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Gurgenci T, O'Leary C, Hui D, Yennu S, Bruera E, Davis M, Agar MR, Zimmermann C, Philip J, Mercadante S, Hardy J, Rosa WE, Good P. Top Ten Tips Palliative Care Clinicians Should Know About Interpreting a Clinical Trial. J Palliat Med 2024. [PMID: 39046924 DOI: 10.1089/jpm.2024.0258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
Evidence-based practice is foundational to high-quality palliative care delivery. However, the clinical trials that compose the evidence base are often methodologically imperfect. Applying their conclusions without critical application to the clinical practice context can harm patients. The tips provided can help clinicians infer judiciously from clinical trial results and avoid credulously accepting findings without critique. We suggest that statistical and mathematical expertise is unnecessary, but rather a keen curiosity about investigators' rationale for certain design choices and how these choices can affect results is key. For a more comprehensive understanding of clinical trials, this article can be used with the authors' corresponding ten tips article that focuses on designing a clinical trial.
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Affiliation(s)
- Taylan Gurgenci
- Department of Palliative and Supportive Care, Mater Health Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
| | - Cian O'Leary
- Cancer Program, Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
| | - David Hui
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sriram Yennu
- Palliative, Rehabilitation & Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, & Integrative Medicine, The University of Texas MD Anderson Cancer, Houston, Texas, USA
| | - Mellar Davis
- Director of Palliative Care Research at Geisinger Medical Center, Geisinger Commonwealth School of Medicine, Scranton PA, Danville, Pennsylvania, USA
| | - Meera R Agar
- Faculty of Health, IMPACCT, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jennifer Philip
- Department of Palliative Care, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Fitzroy, Victoria, Australia
- Department of Palliative Care, Palliative Care Service, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Sebastiano Mercadante
- Pain Relief and Supportive-Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | - Janet Hardy
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - William E Rosa
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Phillip Good
- Department of Palliative and Supportive Care, Mater Health Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
- Cancer Program, Mater Research Institute-University of Queensland, Brisbane, Queensland, Australia
- Department of Palliative and Supportive Care, Mater Health, Brisbane, Queensland, Australia
- Department of Palliative Care, University of Queensland, St Vincent's Private Hospital, Brisbane, Queensland, Australia
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Stone PC, Minton O, Richardson A, Buckle P, Enayat ZE, Marston L, Freemantle N. Methylphenidate Versus Placebo for Treating Fatigue in Patients With Advanced Cancer: Randomized, Double-Blind, Multicenter, Placebo-Controlled Trial. J Clin Oncol 2024; 42:2382-2392. [PMID: 38757263 PMCID: PMC11227299 DOI: 10.1200/jco.23.02639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/24/2024] [Accepted: 02/28/2024] [Indexed: 05/18/2024] Open
Abstract
PURPOSE To compare effects and side effects of 6 weeks of individually dose-titrated methylphenidate or placebo on fatigue in palliative care patients with advanced cancer. METHODS This is a randomized, double-blind, placebo-controlled, multicenter trial. Eligible patients had advanced incurable cancer and fatigue >3/10. Principal exclusions were hypertension; psychiatric, cardiovascular, cerebrovascular, renal, liver, or blood disorders; substance dependency; and epilepsy. Patients were randomly assigned 1:1 methylphenidate or placebo starting at 5 mg twice daily. Dose of methylphenidate/placebo was titrated once per week, over 6 weeks, up to a maximum of 20 mg three times daily. Trial ended at 10 weeks. Primary outcome was the difference in Functional Assessment of Chronic Illness Therapy Fatigue (FACIT-F) scores between groups at 6 ± 2 weeks. Secondary outcomes included adverse effects, quality of life, and mood. RESULTS One hundred sixty-two patients (73 men; mean, 65.8; standard deviation [SD], 10.3 years) were randomly assigned, and three were excluded from analysis. Seventy-seven were allocated placebo (baseline FACIT-F = 22 [SD, 10]); 82 were allocated methylphenidate (FACIT-F = 20 [SD, 9]). After 6 ± 2 weeks, FACIT-F scores were 1.97 points (95% CI, -0.95 to 4.90; P = .186) higher (better) on methylphenidate than placebo. Across 10 weeks of the study, FACIT-F was nominally higher in the methylphenidate group versus placebo (Diff, 2.20 [95% CI, 0.39 to 4.01]), but this did not reach the minimally clinically important difference (5-points). At 6 weeks, there were no differences between groups in quality-of-life or symptom domains except for depression scores (nominally reduced in the methylphenidate group: Diff, -1.35 [95% CI, -2.41 to -0.30]). There were no differences in mortality or serious adverse events. CONCLUSION After 6 ± 2 weeks of treatment, methylphenidate was not superior to placebo for treating fatigue in advanced cancer. Methylphenidate was safe and well-tolerated.
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Affiliation(s)
- Patrick Charles Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, United Kingdom
| | - Ollie Minton
- University Hospitals Sussex NHS Foundation Trust, Worthing Hospital, Lyndhurst Road, Worthing, West Sussex, United Kingdom
| | - Alison Richardson
- University of Southampton & University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, United Kingdom
| | - Peter Buckle
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, United Kingdom
| | - Zinat E. Enayat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, United Kingdom
| | - Louise Marston
- Department of Primary Care & Population Health, Institute of Epidemiology & Health Care, Faculty of Population Health Sciences, University College London (UCL), London, United Kingdom
| | - Nick Freemantle
- Comprehensive Clinical Trials Unit, University College London (UCL), London, United Kingdom
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Bassah N, Beranek J, Kennedy M, Onabadejo J, Santos Salas A. Inequities in access to palliative and end-of-life care in the black population in Canada: a scoping review. Int J Equity Health 2024; 23:81. [PMID: 38664833 PMCID: PMC11044312 DOI: 10.1186/s12939-024-02173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/04/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Improving equity and early access to palliative care for underserved populations in Canada is a priority. Little is known regarding access to palliative and end-of-life care in the Black population. METHODS We undertook a scoping review using the framework by Arksey and O'Malley to identify knowledge, access gaps, and experiences of palliative and end-of-life care among Blacks living with life-limiting illnesses in Canada. Primary studies, discussion papers, books, and reports were considered eligible. We followed a comprehensive search strategy developed by an information scientist. Searches were performed in the following bibliographic databases: Medline, EMBASE, PsycINFO via OVID, CINAHL via EBSCOhost, Scopus and Cochrane Library via Wiley. The search strategy was derived from three main concepts: (1) Black people; (2) Canada and Canadian provinces; (3) Palliative, hospice, or end-of-life care. No publication date or language limits were applied. Titles and abstracts were screened for eligibility by one reviewer and full text by two independent reviewers. RESULTS The search yielded 233 articles. Nineteen articles were selected for full-text review, and 7 articles met the inclusion criteria. These studies were published between 2010 and 2021, and conducted in the provinces of Ontario and Nova Scotia only. Studies used both quantitative and qualitative methods and included cancer decedents, next of kin, family caregivers and religious leaders. Sample sizes in various studies ranged from 6 - 2,606 participants. Included studies reported a general lack of understanding about palliative and end-of-life care, positive and negative experiences, and limited access to palliative and end-of-life care for Blacks, across all care settings. CONCLUSION Findings suggest limited knowledge of palliative care and inequities in access to palliative and end-of-life care for Blacks living with life-limiting illnesses in 2 Canadian provinces. There is an urgent need for research to inform tailored and culturally acceptable strategies to improve understanding and access to palliative care and end-of-life care among Blacks in Canada.
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Affiliation(s)
- Nahyeni Bassah
- Faculty of Nursing, College of Health Sciences, University of Alberta, Third Floor Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB, T6G 1C9, Canada.
