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Flierman I, Gieteling E, Van Rijn M, Van Grootven B, van Doorne I, Jamaludin FS, Willems DL, Muller M, Buurman BM. Effectiveness of transmural team-based palliative care in prevention of hospitalizations in patients at the end of life: A systematic review and meta-analysis. Palliat Med 2023; 37:75-87. [PMID: 36541477 DOI: 10.1177/02692163221135616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Team-based palliative care interventions have shown positive results for patients at the end of life in both hospital and community settings. However, evidence on the effectiveness of transmural, that is, spanning hospital and home, team-based palliative care collaborations is limited. AIM To systematically review whether transmural team-based palliative care interventions can prevent hospital admissions and increase death at home. DESIGN Systematic review and meta-analysis. DATA SOURCES MEDLINE (Ovid), Embase (Ovid), CINAHL (Ebsco), PsychINFO (Ovid), and Cochrane Library (Wiley) were systematically searched until January 2021. Studies incorporating teams in which hospital and community professionals co-managed patients, hospital-based teams with community follow-up, and case-management interventions led by palliative care teams were included. Data was extracted by two researchers independently. RESULTS About 19 studies were included involving 6614 patients, of whom 2202 received an intervention. The overall pooled odds ratio of at least one hospital (re)admissions was 0.46 (95% confidence interval (CI) 0.34-0.68) in favor of the intervention group. The highest reduction in admission was in the hospital-based teams with community follow-up: OR 0.21 (95% CI 0.07-0.66). The pooled effect on home deaths was 2.19 (95% CI 1.26-3.79), favoring the intervention, with also the highest in the hospital-based teams: OR 4.77 (95% CI 1.23-18.47). However, studies had high heterogeneity regarding intervention, study population, and follow-up time. CONCLUSION Transmural team-based palliative care interventions, especially hospital-based teams that follow-up patients at home, show an overall effect on lowering hospital admissions and increasing the number of patients dying at home. However, broad clinical and statistical heterogeneity of included studies results in uncertainty about the effect size.
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Affiliation(s)
- Isabelle Flierman
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam UMC Location AMC, University of Amsterdam, Department of General Practice, Section of Medical Ethics, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands
| | - Elske Gieteling
- Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands.,Amstelland Hospital, Department of Internal Medicine, Amstelveen, The Netherlands
| | - Marjon Van Rijn
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Center of Expertise Urban Vitality, Faculty of Health, Amsterdam University of Applied Science, Amsterdam, The Netherlands
| | - Bastiaan Van Grootven
- Research Foundation Flanders - FWO, Brussels, Belgium + KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium
| | - Iris van Doorne
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands
| | - Faridi S Jamaludin
- Amsterdam UMC, University of Amsterdam, Research Support, Medical Library AMC, Meibergdreef 9, Amsterdam, The Netherlands
| | - Dick L Willems
- Amsterdam UMC Location AMC, University of Amsterdam, Department of General Practice, Section of Medical Ethics, Amsterdam, The Netherlands
| | - Majon Muller
- Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands
| | - Bianca M Buurman
- Amsterdam UMC Location AMC, University of Amsterdam, Department of Internal Medicine, Section of Geriatric Medicine, Amsterdam, The Netherlands.,Amsterdam Public Health, Aging & Later life, Amsterdam, The Netherlands.,Amsterdam UMC Location VUmc, Department of Medicine for Older People, Amsterdam, The Netherlands
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Keall R, Lovell M. Extended-hours palliative care service with a hospital-avoidance and enhanced-care approach: report of a quality improvement project. Int J Palliat Nurs 2020; 26:222-228. [PMID: 32584690 DOI: 10.12968/ijpn.2020.26.5.222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND A community palliative care service (CPCS) identified its after-hours support as sub-optimal in avoiding acute hospitalisation and supporting patients to remain at home. It created and conducted a pilot of an extended hours palliative care service (EHPCS) using current resources. AIMS To evaluate the efficacy of an extended hours palliative care service pilot. METHODS Retrospective chart review of after-hours calls taken before the trial, usual care, was undertaken. During the trial, quantitative data was gathered of the outcome of each after-hours call, including outcomes of occasion of service, reason for and length and times of calls. FINDINGS The extended hours palliative care service, compared with usual care, showed an almost 50% decrease in acute hospitalisation, nearly doubled after-hours palliative care unit admission and a 17% increase in patients staying in their home. EHPCS was positively received by CPCS staff, despite cost and workforce impact. CONCLUSIONS EHPCS can positively impact on reducing avoidable hospitalisations and facilitate palliative care patients to be in their preferred place of care.
