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Walshe C, Dunleavy L, Preston N, Payne S, Ellershaw J, Taylor V, Mason S, Nwosu AC, Gadoud A, Board R, Swash B, Coyle S, Dickman A, Partridge A, Halvorsen J, Hulbert-Williams N. Understanding barriers and facilitators to palliative and end-of-life care research: a mixed method study of generalist and specialist health, social care, and research professionals. BMC Palliat Care 2024; 23:159. [PMID: 38918771 PMCID: PMC11202245 DOI: 10.1186/s12904-024-01488-2] [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: 05/16/2023] [Accepted: 06/14/2024] [Indexed: 06/27/2024] Open
Abstract
BACKGROUND Palliative care provision should be driven by high quality research evidence. However, there are barriers to conducting research. Most research attention focuses on potential patient barriers; staff and organisational issues that affect research involvement are underexplored. The aim of this research is to understand professional and organisational facilitators and barriers to conducting palliative care research. METHODS A mixed methods study, using an open cross-sectional online survey, followed by working groups using nominal group techniques. Participants were professionals interested in palliative care research, working as generalist/specialist palliative care providers, or palliative care research staff across areas of North West England. Recruitment was via local health organisations, personal networks, and social media in 2022. Data were examined using descriptive statistics and content analysis. RESULTS Participants (survey n = 293, working groups n = 20) were mainly from clinical settings (71%) with 45% nurses and 45% working more than 10 years in palliative care. 75% were not active in research but 73% indicated a desire to increase research involvement. Key barriers included lack of organisational research culture and capacity (including prioritisation and available time); research knowledge (including skills/expertise and funding opportunities); research infrastructure (including collaborative opportunities across multiple organisations and governance challenges); and patient and public perceptions of research (including vulnerabilities and burdens). Key facilitators included dedicated research staff, and active research groups, collaborations, and networking opportunities. CONCLUSIONS Professionals working in palliative care are keen to be research active, but lack time, skills, and support to build research capabilities and collaborations. A shift in organisational culture is needed to enhance palliative care research capacity and collaborative opportunities across clinical and research settings.
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Affiliation(s)
- Catherine Walshe
- International Observatory On End-of-Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK.
| | - Lesley Dunleavy
- International Observatory On End-of-Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Nancy Preston
- International Observatory On End-of-Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Sheila Payne
- International Observatory On End-of-Life Care, Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | | | | | | | | | - Amy Gadoud
- Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Ruth Board
- Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | | | - Seamus Coyle
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool, UK
| | - Andrew Dickman
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | | | - Jaime Halvorsen
- NIHR Clinical Research Network North West Coast, Liverpool, UK
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2
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Kutner JS, Pollak KI, Kehl KA, Ritchie CS. Advancing the Science of Palliative Care: Contributions of the Palliative Care Research Cooperative Group. J Palliat Med 2024; 27:588-593. [PMID: 38324008 PMCID: PMC11238828 DOI: 10.1089/jpm.2023.0627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/08/2024] Open
Abstract
The Palliative Care Research Cooperative Group (PCRC) formed to lead, catalyze, and empower a community of scientists to build an evidence base to ensure high-quality care and optimal well-being for persons with serious illness and their caregivers. The PCRC grew to 630 members representing 220 distinct sites. The PCRC awarded 44 pilot grant awards (total investment $1.4 million), resulting in $15.8 million in extramural grant funding, supported monthly webinars, an annual mentorship selective, "Clinical Trials Intensives," research consultation, and grant review. Among the 169 Clinical Trials Intensive participants, 74 subsequently achieved extramural grant award funding with direct costs of over $139 million. The PCRC supported the submission of extramural research applications and fostered community through annual meetings, special interest groups, newsletters, and its website. The PCRC filled an important void in serious illness science and set the stage for the next era of advancing serious illness research.
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Affiliation(s)
- Jean S. Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kathryn I. Pollak
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
- Cancer Prevention and Control, Duke Cancer Institute, Durham, North Carolina, USA
| | - Karen A. Kehl
- Division of Extramural Science Programs, National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Christine S. Ritchie
- Department of Medicine and Center for Aging and Serious Illness, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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3
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Arch JJ, Fishbein JN, Finkelstein LB, Luoma JB. Acceptance and Commitment Therapy Processes and Mediation: Challenges and How to Address Them. Behav Ther 2023; 54:971-988. [PMID: 37863588 PMCID: PMC10665126 DOI: 10.1016/j.beth.2022.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 05/03/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022]
Abstract
Acceptance and commitment therapy (ACT) emphasizes a focus on theory-driven processes and mediating variables, a laudable approach. The implementation of this approach would be advanced by addressing five challenges, including (a) distinguishing ACT processes in measurement contexts, (b) developing and rigorously validating measures of ACT processes, (c) the wide use of psychometrically weaker ACT process measures and the more limited use of stronger measures in earlier work, (d) the inconsistency of past evidence that ACT processes are sensitive or specific to ACT or mediate ACT outcomes specifically, and (e) improving statistical power and transparency. Drawing on the existing literature, we characterize and provide evidence for each of these challenges. We then offer detailed recommendations for how to address each challenge in ongoing and future work. Given ACT's core focus on theorized processes, improving the measurement and evaluation of these processes would significantly advance the field's understanding of ACT.
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Affiliation(s)
- Joanna J Arch
- University of Colorado Boulder and University of Colorado Cancer Center.
| | | | | | - Jason B Luoma
- Portland Psychotherapy Clinic, Research and Training Center
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4
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Micco A, Carpentieri E, Di Sorbo A, Chetta A, Del Donno M. Palliative care and end of life management in patients with idiopathic pulmonary fibrosis. Multidiscip Respir Med 2023; 18:896. [PMID: 36909932 PMCID: PMC9994447 DOI: 10.4081/mrm.2023.896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 01/25/2023] [Indexed: 02/23/2023] Open
Abstract
Idiopathic pulmonary fibrosis (IPF) is a chronic disease with an unknown etiology that causes deterioration of the structure of the lung parenchyma, resulting in a severe and progressive decline in respiratory function and early mortality. IPF is essentially an incurable disease, with a mean overall survival of 5 years in approximately 20% of patients without treatment. The combination of a poor prognosis, uncertainty about the disease's progression, and the severity of symptoms has a significant impact on the quality of life of patients and their families. New antifibrotic drugs have been shown to slow disease progression, but their impact on health-related quality of life (HRQoL) has to be proven yet. To date, studies have shown that palliative care can improve symptom management, HRQoL, and end-of-life care (EoL) in patients with IPF, reducing critical events, hospitalization, and health costs. As a result, it is essential for proper health planning and patient management to establish palliative care early and in conjunction with other therapies, beginning with the initial diagnosis of the disease.
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Affiliation(s)
| | | | | | - Alfredo Chetta
- Pneumology Clinic, Department of Medicine and Surgery, University of Parma, Italy
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5
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Dewhurst F, Wakefield D, Elverson J, McConnell R, Bryan C, Spriggs H, Atkinson K, Frew K. Palliative care inpatients favour research participation irrespective of prognosis, performance or socioeconomic status: multicentre cohort study. BMJ Support Palliat Care 2022:spcare-2022-004037. [PMID: 36522142 DOI: 10.1136/spcare-2022-004037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 11/29/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Palliative care needs to embrace research to guide service development and effective symptom management. Healthcare professionals often feel research is too burdensome for patients who have poor performance status or are near the end of life. Many studies exclude these groups from participating.We aimed to identify whether specialist palliative care inpatients would wish to take part in research and whether preference varies according to study design, demographics, diagnosis, performance status and prognosis. METHODS 100 inpatients in two National Health Service specialist palliative care units and one independent hospice in the Northeast of England completed a short questionnaire about preferences for involvement in research. RESULTS 92% of participants stated they were interested in being involved in research. This was mostly unaffected by age, diagnosis, prognosis, performance and socioeconomic status. Three-quarters were within the last 3 months of life. Simple questions or interviews were the preferred methodology, whereas only half of patients would want further investigations or additional medications and fewer still wanted to participate in online activities, lifestyle change or group activities. CONCLUSIONS Palliative care inpatients welcome the opportunity to be involved in research and should not be excluded on the grounds of advanced disease, poor prognosis and low performance status.
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Affiliation(s)
- Felicity Dewhurst
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
- St Oswald's Hospice, Newcastle upon Tyne, UK
| | - Donna Wakefield
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
- Specialist Palliative Care Team, North Tees and Hartlepool NHS Foundation Trust, Stockton-on-Tees, UK
| | - Joanna Elverson
- St Oswald's Hospice, Newcastle upon Tyne, UK
- Specialist Palliative Care Team, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | | | - Charlotte Bryan
- Specialist Palliative Care Team, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | | | - Kate Atkinson
- Health Education North East, Newcastle upon Tyne, UK
| | - Katherine Frew
- Specialist Palliative Care Team, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
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6
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Abstract
Systems for end of life care around the world vary in availability, structure, and funding. When available, most end of life care is in the hospice model with an interdisciplinary team approach to care of people who are expected to die within months and whose primary goal is to maximize quality of life. Symptom management near the end of life is guided by prognosis and individual priorities. People dying with neurologic disease are likely to have impaired communication or mobility that adds to the complexity of prognostication and symptom management. Neurologic specialists have important roles to play in end of life care due to their unique understanding of disease prognosis as well as end of life symptom burden and management. Neurologic specialists need to become strong advocates for the importance of end of life care by being actively involved in the hospice movement and by addressing current disparities in access to care.
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Affiliation(s)
- Farrah N Daly
- EvenBeam Neuropalliative Care, Leesburg, VA, United States.
| | - Usha Ramanathan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
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7
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Helde Frankling M, Klasson C, Björkhem-Bergman L. Successful Strategies and Areas of Improvement-Lessons Learned from Design and Conduction of a Randomized Placebo-Controlled Trial in Palliative Care, 'Palliative-D'. Life (Basel) 2021; 11:life11111233. [PMID: 34833109 PMCID: PMC8619948 DOI: 10.3390/life11111233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 12/17/2022] Open
Abstract
Clinical trials in palliative care are challenging to design and conduct. Burden on patients should be minimized, while gatekeeping by professionals and next-of kin needs to be avoided. Clinical deterioration due to disease progression affects attrition unrelated to intervention, and different care settings complicate comparisons and reduce the generalizability of the results. The aim of this review is to provide advice for colleagues planning to perform clinical trials in palliative care based on our own experiences from performing the Palliative-D study and by a thorough literature review on this topic. The Palliative-D study was a double-blind trial with 244 randomized patients comparing the effect of vitamin D3 to placebo in patients with advanced or metastatic cancer in the palliative phase of their disease trajectory who were enrolled in specialized palliative home care teams. Endpoints were opioid and antibiotic use, fatigue, and QoL. Recruitment was successful, but attrition rates were higher than expected, and we did not reach targeted power. For the 150 patients who completed the study, the completeness of the data was exceptionally high. Rather than patient reported pain, we choose the difference in the mean change in opioid dose between groups after twelve weeks compared to baseline as the primary endpoint. In this paper we discuss challenges in palliative care research based on lessons learned from the "Palliative-D" trial regarding successful strategies as well as areas for improvement.
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Affiliation(s)
- Maria Helde Frankling
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo Floor 7, SE-141 83 Huddinge, Sweden; (C.K.); (L.B.-B.)
- Thoracic Oncology Center, Theme Cancer, Karolinska University Hospital, Solna, SE-171 64 Stockholm, Sweden
- Correspondence:
| | - Caritha Klasson
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo Floor 7, SE-141 83 Huddinge, Sweden; (C.K.); (L.B.-B.)