- Department of Nursing, Faculty of Health Sciences, University of Buea, P.O Box 63, Buea, South West Region, Cameroon.
| | - Julia Beranek
- Faculty of Nursing, College of Health Sciences, University of Alberta, Third Floor Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB, T6G 1C9, Canada
| | - Megan Kennedy
- Geoffrey & Robyn Sperber Health Sciences Library, Edmonton Clinic Health Academy, 1-150M, 11405 87 Avenue NW, Edmonton, AB, T6G 1C9, Canada
| | - Juliet Onabadejo
- BScN Program, School of Health and Wellness, Red Deer Polytechnic, 100 College Blvd, Box 5005, Red Deer, AB, Canada
| | - Anna Santos Salas
- Faculty of Nursing, College of Health Sciences, University of Alberta, Third Floor Edmonton Clinic Health Academy, 11405 87 Avenue NW, Edmonton, AB, T6G 1C9, Canada
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Jennes DAD, Biesbrouck T, De Roo ML, Smets T, Van Den Noortgate N. Pharmacological Treatment for Terminal Agitation, Delirium and Anxiety in Frail Older Patients. Geriatrics (Basel) 2024; 9:51. [PMID: 38667518 PMCID: PMC11050185 DOI: 10.3390/geriatrics9020051] [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: 03/05/2024] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 04/28/2024] Open
Abstract
CONTEXT Psychological distress symptoms in the last days of life often contribute to the overall symptom burden in frail older patients. Good symptom management practices are crucial to ensure high-quality end-of-life care in an aging population, though the best pharmacological approach to treat these psychological symptoms has yet to be established. OBJECTIVES To identify current evidence-based and practice-based knowledge of pharmacological interventions for the treatment of agitation, delirium, and anxiety during the last days of life in frail older patients. METHODS A systematic, mixed methods review was performed through MEDLINE via PubMed and EMBASE from inception until February 2022 and updated through March 2023. National and international guideline databases and grey literature were searched for additional studies and guidelines. RESULTS Four quantitative studies, two non-randomized and two descriptive, were identified. No randomized controlled trials met inclusion criteria. No qualitative studies were withheld. The three consensus-based protocols that were found through citation searching and screening of grey literature did not meet the standards for inclusion. Haloperidol is recommended in consensus-based guidelines for delirium and is widely used, but high-quality evidence about its efficacy is missing. Better control of agitation or refractory delirium might be achieved with the addition of a benzodiazepine. There is no evidence available about the treatment of anxiety in the last days of life in frail older patients. CONCLUSIONS This mixed methods review demonstrates the lack of good quality evidence that is needed to help clinicians with pharmacological treatment decisions when confronted with psychological symptoms in the last days of life in frail older patients. Population aging will only emphasize the need for further research in this specific population.
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Affiliation(s)
- Dine A. D. Jennes
- Department of Geriatric Medicine, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Tim Biesbrouck
- Department of Geriatric Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, 3000 Leuven, Belgium
| | - Maaike L. De Roo
- Department of Geriatric Medicine, University Hospitals Leuven, 3000 Leuven, Belgium
- Department of Public Health and Primary Care, Gerontology and Geriatrics, KU Leuven, 3000 Leuven, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel [VUB] and Ghent University, 1090 Brussels, Belgium
| | - Nele Van Den Noortgate
- End-of-Life Care Research Group, Vrije Universiteit Brussel [VUB] and Ghent University, 1090 Brussels, Belgium
- Department of Geriatric Medicine, Ghent University Hospital, 9000 Ghent, Belgium
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Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, Divatia JV, Kumar A, Iyer SK, Deodhar J, Bhat RS, Salins N, Thota RS, Mathur R, Iyer RK, Gupta S, Kulkarni P, Murugan S, Nasa P, Myatra SN. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024; 28:200-250. [PMID: 38477011 PMCID: PMC10926026 DOI: 10.5005/jp-journals-10071-24661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 02/28/2024] [Indexed: 03/14/2024] Open
Abstract
End-of-life care (EOLC) exemplifies the joint mission of intensive and palliative care (PC) in their human-centeredness. The explosion of technological advances in medicine must be balanced with the culture of holistic care. Inevitably, it brings together the science and the art of medicine in their full expression. High-quality EOLC in the ICU is grounded in evidence, ethical principles, and professionalism within the framework of the Law. Expert professional statements over the last two decades in India were developed while the law was evolving. Recent landmark Supreme Court judgments have necessitated a review of the clinical pathway for EOLC outlined in the previous statements. Much empirical and interventional evidence has accumulated since the position statement in 2014. This iteration of the joint Indian Society of Critical Care Medicine-Indian Association of Palliative Care (ISCCM-IAPC) Position Statement for EOLC combines contemporary evidence, ethics, and law for decision support by the bedside in Indian ICUs. How to cite this article Mani RK, Bhatnagar S, Butola S, Gursahani R, Mehta D, Simha S, et al. Indian Society of Critical Care Medicine and Indian Association of Palliative Care Expert Consensus and Position Statements for End-of-life and Palliative Care in the Intensive Care Unit. Indian J Crit Care Med 2024;28(3):200-250.
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Affiliation(s)
- Raj K Mani
- Department of Critical Care and Pulmonology, Yashoda Super Specialty Hospital, Ghaziabad, Kaushambi, Uttar Pradesh, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Savita Butola
- Department of Palliative Care, Border Security Force Sector Hospital, Panisagar, Tripura, India
| | - Roop Gursahani
- Department of Neurology, P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Dhvani Mehta
- Division of Health, Vidhi Centre for Legal Policy, New Delhi, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Jigeeshu V Divatia
- Department of Anaesthesia, Critical Care, and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Arun Kumar
- Department of Intensive Care, Medical Intensive Care Unit, Fortis Healthcare Ltd, Mohali, Punjab, India
| | - Shiva K Iyer
- Department of Critical Care, Bharati Vidyapeeth (Deemed to be University) Medical College, Pune, Maharashtra, India
| | - Jayita Deodhar
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Rajani S Bhat
- Department of Interventional Pulmonology and Palliative Medicine, SPARSH Hospitals, Bengaluru, Karnataka, India
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Raghu S Thota
- Department Palliative Care, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Roli Mathur
- Department of Bioethics, Indian Council of Medical Research, Bengaluru, Karnataka, India
| | - Rajam K Iyer
- Department of Palliative Care, Bhatia Hospital; P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, Maharashtra, India
| | - Sudeep Gupta
- Department of Medical Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, India
| | | | - Sangeetha Murugan
- Department of Education and Research, Karunashraya, Bengaluru, Karnataka, India
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dubai, United Arab Emirates
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
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Taylor S, Vercell A, Sawyer C, Khatoon B, Coomber-Moore J, Yorke J, Mula C, Berman R. Enhanced supportive care: prospective cohort study of oncology patients and caregivers. BMJ Support Palliat Care 2024; 14:103-117. [PMID: 37696586 DOI: 10.1136/spcare-2023-004231] [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: 02/15/2023] [Accepted: 08/09/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVES A prospective cohort study to evaluate clinical effectiveness of the enhanced supportive care (ESC) service at a comprehensive cancer centre and to explore the impact of the service on patient and caregiver outcomes and experience. METHODS Patients who received care under the ESC service and their caregivers were eligible. Consented patients (n=184) and caregivers (n=67) completed questionnaires at baseline, 4 weeks and 8 weeks post-ESC. Patient questionnaires assessed quality of life (QOL), symptoms, experience of ESC and health service use. Caregiver questionnaires included QOL and needs assessment. Selected patients (n=13) participated in qualitative interviews. Quantitative analysis explored differences in questionnaire responses over time (p<0.05). Qualitative data were analysed thematically. RESULTS Patient quantitative data showed improvements in QOL (p=0.004 for European Quality of Life Questionnaire 5 dimensions (EQ5D) health index scores) and anxiety (p=0.006) at 4 weeks, reduction in some symptoms (pain p=0.02 at 4 weeks), improvement in self-efficacy, an increase in problems being addressed and a decrease in health service use (reduction in outpatient appointments). Qualitative findings suggested patients were generally satisfied with the ESC service but identified areas for improvement such as increased awareness of ESC and earlier referral. Fewer improvements were noted for caregivers; however, they did report a decrease in unmet needs. CONCLUSION The ESC service had a positive impact on various patient-reported and caregiver-reported outcomes. There were also positive impacts on health service use. Increasing awareness of ESC and engaging patients at an earlier stage in the disease trajectory may further improve patient satisfaction and outcomes.