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Affiliation(s)
- Robyn Keall
- Nurse Practitioner (palliative care), HammondCare, Greenwich, Australia
| | - Melanie Lovell
- Professor, School of Medicine, University of Sydney, Australia
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3
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Soares LGL, Gomes RV, Palma A, Japiassu AM. Quality Indicators of End-of-Life Care Among Privately Insured People With Cancer in Brazil. Am J Hosp Palliat Care 2019; 37:594-599. [PMID: 31726853 DOI: 10.1177/1049909119888180] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
PURPOSE To examine quality indicators of end-of-life (EOL) care among privately insured people with cancer in Brazil. METHODS We evaluated medical records linked to health insurance databank to study consecutive patients who died of cancer. We collected information about demographics, cancer type, and quality indicators of EOL care including emergency department (ED) visits, intensive care unit (ICU) admissions, chemotherapy use, medical imaging utilization, blood transfusions, home care support, days of inpatient care, and hospital deaths. RESULTS We included 865 patients in the study. In the last 30 days of life, 62% visited the ED, 33% were admitted to the ICU, 24% received blood transfusions, and 51% underwent medical imaging. Only 1% had home care support in the last 60 days of life, and 29% used chemotherapy in the last 14 days of life. Patients had an average of 8 days of inpatient care and 52% died in the hospital. Patients with advanced cancer who used chemotherapy were more likely to visit the ED (78% vs 59%; P < .001), undergo medical imaging (67% vs 51%; P < .001), and die in the hospital (73% vs 50%; P = .03) than patients who did not use chemotherapy. In the multivariate analysis, chemotherapy use near death and advanced cancer were associated with ED visits and ICU admissions, respectively (odds ratio >1). CONCLUSION Our study suggests that privately insured people with cancer receive poor quality EOL care in Brazil. Further research is needed to assess the impact of improvements in palliative care provision in this population.
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Affiliation(s)
- Luiz Guilherme L Soares
- End of Life Care Study Group, Department of Health Services and Costs, Unimed Federação, Rio de Janeiro, Brazil.,Palliative Care Program, Hospital de Câncer/Rede Casa, Rio de Janeiro, Brazil
| | - Renato V Gomes
- End of Life Care Study Group, Department of Health Services and Costs, Unimed Federação, Rio de Janeiro, Brazil
| | - Alberto Palma
- End of Life Care Study Group, Department of Health Services and Costs, Unimed Federação, Rio de Janeiro, Brazil
| | - André M Japiassu
- Fundação Oswaldo Cruz, Research Laboratory of Intensive Care Medicine, Rio de Janeiro, Brazil
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4
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Jelinek GA, Boughey M, Marck CH, Phillip J, Weil J, Lane H, Weiland TJ. “Better pathways of Care”: Suggested Improvements to the Emergency Department management of People with Advanced Cancer. J Palliat Care 2018. [DOI: 10.1177/082585971403000203] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: It is difficult to provide optimal care to people with advanced cancer presenting to emergency departments (EDs). Recent data suggest that the ED environment, the skills and priorities of treating staff, and the lack of clear communication related to goals of care contribute to the difficulty. By exploring the views of emergency, palliative care (PC), and oncology clinicians on the care of these patients, this study aimed to describe potential solutions. Methods: This qualitative study involved focus groups with clinicians at two major hospitals and two community PC services in Melbourne, Australia, and semi-structured telephone interviews with emergency clinicians from all other Australian states and territories. Discussions were recorded and transcribed verbatim. Thematic analysis identified ways to improve or enhance care. Results: Throughout discussions with 94 clinicians, a number of possible improvements to care were raised; these were broadly grouped into service areas: clinical care, pathways, information access, and education. Conclusion: The provision of care to patients with advanced cancer in the ED occurs across sites, across disciplines, and across teams. To make improvements to care, we must address these complexities. The improvements suggested in this study place the patient (and the patient's family) at the centre of care.