- Stockholms Sjukhem, Palliative Medicine, Mariebergsgatan 22, SE-112 19 Stockholm, Sweden
| | - Linda Björkhem-Bergman
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, Blickagången 16, Neo Floor 7, SE-141 83 Huddinge, Sweden; (C.K.); (L.B.-B.)
- Stockholms Sjukhem, Palliative Medicine, Mariebergsgatan 22, SE-112 19 Stockholm, Sweden
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8
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Akard TF, Gilmer MJ. Research Cooperative Groups in Pediatric Palliative Care Research. Palliat Med Rep 2020; 1:321-325. [PMID: 34223492 PMCID: PMC8241338 DOI: 10.1089/pmr.2020.0043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2020] [Indexed: 11/20/2022] Open
Abstract
Research cooperative groups aim to facilitate collaborative and rigorous palliative care research. The purpose of this article is to (1) demonstrate how cooperative groups are taking formal and sustainable steps with commitment to pediatric palliative care research programs and (2) provide an example of how one cooperative group is implementing these innovative efforts to partner with programs to integrate pediatrics on an expanding scale. Details are described for how pediatric studies can benefit from cooperative group infrastructure and expertise. In turn, we describe how cooperative groups can benefit from collaborating on pediatric studies through broadening of data dictionaries, data repositories, and reach in palliative care research communities.
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Affiliation(s)
| | - Mary Jo Gilmer
- School of Nursing, Vanderbilt University, Nashville, Tennessee, USA
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9
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Kutner JS, Ritchie CS, Pollak KI. Better Together: The Palliative Care Research Cooperative Group as a Model for Increasing Equity in the Science of Hospice and Palliative Care. J Palliat Med 2020; 23:601-602. [PMID: 31977271 DOI: 10.1089/jpm.2019.0684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jean S Kutner
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Christine S Ritchie
- Department of Medicine, Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn I Pollak
- Department of Population Health Sciences, Duke University Medical Center, Durham, North Carolina, USA
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10
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Zarowitz BJ, Nace DA, Brandt N, Schwartz JB. Pharmacotherapy Research Priorities in Older Adults With Cardiovascular Disease in Nursing Homes, Assisted Living, and Home Care: Report From a Satellite Symposium of the ACC, AGS, NIA Workshop. J Am Med Dir Assoc 2019; 20:787-789. [PMID: 30922866 PMCID: PMC11060503 DOI: 10.1016/j.jamda.2019.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 02/05/2019] [Accepted: 02/07/2019] [Indexed: 01/24/2023]
Affiliation(s)
- Barbara J Zarowitz
- The Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy, Baltimore, MD
| | - David A Nace
- Division of Geriatric Medicine, University of Pittsburgh and Chief of Medical Affairs, UPMC Senior Communities, Pittsburgh, PA
| | - Nicole Brandt
- The Peter Lamy Center on Drug Therapy and Aging, University of Maryland School of Pharmacy, Baltimore, MD
| | - Janice B Schwartz
- Bioengineering & Therapeutic Sciences, University of California in San Francisco and Visiting Research Scientist, San Francisco, CA
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11
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Cross SH, Kamal AH, Taylor DH, Warraich HJ. Hospice Use Among Patients with Heart Failure. Card Fail Rev 2019; 5:93-98. [PMID: 31179019 PMCID: PMC6545999 DOI: 10.15420/cfr.2019.2.2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 03/26/2019] [Indexed: 12/11/2022] Open
Abstract
Despite its many benefits, hospice care is underused for patients with heart failure. This paper discusses the factors contributing to this underuse and offers recommendations to optimise use for patients with heart failure and proposes metrics to optimise quality of hospice care for this patient group.
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Affiliation(s)
- Sarah H Cross
- Sanford School of Public Policy, Duke University Durham, NC, US
| | - Arif H Kamal
- Duke Cancer Institute Durham, NC, US.,Duke Fuqua School of Business, Duke University Durham, NC, US
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University Durham, NC, US.,Margolis Center for Health Policy, Duke University Durham, NC, US.,Duke Clinical Research Institute Durham, NC, US
| | - Haider J Warraich
- Department of Medicine, Division of Cardiology, Duke University Medical Center Durham, NC, US
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12
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Bylund-Grenklo T, Werkander-Harstäde C, Sandgren A, Benzein E, Östlund U. Dignity in life and care: the perspectives of Swedish patients in a palliative care context. Int J Palliat Nurs 2019; 25:193-201. [DOI: 10.12968/ijpn.2019.25.4.193] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tove Bylund-Grenklo
- Senior Lecturer, Department of Caring Science, University of Gävle, and (affiliated) Department of Oncology Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Carina Werkander-Harstäde
- Senior Lecturer, Department of Health and Caring Sciences, Linnaeus University, Växjö, and Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Anna Sandgren
- Associate Professor, Department of Health and Caring Sciences, Linnaeus University, Växjö and Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Eva Benzein
- Professor, Department of Health and Caring Sciences, Linnaeus University, Kalmar and Center for Collaborative Palliative Care, Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Ulrika Östlund
- Associate Professor, Research Supervisor, Centre for Research and Development, Uppsala University/Region Gävleborg, Gävle; (affiliated) Faculty of Medicine and Health, School of Health Sciences, Örebro University; and (affiliated) Department of Public Health and Caring Sciences, Uppsala University, Uppsala, Sweden
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13
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Lyons KD, Padgett LS, Marshall TF, Greer JA, Silver JK, Raj VS, Zucker DS, Fu JB, Pergolotti M, Sleight AG, Alfano CM. Follow the trail: Using insights from the growth of palliative care to propose a roadmap for cancer rehabilitation. CA Cancer J Clin 2019; 69:113-126. [PMID: 30457670 DOI: 10.3322/caac.21549] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite research explicating the benefits of cancer rehabilitation interventions to optimize physical, social, emotional, and vocational functioning, many reports document low rates of referral to and uptake of rehabilitation in oncology. Cancer rehabilitation clinicians, researchers, and policy makers could learn from the multidisciplinary specialty of palliative care, which has benefited from a growth strategy and has garnered national recognition as an important and necessary aspect of oncology care. The purpose of this article is to explore the actions that have increased the uptake and integration of palliative care to yield insights and multimodal strategies for the development and growth of cancer rehabilitation. After examining the history of palliative care and its growth, the authors highlight 5 key strategies that may benefit the field of cancer rehabilitation: 1) stimulating the science in specific gap areas; 2) creating clinical practice guidelines; 3) building clinical capacity; 4) ascertaining and responding to public opinion; and 5) advocating for public policy change. Coordinated and simultaneous advances on these 5 strategies may catalyze the growth, utilization, and effectiveness of patient screening, timely referrals, and delivery of appropriate cancer rehabilitation care that reduces disability and improves quality of life for cancer survivors who need these services.
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Affiliation(s)
- Kathleen D Lyons
- Scientist, Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH
- Assistant Professor of Psychiatry, Department of Psychiatry, Dartmouth College, Hanover, NH
| | - Lynne S Padgett
- Health Psychologist, Washington DC Veterans Affairs Medical Center, Washington, DC
| | - Timothy F Marshall
- Assistant Professor, School of Physical Therapy, Kean University, Union, NJ
| | - Joseph A Greer
- Program Director, Center for Psychiatric Oncology & Behavioral Sciences, Massachusetts General Hospital, Boston, MA
- Assistant Professor of Psychology, Harvard Medical School, Boston, MA
| | - Julie K Silver
- Associate Professor, Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Boston, MA
- Associate in Physiatry, Massachusetts General Hospital and Brigham and Women's Hospital, Boston, MA
| | - Vishwa S Raj
- Associate Professor, Director of Oncology Rehabilitation, Department of Physical Medicine and Rehabilitation, Carolinas Rehabilitation, Department of Supportive Care, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - David S Zucker
- Medical Director & Program Leader, Cancer Rehabilitation Services, Swedish Cancer Institute, Swedish Medical Center, Seattle, WA
| | - Jack B Fu
- Associate Professor, Division of Cancer Medicine, Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Mackenzi Pergolotti
- Director of Research, ReVital Cancer Rehabilitation, Select Medical, Mechanicsburg, PA
| | - Alix G Sleight
- Postdoctoral Fellow, Keck School of Medicine, Department of Preventive Medicine, University of Southern California, Los Angeles, CA
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14
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Courteau C, Chaput G, Musgrave L, Khadoury A. Patients with advanced cancer: when, why, and how to refer to palliative care services. ACTA ACUST UNITED AC 2019; 25:403-408. [PMID: 30607115 DOI: 10.3747/co.25.4453] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Palliative care (pc) is a fundamental component of the cancer care trajectory. Its primary focus is on "the quality of life of people who have a life-threatening illness, and includes pain and symptom management, skilled psychosocial, emotional and spiritual support" to patients and loved ones. Palliative care includes, but is not limited to, end-of-life care. The benefits of early introduction of pc services in the care trajectory of patients with advanced cancer are well known, as indicated by improved quality of life, satisfaction with care, and a potential for increased survival. In turn, early referral of patients with advanced cancer to pc services is strongly recommended. So when, how, and why should patients with advanced cancer be referred to pc services? In this article, we summarize evidence to address these questions about early pc referral: ▪ What are the known benefits?▪ What is the "ideal" pc referral timing?▪ What are the barriers?▪ Which strategies can optimize integration of pc into oncology care?▪ Which communication tools can facilitate skillful introduction of pc to patients?
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Affiliation(s)
- C Courteau
- Department of Family Medicine, McGill University, Montreal, QC
| | - G Chaput
- Division of Supportive and Palliative Medicine, Royal Victoria Hospital of the McGill University Health Centre, Montreal, QC.,Department of Palliative Care, Lachine Hospital Campus of the McGill University Health Centre, Lachine, QC
| | - L Musgrave
- Department of Palliative Care, Lachine Hospital Campus of the McGill University Health Centre, Lachine, QC
| | - A Khadoury
- Department of Palliative Care, Lachine Hospital Campus of the McGill University Health Centre, Lachine, QC
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15
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Merlin JS, Patel K, Thompson N, Kapo J, Keefe F, Liebschutz J, Paice J, Somers T, Starrels J, Childers J, Schenker Y, Ritchie CS. Managing Chronic Pain in Cancer Survivors Prescribed Long-Term Opioid Therapy: A National Survey of Ambulatory Palliative Care Providers. J Pain Symptom Manage 2019; 57:20-27. [PMID: 30342243 DOI: 10.1016/j.jpainsymman.2018.10.493] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 10/28/2022]
Abstract
CONTEXT Chronic pain, or pain lasting more than three months, is common among cancer survivors, who are often prescribed long-term opioid therapy (LTOT). OBJECTIVE Our objective was to explore palliative care providers' experiences with managing chronic pain in cancer survivors prescribed LTOT, specifically in ambulatory palliative care settings, and their strategies for overcoming challenges. METHODS We recruited providers through leading national palliative care organizations who manage chronic pain in cancer survivors. Asked to consider only cancer survivors with chronic pain when responding, participants completed an online survey that included questions about use of opioid risk mitigation tools, confidence in addressing opioid misuse behaviors and discussing/recommending management approaches, and access to addiction treatment. RESULTS Of 157 participants, most were physicians (83%) or nurse practitioners (15%). Most reported using opioid risk mitigation tools such as urine drug testing (71%), opioid treatment agreements (85%), and practitioner database monitoring programs (94%). Participants were confident (7-8/10) managing the most commonly encountered opioid misuse behaviors (missing appointments, marijuana use, and using more opioids than prescribed) and in their ability to recommend nonpharmacologic and nonopioid pharmacologic treatments for chronic pain (10/10). They were least confident prescribing naloxone or managing addiction (5/10); only 27% reported having training or systems in place to address addiction. Only 13% had a waiver to prescribe buprenorphine. CONCLUSION Palliative care providers are comfortable with many aspects of managing chronic pain in cancer survivors on LTOT, although challenges persist, including the lack of systems-based approaches and training in addiction treatment.