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Affiliation(s)
- Sally Taylor
- Christie Patient Centred Research Team, The Christie NHS Foundation Trust, Manchester, UK
- School of Nursing and Midwifery, The University of Manchester, Manchester, UK
| | - Amy Vercell
- Christie Patient Centred Research Team, The Christie NHS Foundation Trust, Manchester, UK
| | - Chelsea Sawyer
- Christie Patient Centred Research Team, The Christie NHS Foundation Trust, Manchester, UK
| | - Binish Khatoon
- Christie Patient Centred Research Team, The Christie NHS Foundation Trust, Manchester, UK
| | - Jake Coomber-Moore
- Christie Patient Centred Research Team, The Christie NHS Foundation Trust, Manchester, UK
| | - Janelle Yorke
- Christie Patient Centred Research Team, The Christie NHS Foundation Trust, Manchester, UK
- School of Nursing and Midwifery, The University of Manchester, Manchester, UK
| | - Carole Mula
- Department of Supportive Care, The Christie NHS Foundation Trust, Manchester, UK
| | - Richard Berman
- Department of Supportive Care, The Christie NHS Foundation Trust, Manchester, UK
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Hoda W, Pandey K. Advancing Evidence-based Palliative Care Research: Navigating Challenges and Proposing Solutions. Indian J Palliat Care 2024; 30:89-92. [PMID: 38633675 PMCID: PMC11021051 DOI: 10.25259/ijpc_243_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/16/2023] [Indexed: 04/19/2024] Open
Abstract
Amid the increasing demand for palliative care, driven by demographic shifts and medical progress, evidence-based practices face obstacles due to limited research. Complex patient conditions and ethical considerations challenge traditional methodologies, while the absence of comprehensive clinical trials hinders innovative interventions. Empowering practitioners with research skills and establishing a palliative care research network are efforts aimed at bridging these gaps. It is important to emphasise that these initiatives collectively aspire to enhance evidence-based practices, ensuring quality care for individuals facing severe illnesses.
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Affiliation(s)
- Wasimul Hoda
- Department of Superspeciality Anaesthesiology, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | - Khushboo Pandey
- Department of Anaesthesiology, All India Institute of Medical Sciences, Rajkot, Gujarat, India
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Reif MM, Secunda KE, Clapp JT, Viglianti EM, Mylvaganam R, Peliska M, Holl JL, Kruser JM. The Duality of "Goals of Care" Language: A Qualitative Focus Group Study With Frontline Clinicians. J Pain Symptom Manage 2023; 66:e658-e665. [PMID: 37597589 PMCID: PMC10845157 DOI: 10.1016/j.jpainsymman.2023.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023]
Abstract
CONTEXT The phrase "goals of care" (GOC) is common in serious illness care, yet it lacks clarity and consistency. Understanding how GOC is used across healthcare contexts is an opportunity to identify and mitigate root causes of serious illness miscommunication. OBJECTIVES We sought to characterize frontline palliative and critical care clinicians' understanding and use of the phrase GOC in clinical practice. METHODS We conducted a secondary qualitative thematic analysis of focus group transcripts (n = 10), gathered as part of a parent study of care delivery for patients with respiratory failure. Participants (n = 59) were members of the palliative and critical care interprofessional teams at two academic medical centers. RESULTS Clinicians primarily use GOC as a shorthand signal among team members to indicate a patient is nearing the end of life. This signal can also indicate conflict with patients and families when clinicians' expectations-typically an expected "transition" toward a different type of care-are not met. Clinicians distinguish their clinical use of GOC from an "ideal" meaning of the phrase, which is broader than end of life and focused on patients' values. Palliative care specialists encourage other clinicians to shift toward the "ideal" GOC concept in clinical practice. CONCLUSION Frontline palliative and critical care clinicians understand a duality in GOC, as an idealized concept and as an expeditious signal for clinical care. Our findings suggest ambiguous phrases like GOC persist because of unmet needs for better ways to discuss and address diverse and complex priorities for patients with serious illness.
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Affiliation(s)
- Michaella M Reif
- Department of Medicine (M.M.R., M.P.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Katharine E Secunda
- Department of Medicine (K.E.S.), Division of Pulmonary, Allergy and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin T Clapp
- Department of Anesthesiology & Critical Care (J.T.C.), University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth M Viglianti
- Division of Pulmonary and Critical Care (E.M.V.), University of Michigan, Ann Arbor, Michigan, USA; Veterans Affairs Center for Clinical Management Research (E.M.V.), HSR&D Center for Innovation, Ann Arbor, Michigan, USA
| | - Ruben Mylvaganam
- Division of Pulmonary and Critical Care (R.M.), Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Michael Peliska
- Department of Medicine (M.M.R., M.P.), University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Jane L Holl
- Department of Neurology, Biological Sciences Division (J.L.H.), University of Chicago, Chicago, Illinois, USA
| | - Jacqueline M Kruser
- Department of Medicine (J.M.K.), Division of Allergy, Pulmonary and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA.
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Linge-Dahl L, Heintz S, Ruch W, Bley M, von Hirschhausen E, Radbruch L. Evaluation of a Study Protocol of the Application of Humor Interventions in Palliative Care Through a First Pilot Study. Palliat Med Rep 2023; 4:239-248. [PMID: 37732024 PMCID: PMC10507944 DOI: 10.1089/pmr.2023.0014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2023] [Indexed: 09/22/2023] Open
Abstract
Background Humor and laughter might have an alleviating effect on pain threshold and enhance coping and building relationships. However, randomized controlled studies in palliative care have struggled with high percentages of attrition and missing values. Objectives We aimed to evaluate a study protocol through a pilot study for the evaluation of a multistage humor intervention with psychological and physiological outcome parameters that may be applied successfully in a palliative care environment. Design This pilot study utilized a pre-post design. The inclusion of a control group for the final study setting recruiting 120 patients is planned. Setting/Subjects The study was a monocenter study in a clinic for palliative care in Germany. All patients were eligible for recruitment. Seven patients were recruited for the pilot study. Measurements Interventions were developed using a humor training for psychiatric patients. Quantitative sensory testing for pain threshold testing and questionnaires on humor as a character trait, pain intensity, life satisfaction, and symptom burden were planned to be evaluated before and after three humor interventions. Results The feasibility of the original study design was re-evaluated after pilot testing. Only two out of the seven patients were able to complete two interventions, requiring modification. Fewer questionnaires, less complex physiological testing, and reduction from three to two interventions were then planned. Conclusion The initial planned research methodology must be adjusted for patients with high symptom burden. In the experimental group of the final study setting, the effects of one to two interventions will be evaluated measuring oxytocin levels in saliva and using standardized questionnaires to determine cheerfulness, life satisfaction and symptom burden, as well as assessing as-needed medication. Trial registration DRKS00028978 German Registry of Clinical Studies.
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Affiliation(s)
- Lisa Linge-Dahl
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - Sonja Heintz
- Faculty of health, School of Psychology, University of Plymouth, Plymouth, United Kingdom
| | - Willibald Ruch
- Department of Psychology, University of Zurich, Zurich, Switzerland
| | - Maria Bley
- Foundation “Humor Hilft Heilen” (Humor Helps to Cure), Bonn, Germany
| | | | - Lukas Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
- Center for Palliative Care, Helios Hospital Bonn/Rhine-Sieg, Bonn, Germany
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Martins CS, Cadavez E, Nunes R. Advance directives in palliative care-a new tool to improve the communication between patients and caregivers? Int J Palliat Nurs 2023; 29:344-349. [PMID: 37478063 DOI: 10.12968/ijpn.2023.29.7.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Abstract
BACKGROUND In palliative care, caregivers frequently act as surrogate decision-makers, but their knowledge of patients' preferences for end-of-life care is sometimes scarce and incorrect. Advance Directives might be a powerful communication tool to promote the dialogue between patients and caregivers. AIMS This work aims to find evidence supporting the use of the Advance Directives documents by health practitioners as a communication tool to improve caregivers' capacity as health surrogates in palliative care. METHODS A literature review was conducted in four databases-Medline, Web of Science, Scopus, and Cochrane to identify studies published until February 27th, 2021, analysing advance directive's use as a communication tool between palliative patients and their caregivers. FINDINGS Of the 1251 papers screened, only one article met the defined criteria, presenting results statistically favourable to advance directive's use, although with the risk of significant bias. CONCLUSIONS Although the results seem promising, more studies are needed to validate this strategy scientifically.