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Affiliation(s)
- George A. Jelinek
- GA Jelinek (corresponding author): Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne; Emergency Practice Innovation Centre, St. Vincent's Hospital, Victoria Street, Fitzroy, VIC 3054, Australia
| | - Mark Boughey
- M Boughey, J Phillip, H Lane: Centre for Palliative Care, University of Melbourne; and St. Vincent's Hospital, Melbourne, Australia
| | - Claudia H. Marck
- CH Marck: Emergency Practice Innovation Centre, St. Vincent's Hospital, Melbourne, Australia
| | - Jennifer Phillip
- M Boughey, J Phillip, H Lane: Centre for Palliative Care, University of Melbourne; and St. Vincent's Hospital, Melbourne, Australia
| | - Jennifer Weil
- TJ Weiland: Emergency Practice Innovation Centre, St. Vincent's Hospital
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Heather Lane
- M Boughey, J Phillip, H Lane: Centre for Palliative Care, University of Melbourne; and St. Vincent's Hospital, Melbourne, Australia
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5
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Wang S, Hsu SH, Huang S, Doan KC, Gross CP, Ma X. Regional Practice Patterns and Racial/Ethnic Differences in Intensity of End-of-Life Care. Health Serv Res 2018; 53:4291-4309. [PMID: 29951996 PMCID: PMC6232508 DOI: 10.1111/1475-6773.12998] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine whether regional practice patterns impact racial/ethnic differences in intensity of end-of-life care for cancer decedents. DATA SOURCES The linked Surveillance, Epidemiology, and End Results (SEER)-Medicare database. STUDY DESIGN We classified hospital referral regions (HRRs) based on mean 6-month end-of-life care expenditures, which represented regional practice patterns. Using hierarchical generalized linear models, we examined racial/ethnic differences in the intensity of end-of-life care across levels of HRR expenditures. PRINCIPAL FINDINGS There was greater variation in intensity of end-of-life care among Hispanics, Asians, and whites in high-expenditure HRRs than in low-expenditure HRRs. CONCLUSIONS Local practice patterns may influence racial/ethnic differences in end-of-life care.
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Affiliation(s)
- Shi‐Yi Wang
- Department of Chronic Disease EpidemiologyYale University School of Public HealthNew HavenCT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale Cancer Center and Yale University School of MedicineNew HavenCT
| | - Sylvia H. Hsu
- Department of Chronic Disease EpidemiologyYale University School of Public HealthNew HavenCT
- Schulich School of BusinessYork UniversityTorontoONCanada
| | - Siwan Huang
- Department of BiostatisticsYale University School of Public HealthNew HavenCT
- Beijing PricewaterhouseCoopers Management Consulting (Shanghai) LimitedBeijingChina
| | - Kathy C. Doan
- Department of Social and Behavioral SciencesYale School of Public HealthYale UniversityNew HavenCT
| | - Cary P. Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale Cancer Center and Yale University School of MedicineNew HavenCT
- Section of General Internal MedicineDepartment of Internal MedicineYale University School of MedicineNew HavenCT
| | - Xiaomei Ma
- Department of Chronic Disease EpidemiologyYale University School of Public HealthNew HavenCT
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) CenterYale Cancer Center and Yale University School of MedicineNew HavenCT
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6
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DeCaria K, Dudgeon D, Green E, Shaw Moxam R, Rahal R, Niu J, Bryant H. Acute care hospitalization near the end of life for cancer patients who die in hospital in Canada. ACTA ACUST UNITED AC 2017; 24:256-261. [PMID: 28874894 DOI: 10.3747/co.24.3704] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute care hospitals have a role in managing the health care needs of people affected by cancer when they are at the end of life. However, there is a need to provide end-of-life care in other settings, including at home or in hospice, when such settings are more appropriate. Using data from 9 provinces, we examined indicators that describe the current landscape of acute care hospital use at the end of life for patients who died of cancer in hospital in Canada. Interprovincial variation was observed in acute care hospital deaths, length of stay in hospital, readmission to hospital, and intensive care unit use at the end of life. High rates of acute care hospital use near the end of life might suggest that community and home-based end-of-life care might not be suiting patient needs.