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Affiliation(s)
- Jessica S Merlin
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA; Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.
| | - Kanan Patel
- Division of Geriatrics, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Nicole Thompson
- Division of Geriatrics, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Jennifer Kapo
- Palliative Medicine Program, Division of Geriatric Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Frank Keefe
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jane Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Judith Paice
- Division Hematology-Oncology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Tamara Somers
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joanna Starrels
- Division of General Internal Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York, USA
| | - Julie Childers
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco (UCSF), San Francisco, California, USA
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Sullivan R, Ugalde A, Sinclair C, Breen LJ. Developing a Research Agenda for Adult Palliative Care: A Modified Delphi Study. J Palliat Med 2018; 22:480-488. [PMID: 30461347 DOI: 10.1089/jpm.2018.0462] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background: Little is known about research priorities in adult palliative care. Identifying research priorities for adult palliative care will help in increasing research quality and translation. Objective: The aim was to identify the views of health professionals' research priorities in adult palliative care that lead to development of a palliative care research agenda in Australia. Design: A modified three-round Delphi survey. Setting/Subjects: Palliative care researchers and clinicians in Australia were invited to participate. Results: A total of 25 panelists completed round 1, 14 completed round 2, and 13 completed round 3. Round 1 resulted in 90 research priorities in 13 categories. Round 2 showed consensus agreement on 19/90 research priorities. Round 3 resulted in the top 10 research priorities of the 19 achieving consensus in round 2. Panelists agreed that research is needed on the transition to palliative care; improving communication about prognosis; increasing access to palliative care for indigenous communities, people who wish to remain at home, and people in aged care; addressing family caregivers' needs; promoting patients' and families' decision making; improving cross-cultural aspects of palliative care; determining the effects of assisted dying legislation; and improving bereavement care in rural, remote, and Aboriginal populations. Conclusions: The expert panelists identified the top 10 research priorities for adult palliative care. These identified research priorities are the most urgent topics requiring attention to increase the quality of life of patients requiring palliative care and their family members.
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Affiliation(s)
| | - Anna Ugalde
- 2 School of Nursing and Midwifery, Deakin University, Geelong, Australia
| | - Craig Sinclair
- 3 Rural Clinical School of Western Australia, University of Western Australia (Albany Centre), Albany, Australia
| | - Lauren J Breen
- 1 School of Psychology, Curtin University, Perth, Australia
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Bakouny Z, Assi T, El Rassy E, Daccache K, Kattan C, Tohme A, Mouhawej MC, Kattan J. Factors associated with the time to first palliative care consultation in Lebanese cancer patients. Support Care Cancer 2018; 27:1529-1533. [PMID: 30406426 DOI: 10.1007/s00520-018-4543-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 11/04/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Early palliative care is recommended for cancer patients. However, palliative care consults (PCC) are often delayed in Lebanon. The aim of this study was to identify the factors associated with timing of PCC and their impact on the place of death. METHODS This is a retrospective, single institution, study conducted at Hotel Dieu de France University Hospital in Lebanon. The clinical and demographic characteristics of oncology patients who received PCC were obtained. Cox and logistic regression models were used to evaluate the factors determining the time to first PCC and location of death, respectively. RESULTS Two hundred and ten patients were included in our analyses with a median age of 69 years (range 22-92 years). The median survival times were: overall survival 18.7 months, time to first PCC 17.9 months, and survival post-PCC 0.6 months. Among patients who were followed-up at home, the median time spent at home was 0.6 months. Late PCC were associated with a childless status (HR = 0.57, 95%CI = 0.37-0.86, p = 0.007), awareness of the diagnosis (HR = 0.64, 95%CI = 0.45-0.91, p = 0.013), and lack of palliative home care (HR = 0.42, 95%CI = 0.25-0.65, p < 0.001). Older patients (OR = 1.03, 95%CI = 1.01-1.05, p = 0.026) and those who had been followed up at home during the PCC (OR = 160.56, 95%CI = 21.39-1205.50, p < 0.001) were significantly more likely to have died at home as opposed to the hospital. DISCUSSION Cancer patients often receive PCC only shortly before their death. PCC for Lebanese cancer patients were found to be significantly delayed in patients that are childless, knowledgeable of their diagnosis, and lack home palliative care.
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Affiliation(s)
- Ziad Bakouny
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Tarek Assi
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon. .,Department of Medical Oncology, Institut Gustave Roussy, Université Paris-Saclay, Gustave Roussy Cancer Campus, F-94805, Villejuif, France.
| | - Elie El Rassy
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Karen Daccache
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Clarisse Kattan
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Aline Tohme
- Department of Palliative Care, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Marie Claire Mouhawej
- Department of Palliative Care, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Joseph Kattan
- Department of Hematology-Oncology, Hotel Dieu de France University Hospital, Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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Morrison RS, Aldridge MD, Block J, Chiu L, Maroney C, Morrison CA, Meier DE. The National Palliative Care Research Center: Ten Years of Promoting and Developing Research in Palliative Care. J Palliat Med 2018; 21:1548-1557. [PMID: 30136886 DOI: 10.1089/jpm.2018.0204] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The evidence base to support high-quality clinical care and number of scientists available to develop this evidence base are inadequate. OBJECTIVE To describe the first 10 years of the National Palliative Care Research Center's (NPCRC) programs and their outcomes. DESIGN Established in 2005, NPCRC was created in direct response to the recommendations of the Institute of Medicine. Specifically, NPCRC was created to expand the palliative care evidence-based needed for both health policy and clinical practice by supporting research scientists, stimulating research and innovation, and creating a community of researchers focused on the needs of persons with serious illness and their families. MEASUREMENTS Subsequent grant funding following NPCRC investment (web searches of NIH Research Portfolio Online Reporting Tools [RePORT], Veterans Administration and Patient Centered Outcomes Research Institute [PCORI] grant databases, grantee on-line surveys, and grantee annual reports) promotions (grantee on-line surveys and annual reports), publications (PubMed searches), and NPCRC participant satisfaction (grantee questionnaires). RESULTS As of July 2017, NPCRC has funded 47 junior investigators representing over 10 disciplines. These investigators have leveraged NPCRC's $7.8 million investment into 52 federal grants totaling $74.8 million dollars and 69 foundation grants totaling $16 million. Thirty-five grants ($5.8 million) have been awarded to experienced investigators, resulting in additional grant funding of $104.5 million dollars ($78.5 million federal, $26 million nonfederal). Satisfaction with NPCRC's program has been uniformly high and policy efforts have resulted in enhanced federal funding opportunities in palliative care research. CONCLUSIONS NPCRC's focus on people and infrastructure in conjunction with a top-down bottom-up strategy has been critical in improving the palliative care evidence base.
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Affiliation(s)
- R Sean Morrison
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa D Aldridge
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - James Block
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York.,2 Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Lily Chiu
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Catherine Maroney
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
| | - Corey A Morrison
- 1 National Palliative Care Research Center of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York.,3 Brown University School of Public Health , Providence, Rhode Island
| | - Diane E Meier
- 2 Center to Advance Palliative Care of the Brookdale Department of Geriatrics and Palliative Medicine , Icahn School of Medicine at Mount Sinai, New York, New York
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Bloomer MJ, Hutchinson AM, Brooks L, Botti M. Dying persons' perspectives on, or experiences of, participating in research: An integrative review. Palliat Med 2018; 32:851-860. [PMID: 29235418 PMCID: PMC6144348 DOI: 10.1177/0269216317744503] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Conducting research with dying persons can be controversial and challenging due to concerns for the vulnerability of the dying and the potential burden on those who participate with the possibility of little benefit. AIM To conduct an integrative review to answer the question 'What are dying persons' perspectives or experiences of participating in research? DESIGN A structured integrative review of the empirical literature was undertaken. DATA SOURCES Cumulative Index Nursing and Allied Health Complete, PsycINFO, MEDLINE, Informit and Embase databases were searched for the empirical literature published since inception of the databases until February 2017. RESULTS From 2369 references, 10 papers were included in the review. Six were qualitative studies, and the remaining four were quantitative. Analysis revealed four themes: value of research, desire to help, expression of self and participation preferences. Dying persons value research participation, regarding their contribution as important, particularly if it provides an opportunity to help others. Participants perceived that the potential benefits of research can and should be measured in ways other than life prolongation or cure. Willingness to participate is influenced by study type or feature and degree of inconvenience. CONCLUSION Understanding dying persons' perspectives of research participation will enhance future care of dying persons. It is essential that researchers do not exclude dying persons from clinically relevant research due to their prognosis, fear or burden or perceived vulnerability. The dying should be afforded the opportunity to participate in research with the knowledge it may contribute to science and understanding and improve the care and treatment of others.
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Affiliation(s)
- Melissa J Bloomer
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
| | - Laura Brooks
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
| | - Mari Botti
- School of Nursing and Midwifery and Centre for Quality and Patient Safety Research, Deakin University, Geelong Waterfront Campus, Geelong, VIC, Australia
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Minoura T, Takeuchi M, Morita T, Kawakami K. Practice Patterns of Medications for Patients With Malignant Bowel Obstruction Using a Nationwide Claims Database and the Association Between Treatment Outcomes and Concomitant Use of H 2-Blockers/Proton Pump Inhibitors and Corticosteroids With Octreotide. J Pain Symptom Manage 2018; 55:413-419.e2. [PMID: 29122616 DOI: 10.1016/j.jpainsymman.2017.10.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 10/12/2017] [Accepted: 10/12/2017] [Indexed: 11/18/2022]
Abstract
CONTEXT Malignant bowel obstruction impairs the quality of life in patients with advanced cancer. Octreotide, acid-suppressing medications such as H2-receptor antagonists (H2-blockers) and proton pump inhibitors (PPIs), and corticosteroids are often used in combination for symptom control. OBJECTIVES We evaluated the practice patterns of medications for patients hospitalized with malignant bowel obstruction using a large claims database in Japan. In addition, we explored the association of adding H2-blockers/PPIs or corticosteroids to octreotide on treatment outcomes. METHODS We analyzed data from a nationwide medical claims database from April 2010 to March 2015 containing 975,000 patients. We included all adult inpatients with cancer who used octreotide 300 μg/day or more and summarized each patient's medication use. We also assessed whether concomitant use of H2-blockers/PPIs or corticosteroids was associated with the number of days of nasogastric tube (NGT) insertion; logistic regression was used to adjust the patients' baseline factors. RESULTS We included 3090 patients; octreotide alone was used in 1649 (53%) cases. A combination of octreotide and H2-blockers or PPIs was used in 419 and 337 cases (14% and 11%), respectively; a combination of octreotide and corticosteroids was used in 374 cases (12%). Of the 1595 patients who underwent NGT insertion, those using corticosteroids with octreotide had a higher odds ratio of NGT removal within four days of insertion (adjusted odds ratio = 1.16; 95% CI = 1.08-1.23). CONCLUSION Octreotide alone was used in the majority of patients, and the concomitant use of corticosteroids was more likely to be associated with early NGT removal.
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Affiliation(s)
- Takaaki Minoura
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Masato Takeuchi
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Koji Kawakami
- Department of Pharmacoepidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan.