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Affiliation(s)
- Catarina Sampaio Martins
- Anesthesiology Consultant and Palliative Care Medical Doctor, Palliative Medicine Service of Centro Hospitalar de Tràs-os-Montes e Alto Douro, Portugal
| | - Emanuel Cadavez
- Oncology Resident Medical Doctor, Oncology Service of Centro Hospitalar de Tràs-os-Montes e Alto Douro, Portugal
| | - Rui Nunes
- Professor, Faculty of Medicine, MEDCIDS-Department of Community Medicine, Information and Decision in Health, University of Porto, Portugal
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11
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Barry C, Paes P, Noble S, Davies A. Challenges to delivering evidence-based palliative medicine. Clin Med (Lond) 2023; 23:182-184. [PMID: 36806204 PMCID: PMC11046501 DOI: 10.7861/clinmed.2022-0336] [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] [Indexed: 02/22/2023]
Abstract
Established as a medical specialty in 1987, palliative medicine approaches middle age facing existential questions of identity, purpose and vision. Time has weakened strong foundations laid by Dame Cicely Saunders in research, education and clinical excellence. Clinical knowledge gaps are wide, and widening. Palliative medicine research is underfunded and underrepresented in discourse. Despite huge advances in modern medicine, there is still clinical uncertainty about simple interventions, such as whether artificial hydration at the end of life is helpful or harmful. Where good quality data do exist, the pace of change is slow, if change is happening at all. Trial design often fails to assess the holistic impact of interventions, using primary endpoints that are inconsistent with outcomes most valued to the patient. Recent years have seen a rapid expansion in innovation and investment in digital technologies, embraced by many in palliative medicine. Experience shows that caution must be applied where the evidence base is sparse. While as a specialty we must remain forward looking and progressive in our mindset, it cannot be assumed that these new interventions alone will provide the solutions to the old problems that exist in palliative medicine.This review summarises the key points presented in the Palliative Medicine section of the RCP Clinical Medicine Conference, 2022.
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Affiliation(s)
- Caroline Barry
- Norfolk and Norwich NHS Foundation Trust, Norwich, UK, and clinical associate professor in translational and clinical medicine, University of East Anglia, Norwich, UK
| | - Paul Paes
- Northumbria Healthcare NHS Foundation Trust, Northumbria, UK
| | | | - Andrew Davies
- Trinity College Dublin, University College Dublin and Our Lady's Hospice, Dublin, Ireland
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12
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Daubman BR, Rosenberg LB, Meier DE. Beyond the Fight: Why President Biden's Cancer Moonshot Must Include Palliative Care. J Clin Oncol 2023; 41:1189-1192. [PMID: 36103638 PMCID: PMC9940938 DOI: 10.1200/jco.22.00838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/30/2022] [Accepted: 07/29/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bethany-Rose Daubman
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Leah B. Rosenberg
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Diane E. Meier
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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13
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Hudson PL, Gardiner C, Alvariza A, Nicholas Dionne-Odom J, Öhlén J, Carduff E, Harding R, Witkamp E, Payne S. Strategies and checklist for designing and conducting palliative care research with family carers: EAPC international expert elicitation study. Palliat Med 2023; 37:163-173. [PMID: 36380493 DOI: 10.1177/02692163221136162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Palliative care services seek to improve the wellbeing of family carers of people living with serious and life-limiting illness. To help achieve this goal, systematic reviews have recommended priority areas for family carer research and the need to improve the quality of study design. Policy makers have also advocated for enhanced family carer support. However, there are specific methodological considerations and challenges in designing and conducting carer research conducted during the course of the serious illness trajectory and in bereavement. AIM To develop strategies to improve the design and conduct of research with family carers. DESIGN Expert elicitation study using an adapted version of the 'Identify, Discuss, Estimate and Aggregate' elicitation protocol, supplemented with strategies from peer-reviewed literature. SETTING/PARTICIPANTS Nine members of the management committee of the European Association for Palliative Care's Reference group on family carer research, comprising international senior research academics in family caregiving. RESULTS A compilation of recommended strategies and checklist was created to: (a) help researchers plan research involving family carers focussing on: preparation, conduct and dissemination and (b) assist ethics committees and funding bodies to evaluate proposals. CONCLUSIONS The strategies and checklist for conducting research with family carers may enhance methodologically rigorous research. Consequently, researchers, practitioners and policy makers will not only gain a more comprehensive understanding of the unmet needs of family carers but also promote the development of empirically sound interventions.
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Affiliation(s)
- P L Hudson
- Centre for Palliative Care, St Vincent's Hospital, Melbourne, Australia.,University of Melbourne, Melbourne, Australia.,Vrije Universiteit Brussel, Brussels, Belgium
| | - C Gardiner
- Health Sciences School, University of Sheffield, UK
| | - A Alvariza
- Department of Health Care Sciences, Palliative Research Centre, Marie Cederschiöld University, Stockholm, Sweden.,Capio Palliative Care, Dalen Hospital, Stockholm, Sweden
| | | | - J Öhlén
- Institute of Health and Care Sciences, and Centre for Person-Centred Care (GPCC), Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Palliative Centre, Sahlgrenska University Hospital, Västra Götaland Region, Gothenburg, Sweden
| | - E Carduff
- Marie Curie Hospice Glasgow, Glasgow, UK
| | - R Harding
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, Cicely Saunders Institute, London, UK
| | - E Witkamp
- Research Center Innovations in Care, Department of Public Health, Erasmus Medical Center, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
| | - S Payne
- International Observatory on End of Life Care, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
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14
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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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15
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Cameron MG, Kersten C. Prospective case series of neuropathic cancer pain in patients treated with an EGFR-inhibitor. Palliat Med 2022; 36:1154-1162. [PMID: 35656645 DOI: 10.1177/02692163221102003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Novel treatments of neuropathic pain are urgently needed. Rapid relief of neuropathic cancer pain in patients treated with epidermal growth factor receptor (EGFR) inhibitors have been reported. Experiments in rodent models confirm the pain relief and reveal novel mechanisms critically involving the EGFR. Clinical pain research is complicated and patients with advanced cancer are heterogeneous, often with complex, deteriorating clinical pictures, hampering feasibility of drug-trial procedures. ACTUAL CASE Prospective case series exploring the EGFR inhibition/neuropathic cancer pain association in order to inform planning clinical trials. POSSIBLE COURSES OF ACTION Symptom assessment method was tailored to what was ethical, feasible, and clinically relevant for each patient. FORMULATION OF A PLAN Patients with neuropathic cancer pain treated off-label with the monoclonal antibody panitumumab were studied to assess feasibility of different measurement tools. OUTCOME Fourteen of 20 patients (70%) experienced clinically significant pain relief. There was good concordance in patient and physician-reported outcomes. LESSONS Results support panitumumab's potential to be of significant benefit to patients with refractory neuropathic cancer pain. Findings also reinforce the difficulty of using conventional drug trial endpoints and designs in this population. VIEW Innovative research methods must be considered for much needed pivotal trials.