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Affiliation(s)
- K DeCaria
- Canadian Partnership Against Cancer, Toronto, and
| | - D Dudgeon
- Canadian Partnership Against Cancer, Toronto, and.,Departments of Medicine and of Oncology, Queen's University, Kingston, ON; and
| | - E Green
- Canadian Partnership Against Cancer, Toronto, and
| | - R Shaw Moxam
- Canadian Partnership Against Cancer, Toronto, and
| | - R Rahal
- Canadian Partnership Against Cancer, Toronto, and
| | - J Niu
- Canadian Partnership Against Cancer, Toronto, and
| | - H Bryant
- Canadian Partnership Against Cancer, Toronto, and.,Departments of Community Health Sciences and of Oncology, University of Calgary, Calgary, AB
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7
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Revels A, Sabo B, Snelgrove-Clarke E, Price S, Field S, Helwig M. Experiences of emergency department nurses in providing palliative care to adults with advanced cancer: a systematic review protocol. ACTA ACUST UNITED AC 2016; 14:75-86. [PMID: 27532465 DOI: 10.11124/jbisrir-2016-002647] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
REVIEW QUESTIONS/OBJECTIVES The objective of this review is to explore the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer so as to contribute to the developing knowledge base on this phenomenon and, in turn, inform future practice and policy changes. Specifically, the review question for this qualitative review is as follows: what are the experiences and perceptions of emergency department nurses in providing palliative care to adults with advanced cancer?
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Affiliation(s)
- Amanda Revels
- 1School of Nursing, Dalhousie University 2Faculty of Medicine, Dalhousie University 3Department of Pediatrics, IWK Health Centre 4Department of Emergency Medicine, Capital District Health Authority 5WK Kellogg Health Sciences Library, Dalhousie University 6Department of Obstetrics & Gynecology, IWK Health Centre, Halifax, Nova Scotia, Canada
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8
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Shimada N, Ishiki H, Iwase S, Chiba T, Fujiwara N, Watanabe A, Kinkawa J, Nojima M, Tojo A, Imai K. Cancer Transitional Care for Terminally Ill Cancer Patients Can Reduce the Number of Emergency Admissions and Emergency Department Visits. Am J Hosp Palliat Care 2016; 34:831-837. [PMID: 27413014 DOI: 10.1177/1049909116658641] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Emergency admissions and emergency department visits (EAs/EDVs) have been used as quality indicators of home care in terminally ill cancer patients. We established a cancer transitional care (CTC) program to monitor and manage terminally ill cancer patients receiving care at home. The purpose of this study was to evaluate the effectiveness of CTC by the frequency of EAs/EDVs. METHODS In a retrospective chart review, we identified 133 patients with cancer admitted to our department, of whom 56 met study eligibility criteria. The CTC consisted of at least 1 or more following components: (1) a 24-hour hotline for general physicians or home care nurses to reach hospital-based physicians, (2) periodic phone calls from an expert hospital-based oncology nurse to home care medical staff, and (3) reports sent to our department from home care medical staff. The primary outcome variable was the frequency of EAs/EDVs. RESULTS There were 32 EAs/EDVs and 69 planned admissions during the observation period. In the last 30 days of life, 16 patients (28.6%) had 1 EA/EDV and none had multiple EAs/EDVs. Compared with previous studies, our study found a similar or lower frequency of EAs/EDVs. CONCLUSION Our findings suggest that the implementation of CTC reduces the number of EAs/EDVs by replacing them with planned admissions. Further prospective studies to evaluate CTC are warranted.