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Brown E, Morrison RS, Gelfman LP. An Update: NIH Research Funding for Palliative Medicine, 2011-2015. J Palliat Med 2018; 21:182-187. [PMID: 28792780 PMCID: PMC5797329 DOI: 10.1089/jpm.2017.0287] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2017] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The evidence base to support palliative care clinical practice is inadequate and opportunities to improve the palliative care evidence base remain despite the field's rapid growth. OBJECTIVE To examine current NIH funding of palliative medicine research, changes since our 2013 report, and trends since our 2008 report. DESIGN We sought to identify NIH funding of palliative medicine from 2011 to 2015 in two stages: (I) we searched the NIH grants database "RePorter" for grants with key words "palliative care," "end-of-life care," "hospice," and "end of life" and (II) we identified palliative care researchers likely to have secured NIH funding using three strategies. METHODS We abstracted (1) the first and last authors' names from original investigations published in major palliative medicine journals from 2013 to 2015; (2) these names from a PubMed-generated list of original articles published in major medicine, nursing, and subspecialty journals using the above key words; and (3) palliative medicine journal editorial board members and key members of palliative medicine initiatives. We crossmatched the pooled names against NIH grants funded from 2011 to 2015. RESULTS The author and NIH RePorter search identified 854 and 419 grants, respectively. The 461 grants categorized as relevant to palliative medicine represented 334 unique PIs. Compared to 2006-2010, the number of NIH-funded junior career development awards nearly doubled (6.1%-10%), articles published in nonpalliative care specialty journals tripled (13%-37%), published palliative care researchers increased by 2.5-fold (839-2120), and NIH-funded original palliative medicine research articles doubled (21%-39%). CONCLUSIONS Despite the challenging NIH funding climate, NIH funding to palliative care remained stable. The increase in early stage career development funding, palliative care investigators, and palliative medicine research published in nonpalliative medicine journals reflects important advances to address the workforce and evidence gaps. Further support for palliative care research is still needed.
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Affiliation(s)
- Elizabeth Brown
- From the Icahn School of Medicine at Mount Sinai, New York, New York
| | - R. Sean Morrison
- The National Palliative Care Research Center, New York, New York
- The Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
| | - Laura P. Gelfman
- The Hertzberg Palliative Care Institute of the Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Geriatric Research Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York
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Phongtankuel V, Meador L, Adelman RD, Roberts J, Henderson CR, Mehta SS, del Carmen T, Reid M. Multicomponent Palliative Care Interventions in Advanced Chronic Diseases: A Systematic Review. Am J Hosp Palliat Care 2018; 35:173-183. [PMID: 28273750 PMCID: PMC5879777 DOI: 10.1177/1049909116674669] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Many patients live with serious chronic or terminal illnesses. Multicomponent palliative care interventions have been increasingly utilized in patient care; however, it is unclear what is being implemented and who is delivering these interventions. OBJECTIVES To (1) describe the delivery of multicomponent palliative care interventions, (2) characterize the disciplines delivering care, (3) identify the components being implemented, and (4) analyze whether the number of disciplines or components being implemented are associated with positive outcomes. DESIGN Systematic review. STUDY SELECTION English-language articles analyzing multicomponent palliative care interventions. OUTCOMES MEASURED Delivery of palliative interventions by discipline, components of palliative care implemented, and number of positive outcomes (eg, pain, quality of life). RESULTS Our search strategy yielded 71 articles, which detailed 64 unique multicomponent palliative care interventions. Nurses (n = 64, 88%) were most often involved in delivering care, followed by physicians (n = 43, 67%), social workers (n = 33, 52%), and chaplains (n = 19, 30%). The most common palliative care components patients received were symptom management (n = 56, 88%), psychological support/counseling (n = 52, 81%), and disease education (n = 48, 75%). Statistical analysis did not uncover an association between number of disciplines or components and positive outcomes. CONCLUSIONS While there has been growth in multicomponent palliative care interventions over the past 3 decades, important aspects require additional study such as better inclusion of key groups (eg, chronic obstructive pulmonary disease, end-stage renal disease, minorities, older adults); incorporating core components of palliative care (eg, interdisciplinary team, integrating caregivers, providing spiritual support); and developing ways to evaluate the effectiveness of interventions that can be readily replicated and disseminated.
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Affiliation(s)
- Veerawat Phongtankuel
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Lauren Meador
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Ronald D. Adelman
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | | | | | - Sonal S. Mehta
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - Tessa del Carmen
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
| | - M.C. Reid
- Department of Medicine, Joan and Sanford I Weill Medical College of Cornell University, New York, NY, USA
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Development and evaluation of a six-day training program in supportive oncology research. Palliat Support Care 2017; 16:656-661. [PMID: 29282163 DOI: 10.1017/s1478951517001092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Early career investigators have few opportunities for targeted training in supportive oncology research. To address this need, we developed, implemented, and evaluated an intensive, six-day workshop on methods in supportive oncology research for trainees and junior faculty across multiple disciplines. METHOD A multidisciplinary team of supportive oncology researchers developed a workshop patterned after the clinical trials workshop offered jointly by the American Society of Clinical Oncology and American Association of Cancer Research. The curriculum included lectures and a mentored experience of writing a research protocol. Each year since 2015, the workshop has accepted and trained 36 early career investigators. Over the course of the workshop, participants present sections of their research protocols daily in small groups led by senior researchers, and have dedicated time to write and revise these sections. Primary outcomes for the workshop included the frequency of completed protocols by the end of the workshop, a pre- and posttest assessing participant knowledge, and follow-up surveys of the participants and their primary mentors.ResultOver three years, the workshop received 195 applications; 109 early career researchers were competitively selected to participate. All participants (109/109, 100%) completed writing a protocol by the end of their workshop. Participants and their primary mentors reported significant improvements in their research knowledge and skills. Each year, participants rated the workshop highly in terms of satisfaction, value, and likelihood of recommending it to a colleague. One year after the first workshop, most respondents (29/30, 96.7%) had either submitted their protocol or written at least one other protocol.Significance of resultsWe developed a workshop on research methods in supportive oncology. More early career investigators applied for the workshop than capacity, and the workshop was fully attended each year. Both the workshop participants and their primary mentors reported improvement in research skills and knowledge.
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Wu DS, Wright SM. Clinical Excellence in Palliative Care: Examples From the Published Literature. Am J Hosp Palliat Care 2017; 35:1037-1042. [DOI: 10.1177/1049909117748882] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: With the expansion of palliative care, the concept of clinical excellence is worthy of study and has not been described well in the literature. Objective: To apply the domains of clinical excellence, as proposed and published by the Miller Coulson Academy of Clinical Excellence, to the field of palliative care. Design: Review of the literature to identify episodes of superb palliative care delivered by individuals and teams. Measurement and Main Results: In reviewing 821 publications, we found multiple palliative care case reports to serve as exemplars for each of the distinct domains of clinical excellence. Conclusions: The domains of excellence are relevant and applicable to the field of palliative care. This article aims to inspire clinicians—and advance the field—by promoting thoughtful reflection on what clinical excellence in palliative care entails.
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Affiliation(s)
- David Shih Wu
- Palliative Care Program, Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Scott M. Wright
- Division of General Internal Medicine, Johns Hopkins Bayview Medical Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Zebrack B, Kayser K, Oktay J, Sundstrom L, Mayer Sachs A. The Association of Oncology Social Work's Project to Assure Quality Cancer Care (APAQCC). J Psychosoc Oncol 2017; 36:19-30. [DOI: 10.1080/07347332.2017.1397832] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Brad Zebrack
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
| | - Karen Kayser
- School of Social Work, Dr. LaRocca Chair in Oncology Social Work, University of Louisville, Kent School of Social Work, Louisville, KY, USA
| | - Julianne Oktay
- School of Social Work, University of Maryland, College Park, MD, USA
| | - Laura Sundstrom
- School of Social Work, University of Michigan, Ann Arbor, MI, USA
| | - Alison Mayer Sachs
- Community Outreach & Cancer Support Services, Eisenhower Lucy Curci Cancer Center, Rancho Mirage, CA, USA
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26
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Tjia J, Kutner JS, Ritchie CS, Blatchford PJ, Bennett Kendrick RE, Prince-Paul M, Somers TJ, McPherson ML, Sloan JA, Abernethy AP, Furuno JP. Perceptions of Statin Discontinuation among Patients with Life-Limiting Illness. J Palliat Med 2017; 20:1098-1103. [PMID: 28520522 DOI: 10.1089/jpm.2016.0489] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Optimal management of chronic medications for patients with life-limiting illness is uncertain. Medication deprescribing may improve outcomes in this population, but patient concerns regarding deprescribing are unclear. OBJECTIVE The aim of this study was to quantify the perceived benefits and concerns of statin discontinuation among patients with life-limiting illness. DESIGN Baseline data from a multicenter, pragmatic clinical trial of statin discontinuation were used. SETTING/SUBJECTS Cognitively intact participants with a life expectancy of 1-12 months receiving statin medications for primary or secondary prevention were enrolled. MEASUREMENTS Responses to a 9-item questionnaire addressing patient concerns about discontinuing statins were collected. We used Pearson chi-square tests to compare responses by primary life-limiting diagnosis (cancer, cardiovascular disease, other). RESULTS Of 297 eligible participants, 58% had cancer, 8% had cardiovascular disease, and 30% other primary diagnoses. Mean (standard deviation) age was 72 (11) years. Fewer than 5% of participants expressed concern that statin deprescribing indicated physician abandonment. About one in five participants reported being told to take statins for the rest of their life (18%) or feeling that discontinuation represented prior wasted effort (18%). Many participants reported benefits of stopping statins, including spending less money on medications (63%), potentially stopping other medications (34%), and having a better quality of life (25%). More participants with cardiovascular disease as a primary diagnosis perceived that quality-of-life benefits related to statin discontinuation (52%) than participants with cancer (27%) or noncardiovascular disease diagnoses (27%) [p = 0.034]. CONCLUSION Few participants expressed concerns about discontinuing statins; many perceived potential benefits. Cardiovascular disease patients perceived greater potential positive impact from statin discontinuation.
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Affiliation(s)
- Jennifer Tjia
- 1 Department of Quantitative Health Sciences, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Jean S Kutner
- 2 Department of Medicine, University of Colorado School of Medicine , Aurora, Colorado
| | - Christine S Ritchie
- 3 Department of Medicine, University of California San Francisco School of Medicine , San Francisco, California
| | - Patrick J Blatchford
- 4 Department of Biostatistics and Informatics, University of Colorado School of Medicine , Aurora, Colorado
| | | | - Maryjo Prince-Paul
- 6 Frances Payne Bolton School of Nursing, Case Western Reserve University , Cleveland, Ohio
| | - Tamara J Somers
- 7 Department of Psychiatry and Behavioral Sciences, Duke University Medical Center , Durham, North Carolina
| | - Mary Lynn McPherson
- 8 Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore, Maryland
| | - Jeff A Sloan
- 9 Department of Health Sciences Research, Mayo Clinic , Rochester, Minnesota
| | | | - Jon P Furuno
- 11 Department of Pharmacy Practice, Oregon State University/Oregon Health & Science University College of Pharmacy , Portland, Oregon
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Ritchie CL, Pollak KI, Kehl KA, Miller JL, Kutner JS. Better Together: The Making and Maturation of the Palliative Care Research Cooperative Group. J Palliat Med 2017; 20:584-591. [PMID: 28448200 DOI: 10.1089/jpm.2017.0138] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To describe the growth and outcomes of the Palliative Care Research Cooperative Group (PCRC). BACKGROUND Despite advances, significant gaps remain in the evidence base to inform care for people with serious illness. To generate this needed evidence and bolster research capacity, the Palliative Care Research Cooperative (PCRC) group was formed. METHODS The PCRC supports investigators in the conduct of multisite clinical studies. After developing a governance structure and completing a proof of concept demonstration study, the PCRC expanded its infrastructure to include additional resource cores (Clinical Studies; Measurement; Data Informatics and Statistics; and Caregiver Studies). The PCRC also supports an Investigator Development Center as many palliative care investigators valued opportunities to advance their skills. Additional key aspects of PCRC resources include a Scientific Review Committee, a Publications Committee, and initiatives to purposefully engage investigators in a community of palliative care science. RESULTS The PCRC has grown to over 300 members representing more than 130 distinct sites. To date, the PCRC has supported the submission of 51 research applications and has engaged in 27 studies. The PCRC supports investigator research development needs through webinars and clinical trials "intensives." To foster a sense of community, the PCRC has convened biannual meetings, developed special interest groups, and regularly communicates via a newsletter and its website. CONCLUSION With a particular focus on facilitating conduct of rigorous multisite clinical studies, the PCRC fosters an engaged multidisciplinary research community, filling an important void in generating and disseminating evidence that informs the provision of high-quality care to people with serious illness.