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Affiliation(s)
| | - Christian Kersten
- Department of Research, Sørlandet Hospital Trust, Kristiansand, Norway
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16
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The Impact of Pancreatic Enzyme Replacement Therapy on Patients With Advanced Pancreatic Adenocarcinoma: A Systematic Review and Narrative Synthesis. Pancreas 2022; 51:405-414. [PMID: 35973015 DOI: 10.1097/mpa.0000000000002049] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Advanced pancreatic cancer has a poor prognosis globally. Patients often develop pancreatic exocrine insufficiency leading to malabsorption. This systematic literature review explores the impact of pancreatic enzyme replacement therapy (PERT) on patients with advanced pancreatic cancer. Data sources include MEDLINE, CINAHL, Embase, Cochrane (CENTRAL), PsychINFO, and Joanna Briggs Institute databases from inception to January 14, 2022, with reference list checking on Google Scholar. Narrative synthesis was used as the eligible studies were likely to be heterogeneous and hard to compare. This synthesis approach uses 4 steps: theory development, preliminary synthesis, exploration of relationships, and assessment of the robustness of the synthesis. Four themes arose from analyzing the study outcomes including PERT education, efficacy of PERT, the patient experience, and lack of awareness regarding enzyme replacement. The included studies did not use validated tools or standardized measurements, which made it difficult to compare or draw conclusions. Pancreatic enzyme replacement therapy shows the potential to improve symptoms, nutrition, weight loss, and survival, but high-quality studies with standardized outcomes have not been completed. Patient and health professional education is required because there seems to be a general lack of awareness about the use of PERT in pancreatic cancer.Systematic Review Registration: PROSPERO 2020 CRD42020195986.
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17
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van Esch HJ, Prins SD, van de Vathorst S, van der Rijt CCD, van der Heide A, van Zuylen L. Reflections on Including Patients in a Randomized Placebo-Controlled Multicentre Trial in the Dying Phase - the SILENCE Study. J Pain Symptom Manage 2022; 63:e545-e552. [PMID: 34954069 DOI: 10.1016/j.jpainsymman.2021.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/25/2021] [Accepted: 12/14/2021] [Indexed: 11/23/2022]
Abstract
A need exists for studies investigating symptom relief at the end of life. Randomised controlled trials (RCTs) are the gold standard for demonstrating efficacy of medication, but they are difficult to perform at the end of life due to barriers such as the vulnerability of patients, and gatekeeping by healthcare professionals. We analyzed and reflected on recruitment, participation, and strategies used in an RCT at the end of life. The SILENCE study, performed in six inpatient hospice facilities, was a placebo-controlled trial to study the effect of ScopolamIne butyLbromidE giveN prophylactiCally for dEath rattle in dying patients. We addressed patients' vulnerability by using an advance consent procedure, and potential gatekeeping by extensive training of health care professionals and the appointment of hospice doctors as daily responsible researchers. In almost three years, 1097 patients were admitted of whom 626 were eligible at first assessment. Of these, 119 (19%) dropped out because of physical deterioration before they could be informed about the study (44) or sign informed consent (75). Twenty-five (4%) patients were not asked to participate. In 24 cases (4%), relatives advised against the patient participating. Overall, 229 patients (37%) gave informed consent to participate. The vulnerability of patients was the most important barrier in this medication study at the end of life. Gatekeeping by HCPs and relatives occurred in a small number of patients. The robust design and applied strategies to facilitate patient recruitment in this study resulted in a successful study with sufficient participants.
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Affiliation(s)
- Harriëtte J van Esch
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands; Laurens Cadenza, Oosterhagen 239, 3078 CL Rotterdam, The Netherlands; Department of Public Health, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands.
| | - Sanne D Prins
- Department of Public Health, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Suzanne van de Vathorst
- Department of Medical ethics,philosophy and history, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Amsterdam UMC, Amsterdam University Medical Centers, Cancer Center Amsterdam, 1007 MB Amsterdam, The Netherlands
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18
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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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19
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Helde Frankling M, Klasson C, Sandberg C, Nordström M, Warnqvist A, Bergqvist J, Bergman P, Björkhem-Bergman L. 'Palliative-D'-Vitamin D Supplementation to Palliative Cancer Patients: A Double Blind, Randomized Placebo-Controlled Multicenter Trial. Cancers (Basel) 2021; 13:cancers13153707. [PMID: 34359609 PMCID: PMC8345220 DOI: 10.3390/cancers13153707] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/18/2021] [Accepted: 07/21/2021] [Indexed: 02/07/2023] Open
Abstract
Simple Summary In this study, the effect of vitamin D supplementation on pain, infections, fatigue and quality of life in patients with advanced cancer with verified vitamin D deficiency was studied. To this end, a randomized controlled trial, ‘Palliative-D’, was conducted, comparing the effect of 4000 IU vitamin D3/day for 12 weeks to placebo in cancer patients admitted to palliative care. Pain was assessed as change in opioid dose and infections measured as days on antibiotics. Vitamin D-supplemented patients increased their opioid doses at a significantly slower rate than patients receiving placebo, i.e., 0.56 µg less fentanyl/h per week with vitamin D treatment. Vitamin D reduced self-assessed fatigue but did not affect antibiotic use or self-assessed Quality of life. The treatment was safe and well-tolerated. In conclusion, correction of vitamin D deficiency may have positive effects on pain and fatigue in palliative cancer patients. Abstract The aim of the ‘Palliative-D’ study was to test the hypothesis that correction of vitamin D deficiency reduces opioid use in cancer patients admitted to palliative care. A multicenter randomized, placebo-controlled, double-blind trial in three home-based palliative care facilities in Sweden was performed. Patients with advanced cancer and 25-hydroxyvitamin D < 50 nmol/L were randomized to vitamin D3 4000 IU/day or placebo for 12 weeks. The primary endpoint was the difference of long-acting opioid use (fentanyl ug/h) between the groups during 12 weeks, based on four time points. Secondary outcomes included changes in antibiotic use, fatigue and Quality of Life (QoL). A total of 244 patients were randomized, and 150 patients completed the 12 weeks. The major reason for drop-out was death due to cancer. The vitamin D-group had a significantly smaller increase of opioid doses compared to the placebo-group; beta coefficient −0.56 (p = 0.03), i.e., 0.56 µg less fentanyl/h per week with vitamin D treatment. Vitamin D-reduced fatigue assessed with ESAS was −1.1 points after 12 weeks (p < 0.01). Antibiotic use or QoL did not differ significantly between the groups. The treatment was safe and well-tolerated. In conclusion, correction of vitamin D deficiency may have positive effects on opioid use and fatigue in palliative cancer patients, but only in those with a survival time more than 12 weeks.
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Affiliation(s)
- Maria Helde Frankling
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, SE-141 83 Huddinge, Sweden; (M.H.F.); (C.K.)
- ASIH Stockholm Södra, Palliative Home Care and Hospice Ward, SE-125 59 Älvsjö, Sweden
| | - Caritha Klasson
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, SE-141 83 Huddinge, Sweden; (M.H.F.); (C.K.)
- ASIH Stockholm Södra, Palliative Home Care and Hospice Ward, SE-125 59 Älvsjö, Sweden
- Stockholms Sjukhem, Palliative Medicine, SE-112 19 Stockholm, Sweden; (C.S.); (M.N.)
| | - Carina Sandberg
- Stockholms Sjukhem, Palliative Medicine, SE-112 19 Stockholm, Sweden; (C.S.); (M.N.)
| | - Marie Nordström
- Stockholms Sjukhem, Palliative Medicine, SE-112 19 Stockholm, Sweden; (C.S.); (M.N.)
| | - Anna Warnqvist
- Department of Environmental Medicine, Division of Biostatistics, Karolinska Institutet, SE-171 77 Stockholm, Sweden;
| | - Jenny Bergqvist
- Department of Surgery, Breast Centre, Capio St Gorans Hospital, SE-112 19 Stockholm, Sweden;
- Department of Oncology-Pathology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - Peter Bergman
- Department of Laboratory Medicine, Division of Clinical Microbiology, Karolinska Institutet, SE-141 86 Stockholm, Sweden;
- Department of Infectious Diseases, Immunodeficiency Unit, Karolinska University Hospital, SE-141 86 Stockholm, Sweden
| | - Linda Björkhem-Bergman
- Department of Neurobiology, Care Sciences and Society (NVS), Division of Clinical Geriatrics, Karolinska Institutet, SE-141 83 Huddinge, Sweden; (M.H.F.); (C.K.)