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Affiliation(s)
- Naoki Shimada
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Hiroto Ishiki
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Satoru Iwase
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Tsukuru Chiba
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Noriko Fujiwara
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Aya Watanabe
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Junya Kinkawa
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Masanori Nojima
- 2 Center for Translational Research, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Arinobu Tojo
- 1 Department of Palliative Medicine, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.,3 Department of Hematology/Oncology, Research Hospital, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Kohzoh Imai
- 4 Center for Antibody and Vaccine Therapy, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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9
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Seow H, Barbera L, Pataky R, Lawson B, O'Leary E, Fassbender K, McGrail K, Burge F, Brouwers M, Sutradhar R. Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents. J Pain Symptom Manage 2016; 51:204-12. [PMID: 26514717 DOI: 10.1016/j.jpainsymman.2015.10.008] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 10/15/2015] [Accepted: 10/21/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Despite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life. OBJECTIVES To examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. METHODS We conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. RESULTS Our cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week. CONCLUSION Our study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week.
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Affiliation(s)
- Hsien Seow
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada; Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
| | - Lisa Barbera
- Department of Radiation Oncology, University of Toronto, Toronto, Ontario, Canada; Odette Cancer Centre, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Reka Pataky
- British Columbia Cancer Research Centre, Vancouver, British Columbia, Canada
| | - Beverley Lawson
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Erin O'Leary
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Konrad Fassbender
- Department of Palliative Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kim McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Fred Burge
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Melissa Brouwers
- Department of Oncology, McMaster University, Hamilton, Ontario, Canada
| | - Rinku Sutradhar
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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10
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Delgado-Guay MO, Rodriguez-Nunez A, Shin SH, Chisholm G, Williams J, Frisbee-Hume S, Bruera E. Characteristics and outcomes of patients with advanced cancer evaluated by a palliative care team at an emergency center. A retrospective study. Support Care Cancer 2015; 24:2287-2295. [DOI: 10.1007/s00520-015-3034-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/15/2015] [Indexed: 11/30/2022]
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Wong J, Gott M, Frey R, Jull A. What is the incidence of patients with palliative care needs presenting to the Emergency Department? a critical review. Palliat Med 2014; 28:1197-205. [PMID: 25118197 DOI: 10.1177/0269216314543318] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Given the context of ageing populations globally, there are a growing number of patients with chronic conditions, some of whom are in the final stages of their disease trajectory, presenting to Emergency Departments. AIM The aim was to estimate the incidence of patients with palliative care needs presenting to the department. METHODS Three databases (MEDLINE, CINAHL and Embase) were systematically searched up to August 2012. The reference lists of included articles were searched as well as Google and Google Scholar. Only studies in English were included. Two reviewers independently reviewed studies at the abstract and full-body stages. A critical review using systematic methods was undertaken as statistical analysis could not be done because of a lack of information. RESULTS Only 10 of 1427 identified records met the inclusion criteria. Different definitions of palliative care were evident. One article provided an incidence density for patients with non-small cell lung cancer, and we calculated the mean presentations to be 52.5 per 100 person-months. Two articles focussed on patients known to palliative care services; we estimated that 2.5 in 1000 Emergency Department visits were made by these patients. The review demonstrated that the studies were so different it was not possible to compare the data. CONCLUSION There is an absence of evidence regarding the incidence of patients with palliative care needs presenting to the Emergency Department. Further research needs to be undertaken in this area to ensure both clinicians and policymakers have sufficient information for service provision.
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Affiliation(s)
- Joanne Wong
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Andrew Jull
- School of Nursing, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Abstract
Canadian population mortality data reveal a significantly reduced proportion of deaths occurring in hospitals after 1994. Hospital deaths peaked at 80.5% in 1994, after a longstanding hospitalization-of-death trend in Canada. A decline in hospital-based death and dying has also occurred in some other countries. As the place of death can have multiple significant direct and indirect impacts on dying individuals, their families, and health services utilization and costs, it is important to understand factors for an out-of-hospital shift. An integrative review of Canadian print literature from 1995 was undertaken to identify these factors, with three themes emerging: (1) changes in health care and health system reforms after 1994 reduced both the availability and desirability of hospital-based care, (2) sociodemographic developments including aging of the population, increased multiculturalism, and diversity in accepted end-of-life care practices shifted place preferences, and (3) advances in palliative and end-of-life care, including a palliative care expansion out of hospital, supported nonhospital death, and dying processes. The period following 1994 was thus a time of major transformation during which the place of death and dying underwent important changes that supported and promoted a transition from hospital-based end-of-life care.