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Affiliation(s)
- Christine L Ritchie
- 1 Department of Medicine, University of California San Francisco , San Francisco, California
| | - Kathryn I Pollak
- 2 Department of Family Medicine, Duke University , Durham, North Carolina
| | - Karen A Kehl
- 3 Office of End-of-Life and Palliative Care Research, National Institute of Nursing Research, National Institutes of Health , Bethesda, Maryland
| | - Jeri L Miller
- 3 Office of End-of-Life and Palliative Care Research, National Institute of Nursing Research, National Institutes of Health , Bethesda, Maryland
| | - Jean S Kutner
- 4 Department of Medicine, University of Colorado School of Medicine , Aurora, Colorado
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Bouça-Machado R, Titova N, Chaudhuri KR, Bloem BR, Ferreira JJ. Palliative Care for Patients and Families With Parkinson's Disease. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2017; 132:475-509. [PMID: 28554419 DOI: 10.1016/bs.irn.2017.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Parkinson's disease is the second most common neurodegenerative disease worldwide. There is widespread consensus that Parkinson patients, their carers, and clinicians involved in their care would benefit from a fully integrated, need-based provision of palliative care. However, the concept of palliative care in Parkinson's disease is still poorly defined and, consequently, poorly implemented into daily clinical practice. A particular challenge is the gradually progressive nature of Parkinson's disease-with insidiously increasing disability-making it challenging to clearly define the onset of palliative care needs for Parkinson patients. As people with Parkinson's disease are now living longer than in the past, future research needs to develop a more robust evidence-based approach to clarify the disease events associated with increased palliative care needs, and to examine these, prospectively, in an integrated palliative care service. The modern palliative care outlook, termed "simultaneous care,",is no longer restricted to the final stage of disease. It involves incorporating a continuity of care, effective management of the chronic-palliative interface, and a multidisciplinary network of professionals working both in the community and in specialized clinics, with active involvement of caregivers. Although promising, there is still a need to demonstrate the effectiveness of palliative care for patients with Parkinson's disease.
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Affiliation(s)
- Raquel Bouça-Machado
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal; CNS-Campus Neurológico Sénior, Torres Vedras, Portugal
| | - Nataliya Titova
- Federal State Budgetary Educational Institution of Higher Education "N.I. Pirogov Russian National Research Medical University" of the Ministry of Healthcare of the Russian Federation, Moscow, Russia
| | - K Ray Chaudhuri
- National Parkinson Foundation International Centre of Excellence, Kings College and Kings College Hospital, London, United Kingdom; Maurice Wohl Clinical Neuroscience Institute, Kings College, London, United Kingdom; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre (BRC) and Dementia Unit at South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Bas R Bloem
- Radboud University Medical Centre, Donders Institute for Brain, Cognition and Behaviour, Nijmegen, The Netherlands
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal; CNS-Campus Neurológico Sénior, Torres Vedras, Portugal; Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.
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Bouça-Machado R, Rosário M, Alarcão J, Correia-Guedes L, Abreu D, Ferreira JJ. Clinical trials in palliative care: a systematic review of their methodological characteristics and of the quality of their reporting. BMC Palliat Care 2017; 16:10. [PMID: 28122560 PMCID: PMC5264484 DOI: 10.1186/s12904-016-0181-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Accepted: 12/23/2016] [Indexed: 12/27/2022] Open
Abstract
Background Over the past decades there has been a significant increase in the number of published clinical trials in palliative care. However, empirical evidence suggests that there are methodological problems in the design and conduct of studies, which raises questions about the validity and generalisability of the results and of the strength of the available evidence. We sought to evaluate the methodological characteristics and assess the quality of reporting of clinical trials in palliative care. Methods We performed a systematic review of published clinical trials assessing therapeutic interventions in palliative care. Trials were identified using MEDLINE (from its inception to February 2015). We assessed methodological characteristics and describe the quality of reporting using the Cochrane Risk of Bias tool. Results We retrieved 107 studies. The most common medical field studied was oncology, and 43.9% of trials evaluated pharmacological interventions. Symptom control and physical dimensions (e.g. intervention on pain, breathlessness, nausea) were the palliative care-specific issues most studied. We found under-reporting of key information in particular on random sequence generation, allocation concealment, and blinding. Conclusions While the number of clinical trials in palliative care has increased over time, methodological quality remains suboptimal. This compromises the quality of studies. Therefore, a greater effort is needed to enable the appropriate performance of future studies and increase the robustness of evidence-based medicine in this important field. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0181-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Raquel Bouça-Machado
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Madalena Rosário
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Joana Alarcão
- Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Leonor Correia-Guedes
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Daisy Abreu
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal
| | - Joaquim J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal. .,Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Avenue Professor Egas Moniz, 1649-028, Lisbon, Portugal.
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LeBlanc TW, Ritchie CS, Friedman F, Bull J, Kutner JS, Johnson KS, Kamal AH. Adherence to Measuring What Matters Items When Caring for Patients With Hematologic Malignancies Versus Solid Tumors. J Pain Symptom Manage 2016; 52:775-782. [PMID: 27810570 PMCID: PMC5472042 DOI: 10.1016/j.jpainsymman.2016.09.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 09/02/2016] [Indexed: 11/19/2022]
Abstract
CONTEXT Measuring What Matters (MWM) prioritizes quality measures in palliative care practice. Hematologic malignancy patients are less likely to access palliative care, yet little is known about their unique needs. Differences in MWM adherence may highlight opportunities to improve palliative care in hematology. OBJECTIVES To assess adherence to MWM measures by palliative care clinicians caring for patients with hematologic malignancies, compared to those with solid tumors. METHODS We used the Quality Data Collection Tool to assess completion of MWM measures across nine sites. RESULTS We included data from 678 patients' first visits and various care settings; 64 (9.4%) had a hematologic malignancy, whereas 614 (90.6%) had a solid tumor. Hematology patients were more likely to be seen in a hospital (52 or 81.3% vs. 420 or 68%), whereas solid tumor patients were more frequently seen at home or in clinics (160 or 26% vs. 7 or 10.9%). Of the nine MWM measures we assessed, high adherence (>90%) was seen regardless of tumor type in measures #3 (Pain Treatment), #7 (Spiritual Concerns), #8 (Treatment Preferences), and #9 (Care Consistent With Preferences). Clinicians seeing hematology patients were significantly less likely to meet measures #2 (Screening for Physical Symptoms; 57.8% vs. 84.2%, P < 0.001), and #5 (Discussion of Emotional Needs; 56.3% vs. 70.0%, P = 0.03). CONCLUSION MWM adherence regarding symptom assessment and meeting emotional needs was lower for patients with hematologic malignancies compared to those with solid tumors. This finding suggests two key areas for quality improvement initiatives in palliative care for patients with hematologic malignancies.
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Affiliation(s)
- Thomas W LeBlanc
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Christine S Ritchie
- University of California at San Francisco School of Medicine, San Francisco, California, USA
| | - Fred Friedman
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | - Jean S Kutner
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Kimberly S Johnson
- Division of Geriatrics, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Geriatrics Research Education and Clinical Center, Durham VAMC, Durham, North Carolina, USA
| | - Arif H Kamal
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
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Kavalieratos D, Corbelli J, Zhang D, Dionne-Odom JN, Ernecoff NC, Hanmer J, Hoydich ZP, Ikejiani DZ, Klein-Fedyshin M, Zimmermann C, Morton SC, Arnold RM, Heller L, Schenker Y. Association Between Palliative Care and Patient and Caregiver Outcomes: A Systematic Review and Meta-analysis. JAMA 2016; 316:2104-2114. [PMID: 27893131 PMCID: PMC5226373 DOI: 10.1001/jama.2016.16840] [Citation(s) in RCA: 690] [Impact Index Per Article: 86.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE The use of palliative care programs and the number of trials assessing their effectiveness have increased. OBJECTIVE To determine the association of palliative care with quality of life (QOL), symptom burden, survival, and other outcomes for people with life-limiting illness and for their caregivers. DATA SOURCES MEDLINE, EMBASE, CINAHL, and Cochrane CENTRAL to July 2016. STUDY SELECTION Randomized clinical trials of palliative care interventions in adults with life-limiting illness. DATA EXTRACTION AND SYNTHESIS Two reviewers independently extracted data. Narrative synthesis was conducted for all trials. Quality of life, symptom burden, and survival were analyzed using random-effects meta-analysis, with estimates of QOL translated to units of the Functional Assessment of Chronic Illness Therapy-palliative care scale (FACIT-Pal) instrument (range, 0-184 [worst-best]; minimal clinically important difference [MCID], 9 points); and symptom burden translated to the Edmonton Symptom Assessment Scale (ESAS) (range, 0-90 [best-worst]; MCID, 5.7 points). MAIN OUTCOMES AND MEASURES Quality of life, symptom burden, survival, mood, advance care planning, site of death, health care satisfaction, resource utilization, and health care expenditures. RESULTS Forty-three RCTs provided data on 12 731 patients (mean age, 67 years) and 2479 caregivers. Thirty-five trials used usual care as the control, and 14 took place in the ambulatory setting. In the meta-analysis, palliative care was associated with statistically and clinically significant improvements in patient QOL at the 1- to 3-month follow-up (standardized mean difference, 0.46; 95% CI, 0.08 to 0.83; FACIT-Pal mean difference, 11.36] and symptom burden at the 1- to 3-month follow-up (standardized mean difference, -0.66; 95% CI, -1.25 to -0.07; ESAS mean difference, -10.30). When analyses were limited to trials at low risk of bias (n = 5), the association between palliative care and QOL was attenuated but remained statistically significant (standardized mean difference, 0.20; 95% CI, 0.06 to 0.34; FACIT-Pal mean difference, 4.94), whereas the association with symptom burden was not statistically significant (standardized mean difference, -0.21; 95% CI, -0.42 to 0.00; ESAS mean difference, -3.28). There was no association between palliative care and survival (hazard ratio, 0.90; 95% CI, 0.69 to 1.17). Palliative care was associated consistently with improvements in advance care planning, patient and caregiver satisfaction, and lower health care utilization. Evidence of associations with other outcomes was mixed. CONCLUSIONS AND RELEVANCE In this meta-analysis, palliative care interventions were associated with improvements in patient QOL and symptom burden. Findings for caregiver outcomes were inconsistent. However, many associations were no longer significant when limited to trials at low risk of bias, and there was no significant association between palliative care and survival.