- ASIH Stockholm Södra, Palliative Home Care and Hospice Ward, SE-125 59 Älvsjö, Sweden
- Stockholms Sjukhem, Palliative Medicine, SE-112 19 Stockholm, Sweden; (C.S.); (M.N.)
- Correspondence:
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20
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Cameron MG, Kersten C. WITHDRAWN: Neuropathic Cancer Pain in Patients Treated With an EGFR-Inhibitor. J Pain Symptom Manage 2021:S0885-3924(21)00401-2. [PMID: 34161812 DOI: 10.1016/j.jpainsymman.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 11/21/2022]
Abstract
This article has been withdrawn because of a publisher error. It should not have been posted.
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Affiliation(s)
| | - Christian Kersten
- Department of Research, Sørlandet Hospital Trust, Kristiansand, Norway
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21
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Kelly M, O'Brien KM, Hannigan A. Using administrative health data for palliative and end of life care research in Ireland: potential and challenges. HRB Open Res 2021; 4:17. [PMID: 33842831 PMCID: PMC8014706 DOI: 10.12688/hrbopenres.13215.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2021] [Indexed: 11/20/2022] Open
Abstract
Background: This study aims to examine the potential of currently available administrative health and social care data for palliative and end-of-life care (PEoLC) research in Ireland. Objectives include to i) identify data sources for PEoLC research ii) describe the challenges and opportunities of using these and iii) evaluate the impact of recent health system reforms and changes to data protection laws. Methods: The 2017 Health Information and Quality Authority catalogue of health and social care datasets was cross-referenced with a recognised list of diseases with associated palliative care needs. Criteria to assess the datasets included population coverage, data collected, data dictionary and data model availability, and mechanisms for data access. Results: Nine datasets with potential for PEoLC research were identified, including death certificate data, hospital episode data, pharmacy claims data, one national survey, four disease registries (cancer, cystic fibrosis, motor neurone and interstitial lung disease) and a national renal transplant registry. The
ad hoc development of the health system in Ireland has resulted in i) a fragmented information infrastructure resulting in gaps in data collections particularly in the primary and community care sector where much palliative care is delivered, ii) ill-defined data governance arrangements across service providers, many of whom are not part of the publically funded health service and iii) systemic and temporal issues that affect data quality. Initiatives to improve data collections include introduction of i) patient unique identifiers, ii) health entity identifiers and iii) integration of the Eircode postcodes. Recently enacted general data protection and health research regulations will clarify legal and ethical requirements for data use. Conclusions: Ongoing reform initiatives and recent changes to data privacy laws combined with detailed knowledge of the datasets, appropriate permissions, and good study design will facilitate future use of administrative health and social care data for PEoLC research in Ireland.
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Affiliation(s)
- Maria Kelly
- National Cancer Registry Ireland, Building 6800, Cork Airport Business Park Kinsale Road, Cork, T12 CDF7, Ireland.,School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland
| | - Katie M O'Brien
- National Cancer Registry Ireland, Building 6800, Cork Airport Business Park Kinsale Road, Cork, T12 CDF7, Ireland.,Department of Health, Block 1 Miesian Plaza, 50 - 58 Lower Baggot Street, Dublin, D02 XW14, Ireland
| | - Ailish Hannigan
- School of Medicine, University of Limerick, Limerick, V94 T9PX, Ireland.,Health Research Institute, University of Limerick, Limerick, V94 T9PX, Ireland
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22
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Kalpakidou AK, Todd C, Omar RZ, Keeley V, Griffiths J, Spencer K, Vickerstaff V, Christidoulides K, Perry R, Katsampa D, Stone P. Study recruitment factors in advanced cancer: the Prognosis in Palliative care Study II (PiPS2) - a multicentre, prospective, observational cohort project. BMJ Support Palliat Care 2021:bmjspcare-2020-002670. [PMID: 33952580 DOI: 10.1136/bmjspcare-2020-002670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The Prognosis in Palliative care Study II (PiPS2) was a large multicentre observational study validating prognostic tools in patients with advanced cancer. Many palliative care studies fail to reach their recruitment target. To inform future studies, PiPS2 rigorously monitored and identified any potential recruitment barriers. METHODS Key recruitment stages (ie, whether patients were eligible for the study, approached by the researchers and whether consent was obtained for enrolment) were monitored via comprehensive screening logs at participating sites (inpatient hospices, hospitals and community palliative care teams). The reasons for patients' ineligibility, inaccessibility or decision not to consent were documented. RESULTS 17 014 patients were screened across 27 participating sites over a 20-month recruitment period. Of those, 4642 (27%) were ineligible for participation in the study primarily due to non-cancer diagnoses. Of 12 372 eligible patients, 9073 (73%) were not approached, the most common reason being a clinical decision not to do so. Other reasons included patients' death or discharge before they were approached by the researchers. Of the 3299 approached patients, 1458 (44%) declined participation mainly because of feeling too unwell, experiencing severe distress or having other competing priorities. 11% (n=1841/17 014) of patients screened were enrolled in the study, representing 15% (n=1841/12 372) of eligible patients. Different recruitment patterns were observed across inpatient hospice, hospital and community palliative care teams. CONCLUSIONS The main barrier to recruitment was 'accessing' potentially eligible patients. Monitoring key recruitment stages may help to identify barriers and facilitators to enrolment and allow results to be put into better context. TRIAL REGISTRATION NUMBER ISRCTN13688211.
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Affiliation(s)
| | - Chris Todd
- Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Vaughan Keeley
- Palliative Medicine Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jane Griffiths
- Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Karen Spencer
- Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | | | | | - Rachel Perry
- Marie Curie Hospice Solihull, Solihull, West Midlands, UK
| | - Dafni Katsampa
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
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23
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Kiani CS, Hunt RW. Lidocaine Continuous Subcutaneous Infusion for Neuropathic Pain in Hospice Patients: Safety and Efficacy. J Pain Palliat Care Pharmacother 2021; 35:52-62. [PMID: 33793373 DOI: 10.1080/15360288.2020.1852357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Lidocaine continuous subcutaneous infusion (L-CSCI) for neuropathic pain in hospice patients has limited evidence for its safety and efficacy, and guidelines are lacking. This study assesses a series of patients admitted to a hospice over a six-month period that had neuropathic pain and received L-CSCI. The primary outcome was improvement in patient-rated distress from pain following L-CSCI titration. Also assessed were changes in oral morphine equivalent dose (OME), frequency of breakthrough medication, functional status, adverse effects and perception of response. Fifteen patients received L-CSCI for an average of 6.7 days (range 1-92). Average pain distress score decreased by 2 or more in six patients. Positive responses to L-CSCI were documented in the clinical notes of 10 patients. Opioid down-titration occurred in four patients. Lidocaine levels were performed in 3 patients but did not change management. Five patients experienced adverse effects attributable to lidocaine and all responded to simple measures. In conclusion, L-CSCI can help manage neuropathic pain in hospice patients, particularly in those who cannot swallow oral medications. Further systematic research is warranted to establish efficacy and tolerability, and to inform guideline development.
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24
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Reed J, O'Hara M, O'Sullivan E, Cobbe S, Reilly MO. Association between attendance at a specialist palliative care day unit and improvement in patient symptoms and quality of life. Int J Palliat Nurs 2021; 27:86-97. [PMID: 33886359 DOI: 10.12968/ijpn.2021.27.2.86] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Specialist palliative day care is an area of palliative care which has a notable scarcity of research. Evidence is needed on the role of palliative day care to improve patients' quality of life and symptom management, while recognising the different patient cohorts that use the service. AIM To determine the symptoms and quality of life of the patient cohort that are affected by the completion of a full therapeutic cycle (8 to 9 weeks) at a specialist palliative care day unit (SPCDU). METHOD A retrospective cohort study was carried out from January 2016 to December 2017. Patient related outcome measures (PROMs) were collected as part of routine clinical paperwork at admission and discharge, and these were used to determine symptoms and quality of life pre-attendance and on completion of an 8 to 9 week therapeutic cycle at the SPCDU. RESULTS Descriptive analysis demonstrated improvement across the many symptoms that were analysed. Quality of life analysis also established improvement. Statistically significant difference was achieved in several areas. Total physical symptoms (p value=.009) confirmed the positive impact attendance at SPCDU has on physical symptoms. Specific symptoms which displayed a statistically significant difference included: poor appetite (p value=.002), weakness (p value=.03) and the anxiety felt by family/friends (p value=.029). The quality of a patient's life also displayed statistically significant difference (p value=.000). CONCLUSION This study demonstrates that attendance at a SPCDU may positively impact a patients' symptoms and quality of life. A more uniform national approach to specialist palliative day care delivery, alongside multi-setting research, may further bolster the image of palliative day care. This will improve referrals to and occupancy of SPDCUs and benefit the palliative patient in the community.