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13
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Healthcare Utilization by Patients Whose Care is Managed by a Primary Palliative Care Clinic. J Hosp Palliat Nurs 2013; 15. [PMID: 24363610 DOI: 10.1097/njh.0b013e3182a02b9d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Lamba S, DeSandre PL, Todd KH, Bryant EN, Chan GK, Grudzen CR, Weissman DE, Quest TE. Integration of palliative care into emergency medicine: the Improving Palliative Care in Emergency Medicine (IPAL-EM) collaboration. J Emerg Med 2013; 46:264-70. [PMID: 24286714 DOI: 10.1016/j.jemermed.2013.08.087] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2012] [Revised: 07/16/2013] [Accepted: 08/16/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Emergency department (ED) providers commonly care for seriously ill patients who suffer from advanced, chronic, life-limiting illnesses in addition to those that are acutely ill or injured. Both the chronically ill and those who present in extremis may benefit from application of palliative care principles. CASE REPORT We present a case highlighting the opportunities and need for better integration of emergency medicine and palliative care. DISCUSSION We offer practical guidelines to the ED faculty/administrators who seek to enhance the quality of patient care in their own unique ED setting by starting an initiative that better integrates palliative principles into daily practice. Specifically, we outline four things to do to jumpstart this collaborative effort. CONCLUSION The Improving Palliative Care in Emergency Medicine project sponsored by the Center to Advance Palliative Care is a resource that assists ED health care providers with the process and structure needed to integrate palliative care into the ED setting.
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Affiliation(s)
- Sangeeta Lamba
- Department of Emergency Medicine, Rutgers-New Jersey Medical School, Newark, New Jersey
| | - Paul L DeSandre
- Department of Veteran's Affairs, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Knox H Todd
- Department of Emergency Medicine, MD Anderson Cancer Center, University of Texas, Houston, Texas
| | - Eric N Bryant
- The Institute for Palliative Medicine at San Diego Hospice, San Diego, California
| | - Garrett K Chan
- Department of Physiological Nursing, University of California, San Francisco, San Francisco, California; Emergency Department Clinical Decision Unit and Palliative Care Service, Stanford Hospital & Clinics, Stanford, California
| | - Corita R Grudzen
- Department of Emergency Medicine, Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - David E Weissman
- Medical College of Wisconsin Palliative Care Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tammie E Quest
- Department of Veteran's Affairs, Atlanta, Georgia; Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
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Demiglio L, Williams AM. A qualitative study examining the sustainability of shared care in the delivery of palliative care services in the community. BMC Palliat Care 2013; 12:32. [PMID: 23984638 PMCID: PMC3844373 DOI: 10.1186/1472-684x-12-32] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 08/12/2013] [Indexed: 11/12/2022] Open
Abstract
Background This paper focuses on the sustainability of existing palliative care teams that provide home-based care in a shared care model. For the purposes of this study, following Evashwick and Ory (2003), sustainability is understood and approached as the ability to continue the program over time. Understanding factors that influence the sustainability of teams and ways to mitigate these factors is paramount to improving the longevity and quality of service delivery models of this kind. Methods Using qualitative data collected in interviews, the aim of this study is twofold: (1) to explore the factors that affect the sustainability of the teams at three different scales, and; (2) based on the results of this study, to propose a set of recommendations that will contribute to the sustainability of PC teams. Results Sustainability was conceptualized from two angles: internal and external. An overview of external sustainability was provided and the merging of data from all participant groups showed that the sustainability of teams was largely dependent on actors and organizations at the local (community), regional (Local Health Integration Network or LHIN) and provincial scales. The three scales are not self-contained or singular entities but rather are connected. Integration and collaboration within and between scales is necessary, as community capacity will inevitably reach its threshold without support of the province, which provides funding to the LHIN. While the community continues to advocate for the teams, in the long-term, they will need additional supports from the LHIN and province. The province has the authority and capacity to engrain its support for teams through a formal strategy. The recommendations are presented based on scale to better illustrate how actors and organizations could move forward. Conclusions This study may inform program and policy specific to strategic ways to improve the provision of team-based palliative home care using a shared care model, while simultaneously providing direction for team-based program delivery and sustainability for other jurisdictions.