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Affiliation(s)
- Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania3Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Jennifer Corbelli
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Di Zhang
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Natalie C Ernecoff
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | - Janel Hanmer
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Zachariah P Hoydich
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dara Z Ikejiani
- Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Camilla Zimmermann
- Department of Supportive Care, University Health Network, Toronto, Ontario, Canada8Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Robert M Arnold
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lucas Heller
- Division of Endocrinology, Department of Medicine, University of Pittsburgh, Pittsburgh
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania2Center of Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Rabow MW, Dahlin C, Calton B, Bischoff K, Ritchie C. New Frontiers in Outpatient Palliative Care for Patients With Cancer. Cancer Control 2016; 22:465-74. [PMID: 26678973 DOI: 10.1177/107327481502200412] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although much evidence has accumulated demonstrating its benefit, relatively little is known about outpatient palliative care in patients with cancer. METHODS This paper reviews the literature and perspectives from content experts to describe the current state of outpatient palliative care in the oncology setting and current areas of innovation and promise in the field. RESULTS Evidence, including from controlled trials, documents the benefits of outpatient palliative care in the oncology setting. As a result, professional medical organizations have guidelines and recommendations based on the key role of palliative care in oncology. Six elements of the practice sit at the frontier of outpatient oncology palliative care, including the setting and timing of palliative care integration into outpatient oncology, the relationships between primary and specialty palliative care, quality and measurement, research, electronic and technical innovations, and finances. CONCLUSIONS Evidence of clinical and health care system benefits supports the recommendations of professional organizations to integrate palliative care into the routine treatment of patients with advanced cancer.
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Song MK, DeVito Dabbs A, Ward SE. A SMART design to optimize treatment strategies for patient and family caregiver outcomes. Nurs Outlook 2016; 64:299-305. [DOI: 10.1016/j.outlook.2016.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 04/18/2016] [Accepted: 04/30/2016] [Indexed: 11/27/2022]
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Kamal AH, Bull J, Kavalieratos D, Nicolla JM, Roe L, Adams M, Abernethy AP. Development of the Quality Data Collection Tool for Prospective Quality Assessment and Reporting in Palliative Care. J Palliat Med 2016; 19:1148-1155. [PMID: 27348507 DOI: 10.1089/jpm.2016.0036] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Assessing and reporting the quality of care provided are increasingly important in palliative care, but we currently lack practical, efficient approaches for collection and reporting. OBJECTIVE In response, the Global Palliative Care Quality Alliance ("Alliance") sought to create a Quality Data Collection Tool for Palliative Care (QDACT-PC). METHODS We collaboratively and iteratively developed QDACT-PC, an electronic, point-of-care quality monitoring system for palliative care that supports prospective quality assessment and reporting in any clinical setting. QDACT-PC is the web-based data collection and reporting interface. Quality measures selected to be used in QDACT-PC were derived from a systematic review summarizing all published palliative care quality measure sets; Alliance clinical providers prioritized measures to be included in QDACT-PC to ensure maximal clinical relevance. Data elements and variables required to ascertain conformance to all selected quality measures were included in the QDACT-PC data dictionary. Whenever possible, variables collected in QDACT-PC align with validated surveys and/or nationally recognized common data elements. QDACT-PC data elements and software programmed business rules inform real-time assessments of conformance to selected quality measures. Data are deposited into a centralized registry for future analyses. RESULTS QDACT-PC can be used to report on >80% of all published palliative care quality measures and 100% of high-priority measure. CONCLUSION Electronic methods for collecting point-of-care quality monitoring data can be developed using collaborative partnerships between community and academic palliative care providers. Feasibility testing and creation of feedback reports are ongoing.
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Affiliation(s)
| | - Janet Bull
- 2 Four Seasons , Flat Rock, North Carolina
| | - Dio Kavalieratos
- 3 Division of General Internal Medicine, Department of Medicine, University of Pittsburgh , Pittsburgh, Pennsylvania
| | | | - Laura Roe
- 1 Duke University , Durham, North Carolina
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Van Hoover C, Holt L. Midwifing the End of Life: Expanding the Scope of Modern Midwifery Practice to Reclaim Palliative Care. J Midwifery Womens Health 2016; 61:306-14. [PMID: 27148997 DOI: 10.1111/jmwh.12454] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Revised: 01/17/2016] [Accepted: 01/21/2016] [Indexed: 11/27/2022]
Abstract
Historically, midwives held an important role in society as cradle-to-grave practitioners who eased individuals, families, and communities through difficult transitions across the life span. In the United States, during the first half of the 20th century, physicians assumed care for people during birth and death, moving these elements of the human experience from homes into the hospital setting. These changes in practice resulted in a dehumanization of birth and death experiences and led to detachment from what it means to be human among members of society. There is a current movement across the United States to incorporate palliative care and hospice care into both the home setting and the inpatient setting. Through their education and training, certified nurse-midwives/certified midwives (CNMs/CMs) are well equipped to serve as hospice and palliative care clinicians. Current midwives, skilled in assisting women and families through the transition of pregnancy to motherhood, can use their education and skills to help individuals and their families through the transition from life to death. The similarities between these states of the human experience (pregnancy to birth and terminal illness to death) allow for a fluidity between these experiences from the midwife perspective. The many parallels between these 2 elements of the human condition include stress, anxiety, and pain. Training in holistic approaches to symptom management and supporting individuals through difficult experiences (eg, birth) gives midwives a unique perspective that is readily translatable to assist individuals and families through the passage between life and death.
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Kamal AH, Bull J, Ritchie CS, Kutner JS, Hanson LC, Friedman F, Taylor DH. Adherence to Measuring What Matters Measures Using Point-of-Care Data Collection Across Diverse Clinical Settings. J Pain Symptom Manage 2016; 51:497-503. [PMID: 26854995 DOI: 10.1016/j.jpainsymman.2015.12.313] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2015] [Revised: 12/15/2015] [Accepted: 12/24/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Measuring What Matters (MWM) for palliative care has prioritized data collection efforts for evaluating quality in clinical practice. How these measures can be implemented across diverse clinical settings using point-of-care data collection on quality is unknown. OBJECTIVES To evaluate the implementation of MWM measures by exploring documentation of quality measure adherence across six diverse clinical settings inherent to palliative care practice. METHODS We deployed a point-of-care quality data collection system, the Quality Data Collection Tool, across five organizations within the Palliative Care Research Cooperative Group. Quality measures were recorded by clinicians or assistants near care delivery. RESULTS During the study period, 1989 first visits were included for analysis. Our population was mostly white, female, and with moderate performance status. About half of consultations were seen on hospital general floors. We observed a wide range of adherence. The lowest adherence involved comprehensive assessments during the first visit in hospitalized patients in the intensive care unit (2.71%); the highest adherence across all settings, with an implementation of >95%, involved documentation of management of moderate/severe pain. We observed differences in adherence across clinical settings especially with MWM Measure #2 (Screening for Physical Symptoms, range 45.7%-81.8%); MWM Measure #5 (Discussion of Emotional Needs, range 46.1%-96.1%); and MWM Measure #6 (Documentation of Spiritual/Religious Concerns, range 0-69.6%). CONCLUSION Variations in clinician documentation of adherence to MWM quality measures are seen across clinical settings. Additional studies are needed to better understand benchmarks and acceptable ranges for adherence tailored to various clinical settings.
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Affiliation(s)
| | - Janet Bull
- Four Seasons, Flat Rock, North Carolina, USA
| | | | - Jean S Kutner
- University of Colorado at Denver, Denver, Colorado, USA
| | - Laura C Hanson
- Palliative Care Program, Division of Geriatric Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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McNeil MJ, Kamal AH, Kutner JS, Ritchie CS, Abernethy AP. The Burden of Polypharmacy in Patients Near the End of Life. J Pain Symptom Manage 2016; 51:178-83.e2. [PMID: 26432571 PMCID: PMC4733587 DOI: 10.1016/j.jpainsymman.2015.09.003] [Citation(s) in RCA: 87] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2015] [Revised: 09/08/2015] [Accepted: 09/15/2015] [Indexed: 11/18/2022]
Abstract
CONTEXT Patients with advanced illness are prescribed multiple medications in the last year of life, intensifying the risk of negative consequences related to polypharmacy. OBJECTIVES To describe the medication burden of patients near the end of life and identify potential areas for improvement in clinician prescribing practices. METHODS This was a prespecified secondary analysis of data from a prospective trial. Eligible participants were adults with less than 12 months estimated prognosis taking a statin medication for primary prevention of cardiovascular disease. Participants were enrolled from 15 sites, randomized to continue or discontinue statin medications, and followed for up to a year. Concomitant medications were recorded at least monthly from study enrollment through death. Prescribed medications were categorized by class and subclass. Descriptive statistics were calculated. RESULTS On average, participants (n = 244) were 74.3 years old (SD 11.5) and lived 264 days (SD 128); 47.5% of the patients had a primary diagnosis of malignant tumor. This population was exposed to medications across 51 classes, 192 subclasses, and 423 individual medications. Patients took an average of 11.5 (SD 5) medications at the time of enrollment and 10.7 (SD 5) medications at death or study termination. The five most common classes of medications prescribed near the end of life were antihypertensives, broncholytics/bronchodilators, laxatives, antidepressants, and gastric protection agents. CONCLUSION There is a significant medication burden placed on patients with advanced illness. Although most medications were prescribed for supportive care, we observed a high prevalence of medications for managing non-life-threatening comorbidities.
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Affiliation(s)
- Michael J McNeil
- Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | - Arif H Kamal
- Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Amy P Abernethy
- Center for Learning Health Care, Duke Clinical Research Institute, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA; Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
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Abstract
There has been a paradigm shift in medicine away from tradition, anecdote and theoretical reasoning from the basic sciences towards evidence-based medicine (EBM). In palliative care however, statistically significant benefits may be marginal and may not be related to clinical meaningfulness. The typical treatment vs. placebo comparison necessitated by ‘gold standard’ randomised controlled trials (RCTs) is not necessarily applicable. The complex multimorbidity of end of life care involves considerations of the patient’s physical, psychological, social and spiritual needs. In addition, the field of palliative care covers a heterogeneous group of chronic and incurable diseases no longer limited to cancer. Adequate sample sizes can be difficult to achieve, reducing the power of studies and high attrition rates can result in inadequate follow up periods. This review uses examples of the management of cancer-related fatigue and death rattle (noisy breathing) to demonstrate the current state of EBM in palliative care. The future of EBM in palliative care needs to be as diverse as the patients who ultimately derive benefit. Non-RCT methodologies of equivalent quality, validity and size conducted by collaborative research networks using a ‘mixed methods approach’ are likely to pose the correct clinical questions and derive evidence-based yet clinically relevant outcomes.
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Affiliation(s)
- Claire Visser
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Gina Hadley
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
| | - Bee Wee
- 1 Harris Manchester College, University of Oxford, Oxford OX3 9DU, UK ; 2 Sir Michael Sobell House, Oxford University Hospitals NHS Trust, Oxford OX3 9DU, UK
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LeBlanc TW, McNeil MJ, Kamal AH, Currow DC, Abernethy AP. Polypharmacy in patients with advanced cancer and the role of medication discontinuation. Lancet Oncol 2015; 16:e333-41. [DOI: 10.1016/s1470-2045(15)00080-7] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
ABSTRACTObjective:The difficulties in conducting palliative care research have been widely acknowledged. In order to generate the evidence needed to underpin palliative care provision, collaborative research is considered essential. Prior to formalizing the development of a research network for the state of Victoria, Australia, a preliminary study was undertaken to ascertain interest and recommendations for the design of such a collaboration.Method:Three data-collection strategies were used: a cross-sectional questionnaire, interviews, and workshops. The questionnaire was completed by multidisciplinary palliative care specialists from across the state (n = 61); interviews were conducted with senior clinicians and academics (n = 21) followed by two stakeholder workshops (n = 29). The questionnaire was constructed specifically for this study, measuring involvement of and perceptions of palliative care research.Results:Both the interview and the questionnaire data demonstrated strong support for a palliative care research network and aided in establishing a research agenda. The stakeholder workshops assisted with strategies for the formation of the Palliative Care Research Network Victoria (PCRNV) and guided the development of the mission and strategic plan.Significance of results:The research and efforts to date to establish the PCRNV are encouraging and provide optimism for the evolution of palliative care research in Australia. The international implications are highlighted.