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Affiliation(s)
| | - Mary O'Hara
- Nurse Lecturer, National University of Ireland, Galway
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25
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Kelly M, O'Brien KM, Hannigan A. Using linked administrative health data for palliative and end of life care research in Ireland: potential and challenges. HRB Open Res 2021; 4:17. [DOI: 10.12688/hrbopenres.13215.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/01/2021] [Indexed: 12/28/2022] Open
Abstract
Background: This study aims to examine the potential of currently available administrative health data for palliative and end-of-life care (PEoLC) research in Ireland. Objectives include to i) identify administrative health data sources for PEoLC research ii) describe the challenges and opportunities of using these and iii) estimate the impact of recent health system reforms and changes to data protection laws. Methods: The 2017 Health Information and Quality Authority catalogue of health and social care datasets was cross-referenced with a recognised list of diseases with associated palliative care needs. Criteria to assess the datasets included population coverage, data collected, data dictionary and data model availability and mechanisms for data access. Results: Eight datasets with potential for PEoLC research were identified, including four disease registries, (cancer, cystic fibrosis, motor neurone and interstitial lung disease), death certificate data, hospital episode data, community prescription data and one national survey. The ad hoc development of the health system in Ireland has resulted in i) a fragmented information infrastructure resulting in gaps in data collections particularly in the primary and community care sector where much palliative care is delivered, ii) ill-defined data governance arrangements across service providers, many of whom are not part of the publically funded health service and iii) systemic and temporal issues that affect data quality. Initiatives to improve data collections include introduction of i) patient unique identifiers, ii) health entity identifiers and iii) integration of the eircode postcodes. Recently enacted general data protection and health research regulations will clarify legal and ethical requirements for data use. Conclusions: With appropriate permissions, detailed knowledge of the datasets and good study design currently available administrative health data can be used for PEoLC research. Ongoing reform initiatives and recent changes to data privacy laws will facilitate future use of administrative health data for PEoLC research.
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26
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Noble S. Venous thromboembolism in palliative care patients: what do we know? Thromb Res 2020; 191 Suppl 1:S128-S132. [PMID: 32736771 DOI: 10.1016/s0049-3848(20)30410-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Accepted: 11/20/2019] [Indexed: 12/21/2022]
Abstract
Despite a breadth of data on the management of cancer-associated thrombosis, all the studies informing clinical guidelines excluded patients receiving palliative care. Patients with advanced cancer have a higher rate of recurrent venous thromboembolism (VTE) and bleeding, making them one of the most challenging populations to treat. The dearth of population-specific research leaves clinicians with few options but to extrapolate data from clinical trials conducted on a healthier population. Recent observational studies have challenged the utility of doing this, suggesting the natural history of VTE in the advanced cancer patient may differ to our first beliefs and that a less aggressive approach to anticoagulation is warranted particularly near the end of life. This paper highlights what we know so far.
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Affiliation(s)
- Simon Noble
- Marie Curie Palliative Care Research Centre, Cardiff University, Cardiff, Wales, UK.
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27
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Harrop E, Morgan F, Longo M, Semedo L, Fitzgibbon J, Pickett S, Scott H, Seddon K, Sivell S, Nelson A, Byrne A. The impacts and effectiveness of support for people bereaved through advanced illness: A systematic review and thematic synthesis. Palliat Med 2020; 34:871-888. [PMID: 32419630 PMCID: PMC7341024 DOI: 10.1177/0269216320920533] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Bereavement support is a key component of palliative care, with different types of support recommended according to need. Previous reviews have typically focused on specialised interventions and have not considered more generic forms of support, drawing on different research methodologies. AIM To review the quantitative and qualitative evidence on the effectiveness and impact of interventions and services providing support for adults bereaved through advanced illness. DESIGN A mixed-methods systematic review was conducted, with narrative synthesis of quantitative results and thematic synthesis of qualitative results. The review protocol is published in PROSPERO ( www.crd.york.ac.uk/prospero , CRD42016043530). DATA SOURCES The databases MEDLINE, Embase, PsycINFO, CINAHL and Social Policy and Practice were searched from 1990 to March 2019. Studies were included which reported evaluation results of bereavement interventions, following screening by two independent researchers. Study quality was assessed using GATE checklists. RESULTS A total of 31 studies were included, reporting on bereavement support groups, psychological and counselling interventions and a mix of other forms of support. Improvements in study outcomes were commonly reported, but the quality of the quantitative evidence was generally poor or mixed. Three main impacts were identified in the qualitative evidence, which also varied in quality: 'loss and grief resolution', 'sense of mastery and moving ahead' and 'social support'. CONCLUSION Conclusions on effectiveness are limited by small sample sizes and heterogeneity in study populations, models of care and outcomes. The qualitative evidence suggests several cross-cutting benefits and helps explain the impact mechanisms and contextual factors that are integral to the support.
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Affiliation(s)
- Emily Harrop
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Fiona Morgan
- Marie Curie Research Centre and SURE, Cardiff University, Cardiff, UK
| | - Mirella Longo
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Lenira Semedo
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Jim Fitzgibbon
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Sara Pickett
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Hannah Scott
- School of Dentistry, Cardiff University, University Hospital Wales, Cardiff, UK
| | - Kathy Seddon
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Stephanie Sivell
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Annmarie Nelson
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Anthony Byrne
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, Cardiff, UK
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28
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Secunda K, Wirpsa MJ, Neely KJ, Szmuilowicz E, Wood GJ, Panozzo E, McGrath J, Levenson A, Peterson J, Gordon EJ, Kruser JM. Use and Meaning of "Goals of Care" in the Healthcare Literature: a Systematic Review and Qualitative Discourse Analysis. J Gen Intern Med 2020; 35:1559-1566. [PMID: 31637653 PMCID: PMC7210326 DOI: 10.1007/s11606-019-05446-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The specific phrase "goals of care" (GOC) is pervasive in the discourse about serious illness care. Yet, the meaning of this phrase is ambiguous. We sought to characterize the use and meaning of the phrase GOC within the healthcare literature to improve communication among patients, families, clinicians, and researchers. METHODS A systematic review of the English language healthcare literature indexed in MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Scopus was performed in October of 2018. We searched for all publications with the exact phrase "goals of care" within the title or abstract; no limitations on publication date or format were applied; conference abstracts were excluded. We used qualitative, discourse analysis to identify key themes and generate an operational definition and conceptual model of GOC. RESULTS A total of 214 texts were included in the final analysis. Use of GOC increased over time with 87% of included texts published in the last decade (2009-2018). An operational definition emerged from consensus within the published literature: the overarching aims of medical care for a patient that are informed by patients' underlying values and priorities, established within the existing clinical context, and used to guide decisions about the use of or limitation(s) on specific medical interventions. Application of the GOC concept was described as important to the care of patients with serious illness, in order to (1) promote patient autonomy and patient-centered care, (2) avoid unwanted care and identify valued care, and (3) provide psychological and emotional support for patients and their families. DISCUSSION The use of the phrase "goals of care" within the healthcare literature is increasingly common. We identified a consensus, operational definition that can facilitate communication about serious illness among patients, families, and clinicians and provide a framework for researchers developing interventions to improve goal-concordant care.