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Affiliation(s)
- Lily Demiglio
- School of Geography and Earth Sciences, McMaster University, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada.
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16
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Do Patient-Reported Symptoms Predict Emergency Department Visits in Cancer Patients? A Population-Based Analysis. Ann Emerg Med 2013; 61:427-437.e5. [DOI: 10.1016/j.annemergmed.2012.10.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 10/02/2012] [Accepted: 10/05/2012] [Indexed: 11/18/2022]
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Quest T, Herr S, Lamba S, Weissman D. Demonstrations of clinical initiatives to improve palliative care in the emergency department: a report from the IPAL-EM Initiative. Ann Emerg Med 2013; 61:661-7. [PMID: 23548402 DOI: 10.1016/j.annemergmed.2013.01.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Revised: 12/31/2012] [Accepted: 01/14/2013] [Indexed: 12/12/2022]
Abstract
STUDY OBJECTIVE We describe 11 clinical demonstrations of emergency department (ED) and palliative care integration to include traditional consultation services with hospital-based palliative care consultants through advanced integration demonstrations in which the ED provides subspecialty palliative care practice. METHODS An interview guide was developed by the Improving Palliative Care in Emergency Medicine board that consists of emergency clinicians and palliative care practitioners. Structured interviews of 11 program leaders were conducted to describe the following key elements of the ED-palliative care integration, to include structure, function, and process of the programs, as well as strengths, areas of improvement, and any tools or outcome measures developed. RESULTS In this limited number of programs, a variety of strategies are used to integrate palliative care in the ED, from traditional consultation to well-defined partnerships that include board-certified emergency clinicians in hospice and palliative medicine. CONCLUSION A variety of methods to integrate palliative care in the emergency setting have emerged. Few programs collect outcomes-based metrics, and there is a lack of standardization about what metrics are tracked when tracking occurs.
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Affiliation(s)
- Tammie Quest
- Department of Veterans Affairs and Emory University, Atlanta, GA, USA.
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Limehouse WE, Ramana Feeser V, Bookman KJ, Derse A. A model for emergency department end-of-life communications after acute devastating events--part II: moving from resuscitative to end-of-life or palliative treatment. Acad Emerg Med 2012; 19:1300-8. [PMID: 23167864 DOI: 10.1111/acem.12018] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Revised: 05/31/2012] [Accepted: 06/14/2012] [Indexed: 12/20/2022]
Abstract
The model for emergency department (ED) end-of-life communications after acute devastating events addresses decision-making capacity, surrogates, and advance directives, including legal definitions and application of these steps. Part II concerns communications moving from resuscitative to palliative and end-of-life treatments. After completing the steps involved in determining decision-making, emergency physicians (EPs) should consider starting palliative measures versus continuing resuscitative treatment. As communications related to these end-of-life decisions increasingly fall within the scope of emergency medicine (EM) practice, we need to become educated about and comfortable with them.
