated and compared across institutions and roles. Regression analyses to explore relationships (α = 0.05) between selected demographic variables and SUS and MARS scores were also conducted.

Results

Ninety eight healthcare providers (n = 98) pilot tested the NAPCare PMG app. Overall, across institutions and roles, the app received an SUS score of 76.0 (a score > 68 is considered above average) and a MARS score of 4.10 (on a scale of 1 = poor, 5 = excellent). 89.8% (n = 88) “agreed” or “strongly agreed” that the app will help them better manage cancer pain. Age, years of experience, and training in palliative care were significant in predicting SUS scores (p-values, 0.0124, 0.0371, and 0.0189, respectively); institution was significant in predicting MARS scores (p = 0.0030).

Conclusion

The NAPCare PMG mobile app was well-received, and participants rated it highly on both the SUS and MARS. Regression analyses suggest end-user variables important to consider in designing and evaluating mobile apps in lower resourced settings. Our app design and pilot testing process illustrate the benefits of cross global collaborations to build research capacity and generate knowledge within the local context.

The Impact of International Research Collaborations on the Citation Metrics and the Scientific Potential of South American Palliative Care Research: Bibliometric Analysis

Background

Progress in palliative care (PC) requires scientific advances which could potentially be catalyzed by international research collaboration (IRC). It is currently not known how often IRC occurs with PC investigators in South America.

Objectives

To evaluate the percentage of South America journal articles on PC involving IRCs and the impact of these collaborations on the scientific potential the studies and on their citations.

Methods

This was a bibliometric analysis of studies published between January 1, 1998, and December 31, 2017. A search of Pubmed, Embase, Lilacs, and Web of Science (WOS) was performed using the terms "palliative care," "hospice care," "hospices" and "terminal care," combined with the name of South America countries. The scientific potential was assessed by analyzing study design, characteristics of the journal and funding. IRCs were further subdivided in internal (within South America countries) and external (with countries outside South America).

Findings

Of the 641 articles, 117 (18.2%) involved IRCs (internal: 18, 2.8%; external: 110, 17.2%). Articles with IRCs had higher median two-year citations in WOS (2 vs. 1, p < 0.001), Scopus (3 vs. 1, p < 0.001) and Google Scholar (4.5 vs. 2, p < 0.001) compared to articles without IRC. Moreover, they were more often funded (40.7% vs. 9.7%, p < 0.001), published in Pubmed-indexed (76.1% vs. 41.6%; p < 0.001) and in WOS-indexed (70.1% vs. 29.6%; p < 0.001) journals, and with study designs most often classified as clinical trial (5.1% vs. 1.0%; p = 0.002) and cohort (10.3% vs. 2.9%; p < 0.001) compared to articles without IRC.

Conclusions

Studies with international research collaborations, both internal and external to South America, are more frequently cited and have characteristics with greater scientific potential than do studies without international collaborations.

Palliative and End-of-Life Care in a Small Caribbean Country: A Mortality Follow-back Study of Home Deaths

CONTEXT

Empirical information on circumstances of dying from advanced illness in developing countries remains sparse. Evidence indicates that out-of-hospital end-of-life care can have significant benefits such as increased satisfaction for the patient and caregivers and cost-effective for a health-care system. Services that are aimed to deliver care at private homes may be a good model for low- and middle-income countries or other low-resourced settings.

OBJECTIVES

To examine specialized, generalist, and informal palliative care provision and to describe the end-of-life care goals and treatments received.

METHOD

A mortality follow-back study with data obtained from general practitioners certifying a random sample of death certificates of adult decedents who died between March and August 2018. The questionnaire inquired about the characteristics of care and treatment preceding death.

RESULTS

Three hundred nine questionnaires were mailed, and the response rate was 31% (N = 96), of which 76% were nonsudden deaths. Of these cases, 27.4% received no palliative care, 39.7% received it from a general practitioner, and 6.8% from a specialized palliative care service. Comfort maximization (60.3%) was the main goal of care in the last week of life, and analgesics (53.4%) were the predominant treatment for achieving this goal. In addition, 60.3% received informal palliative care from a family member.

CONCLUSION

The largest part of end-of-life care at home in Trinidad and Tobago is provided by family members, whereas professional caregivers feature less prominently. To ensure quality in end-of-life care, better access to analgesics is needed, and adequate support and education for family members as well as general practitioners are highly recommended.

Enhancing Pediatric Palliative Care for Latino Children and Their Families: A Review of the Literature and Recommendations for Research and Practice in the United States

As the demand for pediatric palliative care (PC) increases, data suggest that Latino children are less likely to receive services than non-Latino children. Evidence on how to best provide PC to Latino children is sparse. We conducted a narrative review of literature related to PC for Latino children and their families in the United States. In the United States, Latinos face multiple barriers that affect their receipt of PC, including poverty, lack of access to health insurance, language barriers, discrimination, and cultural differences. Pediatric PC research and clinical initiatives that target the needs of Latino families are sparse, underfunded, but essential. Education of providers on Latino cultural values is necessary. Additionally, advocacy efforts with a focus on equitable care and policy reform are essential to improving the health of this vulnerable population.