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Kutner JS, Blatchford PJ, Taylor DH, Ritchie CS, Bull JH, Fairclough DL, Hanson LC, LeBlanc TW, Samsa GP, Wolf S, Aziz NM, Currow DC, Ferrell B, Wagner-Johnston N, Zafar SY, Cleary JF, Dev S, Goode PS, Kamal AH, Kassner C, Kvale EA, McCallum JG, Ogunseitan AB, Pantilat SZ, Portenoy RK, Prince-Paul M, Sloan JA, Swetz KM, Von Gunten CF, Abernethy AP. Safety and benefit of discontinuing statin therapy in the setting of advanced, life-limiting illness: a randomized clinical trial. JAMA Intern Med 2015; 175:691-700. [PMID: 25798575 PMCID: PMC4618294 DOI: 10.1001/jamainternmed.2015.0289] [Citation(s) in RCA: 347] [Impact Index Per Article: 38.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE For patients with limited prognosis, some medication risks may outweigh the benefits, particularly when benefits take years to accrue; statins are one example. Data are lacking regarding the risks and benefits of discontinuing statin therapy for patients with limited life expectancy. OBJECTIVE To evaluate the safety, clinical, and cost impact of discontinuing statin medications for patients in the palliative care setting. DESIGN, SETTING, AND PARTICIPANTS This was a multicenter, parallel-group, unblinded, pragmatic clinical trial. Eligibility included adults with an estimated life expectancy of between 1 month and 1 year, statin therapy for 3 months or more for primary or secondary prevention of cardiovascular disease, recent deterioration in functional status, and no recent active cardiovascular disease. Participants were randomized to either discontinue or continue statin therapy and were monitored monthly for up to 1 year. The study was conducted from June 3, 2011, to May 2, 2013. All analyses were performed using an intent-to-treat approach. INTERVENTIONS Statin therapy was withdrawn from eligible patients who were randomized to the discontinuation group. Patients in the continuation group continued to receive statins. MAIN OUTCOMES AND MEASURES Outcomes included death within 60 days (primary outcome), survival, cardiovascular events, performance status, quality of life (QOL), symptoms, number of nonstatin medications, and cost savings. RESULTS A total of 381 patients were enrolled; 189 of these were randomized to discontinue statins, and 192 were randomized to continue therapy. Mean (SD) age was 74.1 (11.6) years, 22.0% of the participants were cognitively impaired, and 48.8% had cancer. The proportion of participants in the discontinuation vs continuation groups who died within 60 days was not significantly different (23.8% vs 20.3%; 90% CI, -3.5% to 10.5%; P=.36) and did not meet the noninferiority end point. Total QOL was better for the group discontinuing statin therapy (mean McGill QOL score, 7.11 vs 6.85; P=.04). Few participants experienced cardiovascular events (13 in the discontinuation group vs 11 in the continuation group). Mean cost savings were $3.37 per day and $716 per patient. CONCLUSIONS AND RELEVANCE This pragmatic trial suggests that stopping statin medication therapy is safe and may be associated with benefits including improved QOL, use of fewer nonstatin medications, and a corresponding reduction in medication costs. Thoughtful patient-provider discussions regarding the uncertain benefit and potential decrement in QOL associated with statin continuation in this setting are warranted. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01415934.
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Affiliation(s)
- Jean S Kutner
- Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Patrick J Blatchford
- Department of Biostatistics and Informatics, Colorado School of Public Health, Denver
| | - Donald H Taylor
- Sanford School of Public Policy, Duke University, Durham, North Carolina
| | - Christine S Ritchie
- San Francisco Veterans Affairs Medical Center, Center for Research on Aging, Jewish Home of San Francisco, San Francisco, California5Division of Geriatrics, Department of Medicine, University of California, San Francisco
| | - Janet H Bull
- Four Seasons Compassion for Life, Flat Rock, North Carolina
| | - Diane L Fairclough
- Department of Biostatistics and Informatics, Colorado School of Public Health, Denver
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina, Chapel Hill
| | - Thomas W LeBlanc
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Greg P Samsa
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Steven Wolf
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Noreen M Aziz
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - David C Currow
- Discipline, Palliative, and Supportive Services, Flinders University, Adelaide, Australia
| | - Betty Ferrell
- Department of Nursing Research, City of Hope Medical Center, City of Hope, California
| | | | - S Yousuf Zafar
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - James F Cleary
- Division of Hematology/Oncology, Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison
| | - Sandesh Dev
- Department of Medicine, Phoenix Veterans Affairs Health Care System, Phoenix, Arizona
| | - Patricia S Goode
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama17Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | - Arif H Kamal
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - Elizabeth A Kvale
- Veterans Affairs Geriatric Research, Education, and Clinical Center, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama17Division of Gerontology, Geriatrics, and Palliative Care, University of Alabama at Birmingham
| | | | - Adeboye B Ogunseitan
- Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Russell K Portenoy
- Metropolitan Jewish Health System, Hospice and Palliative Care, New York, New York
| | - Maryjo Prince-Paul
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio
| | - Jeff A Sloan
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Keith M Swetz
- Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Amy P Abernethy
- Center for Learning Health Care, Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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Abernethy AP, Capell WH, Aziz NM, Ritchie C, Prince-Paul M, Bennett RE, Kutner JS. Ethical conduct of palliative care research: enhancing communication between investigators and institutional review boards. J Pain Symptom Manage 2014; 48:1211-21. [PMID: 24879998 PMCID: PMC4247357 DOI: 10.1016/j.jpainsymman.2014.05.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 04/21/2014] [Accepted: 05/06/2014] [Indexed: 11/22/2022]
Abstract
Palliative care has faced moral and ethical challenges when conducting research involving human subjects. There are currently no resources to guide institutional review boards (IRBs) in applying standard ethical principles and terms-in a specific way-to palliative care research. Using as a case study a recently completed multisite palliative care clinical trial, this article provides guidance and recommendations for both IRBs and palliative care investigators to facilitate communication and attain the goal of conducting ethical palliative care research and protecting study participants while advancing the science. Beyond identifying current challenges faced by palliative care researchers and IRBs reviewing palliative care research, this article suggests steps that the palliative care research community can take to establish a scientifically sound, stable, productive, and well-functioning relationship between palliative care investigators and the ethical bodies that oversee their work.
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Affiliation(s)
- Amy P Abernethy
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Warren H Capell
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Noreen M Aziz
- Division of Extramural Activities, National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland, USA
| | - Christine Ritchie
- University of California at San Francisco, San Francisco, California, USA
| | - Maryjo Prince-Paul
- Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA
| | | | - Jean S Kutner
- University of Colorado School of Medicine, Aurora, Colorado, USA.
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Tjia J, Cutrona SL, Peterson D, Reed G, Andrade SE, Mitchell SL. Statin discontinuation in nursing home residents with advanced dementia. J Am Geriatr Soc 2014; 62:2095-101. [PMID: 25369872 PMCID: PMC4241149 DOI: 10.1111/jgs.13105] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe patterns of, and factors associated with, statin use and discontinuation in nursing home (NH) residents progressing to advanced dementia and followed for at least 90 days. DESIGN Retrospective inception cohort using a dataset linking 2007 to 2008 Minimum Data Set (MDS) to Medicare denominator and Part D files. SETTING All NHs in five states (Minnesota, Massachusetts, Pennsylvania, California, Florida). PARTICIPANTS NH residents with dementia. MEASUREMENTS Residents who developed advanced dementia were observed from baseline (date of progression to very severe cognitive impairment with eating problems) and followed for at least 90 days to statin discontinuation or death. Logistic regression was used to identify baseline factors associated with statin use. Cox proportional hazard regression was used to identify factors associated with time to statin discontinuation. RESULTS Of 10,212 residents, 16.6% (n = 1,699) used statins. Greater odds of statin use were associated with having diabetes mellitus (adjusted odds ratio (AOR) = 1.24, 95% confidence interval (CI) = 1.09-1.40), stroke (AOR = 1.31, 95% CI = 1.16-1.48), and hypertension (AOR = 1.35, 95% CI = 1.18-1.54); hospice enrollment was associated with lower odds (AOR = 0.75, 95% CI = 0.64-0.89). In follow-up, 37.2% (n = 632) discontinued statins. Median time to discontinuation was 36 days (interquartile range 12-110 days). Shorter time to discontinuation was associated with hospitalization in past 30 days (adjusted hazard ratio (AHR) = 1.67, 95% CI = 1.40-1.99) and more daily medications (AHR = 1.02, 95% CI = 1.01-1.04). When statins were discontinued, 15.0% (n = 95) of residents stopped only statins, and 47.5% (n = 300) stopped at least one other medication. CONCLUSION Most NH residents who use statins at the time of progression to advanced dementia continue use in follow-up.
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Affiliation(s)
- Jennifer Tjia
- University of Massachusetts Medical School, Worcester, MA
| | | | | | - George Reed
- University of Massachusetts Medical School, Worcester, MA
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Partridge AH, Seah DS, King T, Leighl NB, Hauke R, Wollins DS, Von Roenn JH. Developing a Service Model That Integrates Palliative Care Throughout Cancer Care: The Time Is Now. J Clin Oncol 2014; 32:3330-6. [DOI: 10.1200/jco.2013.54.8149] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Palliative care is a fundamental component of cancer care. As part of the 2011 to 2012 Leadership Development Program (LDP) of the American Society of Clinical Oncology (ASCO), a group of participants was charged with advising ASCO on how to develop a service model integrating palliative care throughout the continuum of cancer care. This article presents the findings of the LDP group. The group focused on the process of palliative care delivery in the oncology setting. We identified key elements for models of palliative care in various settings to be potentially equitable, sustainable, feasible, and acceptable, and here we describe a dynamic model for the integrated, simultaneous implementation of palliative care into oncology practice. We also discuss critical considerations to better integrate palliative care into oncology, including raising consciousness and educating both providers and the public about the importance of palliative care; coordinating palliative care efforts through strengthening affiliations and/or developing new partnerships; prospectively evaluating the impact of palliative care on patient and provider satisfaction, quality improvement, and cost savings; and ensuring sustainability through adequate reimbursement and incentives, including linkage of performance data to quality indicators, and coordination with training efforts and maintenance of certification requirements for providers. In light of these findings, we believe the confluence of increasing importance of incorporation of palliative care education in oncology education, emphasis on value-based care, growing use of technology, and potential cost savings makes developing and incorporating palliative care into current service models a meaningful goal.