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Affiliation(s)
- Walter E. Limehouse
- Department of Medicine; Division of Emergency Medicine; Medical University of South Carolina; Charleston SC
| | - V. Ramana Feeser
- Department of Emergency Medicine; Virginia Commonwealth University Medical Center; Richmond VA
| | - Kelly J. Bookman
- Department of Emergency Medicine; University of Colorado; Aurora CO
| | - Arthur Derse
- Department of Emergency Medicine and Center for Bioethics and Medical Humanities Medical College of Wisconsin; Milwaukee WI
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DeMiglio L, Williams A. Shared care: the barriers encountered by community-based palliative care teams in Ontario, Canada. HEALTH & SOCIAL CARE IN THE COMMUNITY 2012; 20:420-429. [PMID: 22469189 DOI: 10.1111/j.1365-2524.2012.01060.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
To meet the complex needs of patients requiring palliative care and to deliver holistic end-of-life care to patients and their families, an interprofessional team approach is recommended. Expert palliative care teams work to improve the quality of life of patients and families through pain and symptom management, and psychosocial spiritual and bereavement support. By establishing shared care models in the community setting, teams support primary healthcare providers such as family physicians and community nurses who often have little exposure to palliative care in their training. As a result, palliative care teams strive to improve not only the end-of-life experience of patients and families, but also the palliative care capacity of primary healthcare providers. The aim of this qualitative study was to explore the views and experiences of community-based palliative care team members and key-informants about the barriers involved using a shared care model to provide care in the community. A thematic analysis approach was used to analyse interviews with five community-based palliative care teams and six key-informants, which took place between December 2010 and March 2011. Using the 3-I framework, this study explores the impacts of Institution-related barriers (i.e. the healthcare system), Interest-related barriers (i.e. motivations of stakeholders) and Idea-related barriers (i.e. values of stakeholders and information/research), on community-based palliative care teams in Ontario, Canada. On the basis of the perspective of team members and key-informants, it is suggested that palliative care teams experience sociopolitical barriers in an effort to establish shared care in the community setting. It is important to examine the barriers encountered by palliative care teams to address how to better develop and sustain them in the community.
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Affiliation(s)
- Lily DeMiglio
- School of Geography & Earth Sciences, McMaster University, Hamilton, ON, Canada.
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Grudzen CR, Hwang U, Cohen JA, Fischman M, Morrison RS. Characteristics of emergency department patients who receive a palliative care consultation. J Palliat Med 2012; 15:396-9. [PMID: 22468771 DOI: 10.1089/jpm.2011.0376] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND A large gap exists between the practice of emergency medicine and palliative care. Although hospice and palliative medicine has recently been recognized as a subspecialty of emergency medicine, few palliative care teams routinely interact with emergency providers, and primary palliative care skills among emergency providers are lacking. OBJECTIVE To identify the proportion and characteristics of patients who receive a palliative care consultation and arrive via the emergency department (ED). METHODS A descriptive study of adult ED patients from an urban, academic tertiary care hospital who received a palliative care consultation in January 2005 or January 2009. RESULTS In January 2005, 100 of the 161 consults (62%) arrived via the ED versus 63 of 124 consults (51%) in January 2009 (p=0.06). Mean days from admission to consultation in January 2005 were six days (standard deviation 11), versus nine days (SD 26) in January 2009 (p=0.35). Three of the 100 consultations (3%) in January 2005 were initiated in the ED, versus 4 of the 64 (6%) in January 2009. CONCLUSIONS At an urban academic medical center with a well-developed palliative care service, the majority of palliative care consultations were for patients who arrive via the ED. Despite this, only a small minority of consultations originated from emergency providers and consultation was on average initiated days into a patient's hospital stay.
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Affiliation(s)
- Corita R Grudzen
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Quest TE, Asplin BR, Cairns CB, Hwang U, Pines JM. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med 2011; 18:e70-6. [PMID: 21676052 PMCID: PMC3368013 DOI: 10.1111/j.1553-2712.2011.01088.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Palliative care focuses on the physical, spiritual, psychological, and social care from diagnosis to cure or death of a potentially life-threatening illness. When cure is not attainable and end of life approaches, the intensity of palliative care is enhanced to deliver the highest quality care experience. The emergency department (ED) frequently cares for patients and families during the end-of-life phase of the palliative care continuum. The intersection between palliative care and emergency care continues to be more clearly defined. Currently, there is a mounting body of evidence to guide the most effective strategies for improving palliative and end-of-life care in the ED. In a workgroup session at the 2009 Agency for Healthcare Research and Quality (AHRQ)/American College of Emergency Physicians (ACEP) conference "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach," four key research questions arose: 1) which patients are in greatest need of palliative care services in the ED, 2) what is the optimal role of emergency clinicians in caring for patients along a chronic trajectory of illness, 3) how does the integration and initiation of palliative care training and services in the ED setting affect health care utilization, and 4) what are the educational priorities for emergency clinical providers in the domain of palliative care? Workgroup leaders suggest that these four key questions may be answered by strengthening the evidence using six categories of inquiry: descriptive, attitudinal, screening, outcomes, resource allocation, and education of clinicians.
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