The Development of Palliative Care in Argentina: A Mapping Study Using Latin American Association for Palliative Care Indicators

BACKGROUND

The Latin American Association for Palliative Care (ALCP) developed 10 indicators to monitor the development of palliative care. The indicators have been applied across Latin American countries but have not been used internally.

OBJECTIVE

The aims of this study were to document the development of palliative care in Argentina at the national and provincial levels by using a selection of the indicators developed by the ALCP and identify the difficulties and needs of healthcare professionals working in palliative care. This is the first study to apply the indicators intranationally.

METHODS

This was a cross-sectional pilot study based on two questionnaires with representatives from each province, one workshop, and telephone conversations to corroborate the collected data. These data were used to calculate a preselection of eight ALCP indicators covering four main areas of development: education, policy, service delivery, and medication. A total of 30 participants took part in the study.

RESULTS

The application of the ALCP indicators at the province level led to the identification of inequalities in the development and distribution of services across the country. The provinces in the north-west were identified as the region with the greatest need for development. The main difficulties for healthcare professionals were lack of national service registries, certified palliative care specialties, and opportunities for continuous training.

DISCUSSION

The ALCP indicators are useful tools for mapping palliative care development within countries. Further work needs to be carried out to increase their specificity and integrate them in policy design and service delivery.

Provision of Palliative Care in Low- and Middle-Income Countries: Overcoming Obstacles for Effective Treatment Delivery

Despite being declared a basic human right, access to adult and pediatric palliative care for millions of individuals in need in low- and middle-income countries (LMICs) continues to be limited or absent. The requirement to make palliative care available to patients with cancer is increasingly urgent because global cancer case prevalence is anticipated to double over the next two decades. Fifty percent of these cancers are expected to occur in LMICs, where mortality figures are disproportionately greater as a result of late detection of disease and insufficient access to appropriate treatment options. Notable initiatives in many LMICs have greatly improved access to palliative care. These can serve as development models for service scale-up in these regions, based on rigorous evaluation in the context of specific health systems. However, a multipronged public health approach is needed to fulfill the humane and ethical obligation to make palliative care universally available. This includes health policy that supports the integration of palliative care and investment in systems of health care delivery; changes in legislation and regulation that inappropriately restrict access to opioid medications for individuals with life-limiting illnesses; education and training of health professionals; development of a methodologically rigorous data and research base specific to LMICs that encompasses health systems and clinical care; and shifts in societal and health professional attitudes to palliative and end-of-life care. International partnerships are valuable to achieve these goals, particularly in education and research, but leadership and health systems stewardship within LMICs are critical factors that will drive and implement change.

Palliative care research in Latin America and the Caribbean: from the beginning to the Declaration of Venice and beyond

BACKGROUND

Research in palliative care has increased significantly in the last decade, while the vast majority of the global disease burden occurs in developing countries.

AIMS

To explore the palliative care research activity in Latin America and the Caribbean (LAC) and its visibility in the international palliative care literature, with a special focus on research studies.

METHODS

A bibliometric analysis was conducted in MEDLINE(®), Embase(®), PsycINFO(®), and CINAHL(®). Inclusion criteria were: (1) articles published in peer-reviewed scientific journals; (2) main subject was palliative care; (3) research study; (4) the first author or coauthors was based in LAC; and/or (5) the data collected derived from LAC.

RESULTS

One hundred six articles from 10 countries were identified in the literature research. The first publication dates from 1989 and was a qualitative study in Brazil. This study shows a modest contribution of publications from LAC. However, the volume of publications within the region is distributed unequally, reflecting the heterogeneity of the region: Brazil published more than half of the articles, while 35 countries have no publications. Most of the studies were quantitative research, predominantly cross-sectional studies. Qualitative studies often used interviews. Health care service was the most researched issue. Seventy percent of studies were carried out in institutions.

CONCLUSIONS

Palliative care research should have a place in LAC. The development of a regional research agenda tailored to the needs and features of the region considering the health care structure and local resources available is indispensable.

Use of palliative care services and general practitioner visits at the end of life in The Netherlands and Belgium

CONTEXT

At the end of life, some personalized and specialized care is required. The way that general practitioner (GP) visits and palliative care services at the end of life are organized in different countries may impact the frequency of care provision. However, nationwide data on the prevalence of these interventions and comparisons among countries are scarce.

OBJECTIVES

To compare the frequency of GP visits and use of palliative care services at the end of life in two European countries and identify the associated factors.

METHODS

In 2007, two mortality follow-back studies were conducted simultaneously in The Netherlands and Belgium, using existing Sentinel GP networks and similar standardized procedures. Within the one-year period, all registered patients who died at home or in a care home were selected.

RESULTS

From the data of 543 registered patients, GP visits were more frequent at the end of life in The Netherlands than in Belgium: the mean number of GP visits in the last week of life was 5.1 vs. 3.2 (home) and 4.4 vs. 2.3 (care home). Conversely, palliative care services in the last three months of life were used more frequently in Belgium than in The Netherlands: 78% vs. 41% (home) and 39% vs. 5% (care homes). The differences between countries remained consistent despite correcting for possible confounders. Having more frequent GP visits at home was associated with cancer-related deaths both in The Netherlands and Belgium.