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Affiliation(s)
- Ann H. Partridge
- Ann H. Partridge and Davinia S.E. Seah, Dana-Farber Cancer Institute, Boston, MA; Tari King, Memorial Sloan-Kettering Cancer Center, New York, NY; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Ralph Hauke, Nebraska Cancer Specialists, Omaha, NE; Dana S. Wollins, American Society of Clinical Oncology, Alexandra, VA; and Jamie Hayden Von Roenn, Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Davinia S.E. Seah
- Ann H. Partridge and Davinia S.E. Seah, Dana-Farber Cancer Institute, Boston, MA; Tari King, Memorial Sloan-Kettering Cancer Center, New York, NY; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Ralph Hauke, Nebraska Cancer Specialists, Omaha, NE; Dana S. Wollins, American Society of Clinical Oncology, Alexandra, VA; and Jamie Hayden Von Roenn, Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Tari King
- Ann H. Partridge and Davinia S.E. Seah, Dana-Farber Cancer Institute, Boston, MA; Tari King, Memorial Sloan-Kettering Cancer Center, New York, NY; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Ralph Hauke, Nebraska Cancer Specialists, Omaha, NE; Dana S. Wollins, American Society of Clinical Oncology, Alexandra, VA; and Jamie Hayden Von Roenn, Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Natasha B. Leighl
- Ann H. Partridge and Davinia S.E. Seah, Dana-Farber Cancer Institute, Boston, MA; Tari King, Memorial Sloan-Kettering Cancer Center, New York, NY; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Ralph Hauke, Nebraska Cancer Specialists, Omaha, NE; Dana S. Wollins, American Society of Clinical Oncology, Alexandra, VA; and Jamie Hayden Von Roenn, Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Ralph Hauke
- Ann H. Partridge and Davinia S.E. Seah, Dana-Farber Cancer Institute, Boston, MA; Tari King, Memorial Sloan-Kettering Cancer Center, New York, NY; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Ralph Hauke, Nebraska Cancer Specialists, Omaha, NE; Dana S. Wollins, American Society of Clinical Oncology, Alexandra, VA; and Jamie Hayden Von Roenn, Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Dana S. Wollins
- Ann H. Partridge and Davinia S.E. Seah, Dana-Farber Cancer Institute, Boston, MA; Tari King, Memorial Sloan-Kettering Cancer Center, New York, NY; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Ralph Hauke, Nebraska Cancer Specialists, Omaha, NE; Dana S. Wollins, American Society of Clinical Oncology, Alexandra, VA; and Jamie Hayden Von Roenn, Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Jamie Hayden Von Roenn
- Ann H. Partridge and Davinia S.E. Seah, Dana-Farber Cancer Institute, Boston, MA; Tari King, Memorial Sloan-Kettering Cancer Center, New York, NY; Natasha B. Leighl, Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Ralph Hauke, Nebraska Cancer Specialists, Omaha, NE; Dana S. Wollins, American Society of Clinical Oncology, Alexandra, VA; and Jamie Hayden Von Roenn, Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
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45
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Blum D, Inauen R, Binswanger J, Strasser F. Barriers to research in palliative care: A systematic literature review. PROGRESS IN PALLIATIVE CARE 2014. [DOI: 10.1179/1743291x14y.0000000100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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LeBlanc TW, Abernethy AP. Building the palliative care evidence base: Lessons from a randomized controlled trial of oxygen vs room air for refractory dyspnea. J Natl Compr Canc Netw 2014; 12:989-92. [PMID: 24994919 DOI: 10.6004/jnccn.2014.0095] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Palliative care is increasingly seen as a standard component of high-quality comprehensive cancer care. However, several challenges remain to its widespread integration into clinical oncology practice, including workforce problems, reimbursement concerns, and a fledgling evidence base. This article discusses issues surrounding evidence base development in palliative cancer care, using the example of a recently published randomized controlled trial of oxygen versus room air. The Oxygen Trial randomized patients with refractory dyspnea and adequate Pao2 to oxygen or room air, administered via nasal cannula. Both groups experienced improvements in self-rated dyspnea scores, but no statistical differences were seen between intervention arms. These results suggest that supplementary oxygen is often unnecessary in the palliative setting, and that room air is similarly efficacious. This example highlights the importance and need for ongoing development of the evidence base in palliative medicine. The Palliative Care Research Cooperative (PCRC) is a novel National Institute of Nursing Research-funded research infrastructure that seeks to expand the palliative care evidence base. Its first multisite trial was recently completed, assessing the pragmatic question of whether statin medications can be safely discontinued in end-of-life settings. The PCRC will be a vehicle through which a high-quality evidence base will continue to expand and develop. Such ongoing research efforts are needed to inform and improve palliative care practice.
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Affiliation(s)
- Thomas W LeBlanc
- From the Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine; Center for Learning Health Care, Duke Clinical Research Institute; and Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.From the Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine; Center for Learning Health Care, Duke Clinical Research Institute; and Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Amy P Abernethy
- From the Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine; Center for Learning Health Care, Duke Clinical Research Institute; and Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina.From the Division of Hematologic Malignancies and Cellular Therapy, Department of Medicine, Duke University School of Medicine; Center for Learning Health Care, Duke Clinical Research Institute; and Division of Medical Oncology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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47
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Demiris G, Parker Oliver D, Capurro D, Wittenberg-Lyles E. Implementation science: implications for intervention research in hospice and palliative care. THE GERONTOLOGIST 2014; 54:163-71. [PMID: 23558847 PMCID: PMC3954415 DOI: 10.1093/geront/gnt022] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Accepted: 02/22/2013] [Indexed: 11/14/2022] Open
Abstract
This article provides a general introduction to implementation science-the discipline that studies the implementation process of research evidence-in the context of hospice and palliative care. By discussing how implementation science principles and frameworks can inform the design and implementation of intervention research, we aim to highlight how this approach can maximize the likelihood for translation and long-term adoption in clinical practice settings. We present 2 ongoing clinical trials in hospice that incorporate considerations for translation in their design and implementation as case studies for the implications of implementation science. This domain helps us better understand why established programs may lose their effectiveness over time or when transferred to other settings, why well-tested programs may exhibit unintended effects when introduced in new settings, or how an intervention can maximize cost-effectiveness with strategies for effective adoption. All these challenges are of significance to hospice and palliative care, where we seek to provide effective and efficient tools to improve care services. The emergence of this discipline calls for researchers and practitioners to carefully examine how to refine current and design new and innovative strategies to improve quality of care.
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Affiliation(s)
- George Demiris
- *Address correspondence to George Demiris, School of Nursing, University of Washington, Seattle, WA 98195. E-mail:
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Powell RA, Harding R, Namisango E, Katabira E, Gwyther L, Radbruch L, Murray SA, El-Ansary M, Leng M, Ajayi IO, Blanchard C, Kariuki H, Kasirye I, Namukwaya E, Gafer N, Casarett D, Atieno M, Mwangi-Powell FN. Palliative care research in Africa: consensus building for a prioritized agenda. J Pain Symptom Manage 2014; 47:315-24. [PMID: 23870840 DOI: 10.1016/j.jpainsymman.2013.03.022] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 03/20/2013] [Accepted: 03/29/2013] [Indexed: 11/20/2022]
Abstract
CONTEXT Palliative care research in Africa is in its relative infancy, with dedicated financial support extremely limited. Therefore, setting research priorities to optimize use of limited resources is imperative. OBJECTIVES To develop a prioritized research agenda for palliative care in Africa. METHODS We used a two-stage process involving palliative care professionals and researchers: 1) generation of an initial topic list at a consultative workshop of experts and 2) prioritization of that list using a consensus development process, the nominal group technique. RESULTS Phase 1: 41 topics were generated across five groups, with several topics nominated in more than one group. Phase 2: 16 topics and three broad thematic areas were identified. The two most prioritized topics within each of the three themes were the following: Theme 1: patient, family, and volunteers-1) care outcomes and the impact of palliative care as perceived by patients and caregivers and 2) palliative care needs of children; Theme 2: health providers-1) impact of palliative care training on care and practice and 2) integration of palliative care and antiretroviral therapy services; and Theme 3: health systems-1) palliative care needs assessments at the micro-, meso-, and macro-levels and 2) integration of palliative care into health systems and educational curricula. CONCLUSION Consensus-based palliative care topics determined by the study can assist researchers in optimizing limited research capacities by focusing on these prioritized areas. Subsequent to the identification and publication of the research agenda, concrete steps will be undertaken by the African Palliative Care Research Network and other partners to help implement it.
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Affiliation(s)
| | - Richard Harding
- King's College London, Department of Palliative Care, Policy and Rehabilitation, Cicely Saunders Institute, London, United Kingdom; Palliative Medicine Programme, Department of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Eve Namisango
- African Palliative Care Association, Kampala, Uganda
| | - Elly Katabira
- College of Health Sciences, Makerere University, Kampala, Uganda
| | - Liz Gwyther
- Division of Family Medicine, School of Public Health University of Cape Town, Cape Town, South Africa
| | - Lukas Radbruch
- Department of Palliative Medicine, University of Bonn, Bonn, Germany; Palliative Care Centre, Malteser Hospital Bonn/Rhein-Sieg, Bonn, Germany
| | - Scott A Murray
- Primary Palliative Care Research Group, General Practice Section, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Maged El-Ansary
- Anesthesia Department, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mhoira Leng
- Makerere Palliative Care Unit, Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ike O Ajayi
- Department of Epidemiology and Medical Statistics, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria; Centre for Palliative Care, Ibadan, Nigeria
| | - Charmaine Blanchard
- Gauteng Centre of Excellence for Palliative Care, Chris Hani Baragwanath Academic Hospital and University of Witwatersrand, Johannesburg, South Africa
| | - Helen Kariuki
- Department of Medical Physiology, University of Nairobi, Kenya
| | | | - Elizabeth Namukwaya
- Makerere Palliative Care Unit, Department of Medicine, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Nahla Gafer
- Palliative Care Unit, Radiation and Isotope Centre, Khartoum, Sudan
| | - David Casarett
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Aziz NM, Grady PA, Curtis JR. Training and career development in palliative care and end-of-life research: opportunities for development in the U.S. J Pain Symptom Manage 2013; 46:938-46. [PMID: 23631858 PMCID: PMC3735668 DOI: 10.1016/j.jpainsymman.2013.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 01/26/2013] [Accepted: 02/12/2013] [Indexed: 11/25/2022]
Abstract
There has been a dramatic increase in attention to the field of palliative care and end-of-life (PCEOL) research over the past 20 years. This increase is particularly notable in the development of palliative care clinical and educational programs. However, there remain important shortcomings in the evidence base to ensure access to and delivery of effective palliative care for patients with life-limiting illness and their families. Development of this evidence base will require that we train the next generation of researchers to focus on issues in PCEOL. The purpose of this article was to explore the current status of the recruitment, training, and retention of future investigators in PCEOL research in the U.S. and propose recommendations to move us forward. Some key contextual issues for developing and supporting this research workforce are articulated, along with timely and important research areas that will need to be addressed during research training and career development. We provide targeted key recommendations to facilitate the nurturing and support of the future research workforce that is needed to ensure the development and implementation of the science necessary for providing high-quality, evidence-based palliative care to all who need and desire it.
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Affiliation(s)
- Noreen M Aziz
- National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
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Kurella Tamura M, Meier DE. Five policies to promote palliative care for patients with ESRD. Clin J Am Soc Nephrol 2013; 8:1783-90. [PMID: 23744000 PMCID: PMC3789338 DOI: 10.2215/cjn.02180213] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Patients with ESRD experience complex and costly care that does not always meet their needs. Palliative care, which focuses on improving quality of life and relieving suffering for patients with serious illnesses, could address a large unmet need among patients with ESRD. Strengthening palliative care is a top policy priority for health reform efforts based on strong evidence that palliative care improves value. This commentary outlines palliative care policies for patients with ESRD and is directed at policymakers, dialysis providers, nephrology professional societies, accreditation organizations, and funding agencies who play a key role in the delivery and determination of quality of ESRD care. Herein we suggest policies to promote palliative care for patients with ESRD by addressing key barriers, including the lack of access to palliative care, lack of capacity to deliver palliative care, and a limited evidence base. We also provide examples of how these policies could be implemented within the existing ESRD care infrastructure.
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Affiliation(s)
- Manjula Kurella Tamura
- Veterans Affairs Palo Alto Health Care System Geriatrics Research Education and Clinical Center. Palo Alto, California
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, California; and
| | - Diane E. Meier
- Center to Advance Palliative Care and Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
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