CONCLUSION

Independent of the differences in patient populations (at home and care home) between countries, there are more frequent GP visits at the end of life in The Netherlands and greater use of palliative care services in Belgium.

A pan-European survey of research in end-of-life cancer care

Background

To date, there is no coordinated strategy for end-of-life (EOL) cancer care research in Europe. The PRISMA (Reflecting the Positive Diversities of European Priorities for Research and Measurement in End-of-life Care) project is aiming to develop a programme integrating research and measurement in EOL care. This survey aimed to map and describe present EOL cancer care research in Europe and to identify priorities and barriers.

Material and methods

A questionnaire of 62 questions was developed and 201 researchers in 41 European countries were invited to complete it online in May 2009. An open invitation to participate was posted on the internet.

Results

Invited contacts in 36 countries sent 127 replies; eight additional responses came through websites. A total of 127 responses were eligible for analysis. Respondents were 69 male and 58 female, mean age 49 (28–74) years; 85% of the scientific team leaders were physicians. Seventy-one of 127 research groups were located in a teaching hospital or cancer centre. Forty-five percent of the groups had only one to five members and 28% six to ten members. Sixty-three of 92 groups reported specific funding for EOL care research. Seventy-five percent of the groups had published papers in journals with impact factor ≤5 in the last 3 years; 8% had published in journals with impact factor >10. Forty-four out of 90 groups reported at least one completed Ph.D. in the last 3 years. The most frequently reported active research areas were pain, assessment and measurement tools, and last days of life and quality of death. Very similar areas—last days of life and quality of death, pain, fatigue and cachexia, and assessment and measurement tools—were ranked as the most important research priorities. The most important research barriers were lack of funding, lack of time, and insufficient knowledge/expertise.

Conclusions

Most research groups in EOL care are small. The few large groups (14%) had almost half of the reported publications, and more than half of the current Ph.D. students. There is a lack of a common strategy and coordination in EOL cancer care research and a great need for international collaboration.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-010-1048-x) contains supplementary material, which is available to authorized users.

Disparities in the contribution of low- and middle-income countries to palliative care research

CONTEXT

Important aspects of the palliative care needs of patients from low- and middle-income countries (LMIC) are largely unexplored. About 44 million of the 56 million annual deaths worldwide occur in developing countries, and it is estimated that more than 33 million of those concerned would benefit from palliative care. In this context, the understanding of specific social and cultural needs is fundamental to the development of appropriate health policy and clinical practice concerning palliative and end-of-life care.

OBJECTIVES

This study aims to answer the question: what are the contributions, in terms of generation of knowledge, of LMIC to the published palliative care literature?

METHODS

A bibliometric analysis was conducted in Medline and EMBASE (to June 2008). Articles were included when either the first author (institutional affiliation or contact address) or the data collection was derived from LMIC, as defined by criteria of the World Bank. Excluded were articles done in migrant and non-palliative care populations.

RESULTS

The literature search resulted in 845 references. In total, 245 articles coming from LMIC were identified, being published by 34 LMIC (27.3% of LMIC). The first publications appeared in 1982. The study shows a rather modest contribution of publications from LMIC. However, the volume of publications within LMIC is distributed unequally: upper-middle-income countries published almost half of the articles (46.9%), whereas only 11% of the publications came from low-income countries. In contrast, 104 LMIC (72.7% of LMIC) do not have any registered publications. Surprisingly, 25% of the articles with data from LMIC have been done and published by high-income countries. Reasons for the underrepresentation, as well a possible correction of this imbalance, are discussed.

CONCLUSION

Palliative care research should be a priority in LMIC, where many patients could benefit tremendously from it, and publication of findings in these countries should be encouraged.

Palliative care for Latino patients and their families: whenever we prayed, she wept

Latinos account for 15% of the US population, a proportion projected to grow to 30% by the year 2050. Although there is tremendous diversity within this community, commonalities of language, beliefs, attitudes, and behaviors unite Latinos, making them more similar than different. Differences by national origin, although important, are attenuated when immigrants come to the United States, dominated by an English-language, Anglo-centric culture. For non-Latino and non-Spanish-speaking clinicians, communication barriers and cultural misunderstandings can impede the care of dying Latino patients and their families. We present the case of a young, pregnant, Spanish-speaking woman from Central America diagnosed with a fatal leukemia. As illustrated by this case, Latino immigrants face a number of external challenges to optimal end-of-life care: (1) geographic distance as well as political and economic realities often separate patients from their valued families; (2) undocumented immigrants are frequently uninsured and fear of deportation may create a barrier to accessing health services; (3) language and literacy barriers; and (4) concerns about discrimination. Other Latino issues that may be more pronounced in end-of-life settings include cultural themes and religious and spiritual influences. We recommend that professional interpreters must be used for discussions about goals of care with Spanish-speaking patients and families or when negotiating conflict between the patient, family, and the health care team. Concrete suggestions are provided for clinicians in working with interpreters, eliciting culturally based attitudes and beliefs, and implementing universal strategies for clear health communication.