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Affiliation(s)
- Katharine Secunda
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Kathy J Neely
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Eytan Szmuilowicz
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Gordon J Wood
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Hospital Medicine, Northwestern University Feinberg School of Medicine, Chicago, USA
| | | | - Joan McGrath
- Northwestern Memorial Hospital, Chicago, IL, USA
| | - Anne Levenson
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jonna Peterson
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Galter Health Sciences Library and Learning Center, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Elisa J Gordon
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA.,Department of Surgery, Division of Transplantation, Northwestern University Feinberg School of Medicine, Chicago, USA.,Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, USA.,Center for Bioethics and Medical Humanities, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Jacqueline M Kruser
- Northwestern University Feinberg School of Medicine, 633 N. St. Clair Street, 20th Floor, Chicago, IL, 60611, USA. .,Department of Medicine, Division of Pulmonary and Critical Care, Northwestern University Feinberg School of Medicine, Chicago, USA. .,Center for Health Services and Outcomes Research, Northwestern University Feinberg School of Medicine, Chicago, USA.
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29
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Gierach M, Brechtelsbauer D, Serfling J, Bloom K, Strickland G, Heins J. Students Practicing Interprofessional Collaboration in the Context of Hospice and Palliative Care. Am J Hosp Palliat Care 2020; 37:1062-1067. [DOI: 10.1177/1049909120917365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Interprofessional education allows students to collaborate with students and professionals of multiple disciplines. An Interdisciplinary Palliative Care (IPC) Seminar, held in the Midwest, involves students from disciplines of medicine, nursing, pharmacy, social work, and chaplaincy. The curriculum of the seminar incorporates asynchronous and synchronous didactic presentations, experiential learning through group exercises and discussion, along with home visits by students in interdisciplinary dyads. The purpose of this study was to determine whether students’ participation in a 3-week IPC seminar would positively influence their socialization and value of interprofessional collaboration with the ultimate goal of developing skilled professionals who engage in interprofessional practice in hospice and palliative care settings. This descriptive study invited participants to take a pre- and postseminar online survey using the Interprofessional Socialization and Valuing Scale-21 (ISVS-21) to assess shifts in students’ perceptions of interprofessional socialization and the value of collaborative health-care practice. In their pre-and postseminar scores, 71 participants reported they more strongly agreed with all items on the ISVS-21 after completing the seminar. The results from this study suggest the IPC Seminar is an effective educational model for advancing the value of interprofessional socialization and collaborative practice in hospice and palliative health-care.
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Affiliation(s)
- Michelle Gierach
- Department of Nursing, Augustana University, Sioux Falls, SD, USA
| | | | - Jody Serfling
- Department of Nursing, Augustana University, Sioux Falls, SD, USA
| | - Katie Bloom
- College of Health & Human Services, Western Michigan University, Kalamazoo, MI, USA
| | - Gary Strickland
- Pastoral Care, Sioux Falls Seminary, Sioux Falls Seminary, Sioux Falls, SD, USA
| | - Jodi Heins
- College of Pharmacy and Allied Health Professions, South Dakota State University, Brookings, SD, USA
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30
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Harrop E, Scott H, Sivell S, Seddon K, Fitzgibbon J, Morgan F, Pickett S, Byrne A, Nelson A, Longo M. Coping and wellbeing in bereavement: two core outcomes for evaluating bereavement support in palliative care. BMC Palliat Care 2020; 19:29. [PMID: 32164642 PMCID: PMC7068975 DOI: 10.1186/s12904-020-0532-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/21/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bereavement support is a core part of palliative care. However, the evidence base is limited by a lack of consistency in the outcomes used to evaluate services and models of support, which makes it difficult to compare approaches. Core Outcome Sets (COS) represent the minimum that should be measured in research into specific conditions or services. The aim of this study was to use a stakeholders' perspective to develop a COS for evaluating bereavement support for adults in adult palliative care settings. METHODS A list of outcomes relevant to bereavement support was created following a systematic review of the quantitative and qualitative literature. At an expert workshop 21 stakeholders discussed their views on the most important outcomes and compared these to and critiqued the lists constructed from the review. These lists and discussions informed a two round international DELPHI survey (n = 240) designed to reach consensus on which outcomes/outcome dimensions should be included in the COS. To prioritise and validate the items emerging from the survey, participants at a subsequent consensus day ranked the relative importance of these items (n = 23). A final feedback exercise with these consensus day participants was conducted to confirm the selection of outcomes and dimensions. RESULTS 'Ability to cope with grief' and 'Quality of life and mental wellbeing' were selected as two core outcomes. Twenty-one different dimensions to explore when assessing these outcomes were also identified. The coping related dimensions have been categorised as: Negative and overwhelming grief; Communication and connectedness; Understanding, accepting and finding meaning in grief; Finding balance between grief and life going forwards; Accessing appropriate support. Those relating to quality of life and wellbeing have been categorised as; Participation in work and/or regular activities; Relationships and social functioning; Positive mental wellbeing and Negative mental and emotional state. CONCLUSION This COS outlines a more consistent way forward for bereavement researchers and practitioners, whilst also orientating towards public health and resilience-based approaches to bereavement care. Further work is planned to identify and develop measures which are specific to this core outcome set, and which will facilitate the future comparability of bereavement services and interventions.
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Affiliation(s)
- Emily Harrop
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Hannah Scott
- School of Dentistry, Cardiff University, University Hospital Wales, Heath Park, Cardiff, CF14 4XY UK
| | - Stephanie Sivell
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Kathy Seddon
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Jim Fitzgibbon
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Fiona Morgan
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Sara Pickett
- Swansea Centre for Health Economics, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Anthony Byrne
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Annmarie Nelson
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
| | - Mirella Longo
- Marie Curie Research Centre, Division of Population Medicine, Cardiff University, 8th Floor Neuadd Meirionydd, Heath Park Way, Cardiff, CF14 4YS UK
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31
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Sood R, Mancinetti M, Betticher D, Cantin B, Ebneter A. Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review. Ann Med Surg (Lond) 2020; 50:14-23. [PMID: 31908774 PMCID: PMC6940657 DOI: 10.1016/j.amsu.2019.12.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 11/21/2019] [Accepted: 12/10/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed. METHODS Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients. RESULTS Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary. CONCLUSION Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.
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Affiliation(s)
- R. Sood
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
| | - M. Mancinetti
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
- Medical Education Unit, University of Fribourg, Avenue de l'Europe 20, 1700, Fribourg, Switzerland
| | - D. Betticher
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
| | - B. Cantin
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
- Palliative Care Department, Fribourg Hospital, Avenue Jean-Paul II 12, 1752, Villars-sur-Glâne, Switzerland
| | - A. Ebneter
- Internal Medicine Department, Fribourg Hospital, Chemin des Pensionnats 2-6, 1752, Villars-sur-Glâne, Switzerland
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32
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Bickel KE, Kennedy R, Levy C, Burgio KL, Bailey FA. The Relationship of Post-traumatic Stress Disorder to End-of-life Care Received by Dying Veterans: a Secondary Data Analysis. J Gen Intern Med 2020; 35:505-513. [PMID: 31792872 PMCID: PMC7018872 DOI: 10.1007/s11606-019-05538-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 08/06/2019] [Accepted: 10/18/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) can be exacerbated by subsequent trauma, but it is unclear if symptoms are worsened by impending death. PTSD symptoms, including hyperarousal, negative mood and thoughts, and traumatic re-experiencing, can impact end-of-life symptoms, including pain, mood, and poor sleep. Thus, increased symptoms may lead to increased end-of-life healthcare utilization. OBJECTIVES To determine if veterans with PTSD have increased end-of-life healthcare utilization or medication use and to examine predictors of medication administration. DESIGN Secondary analysis of a stepped-wedge design implementation trial to improve end-of-life care for Veterans Affairs (VA) inpatients. Outcome variables were collected via direct chart review. Analyses included hierarchical, generalized estimating equation models, clustered by medical center. SUBJECTS Veterans, inpatient at one of six VA facilities, dying between 2005 and 2011. MAIN MEASURES Emergency room (ER) visits, hospitalizations, and medication administration in the last 7 days of life. KEY RESULTS Of 5341 veterans, 468 (8.76%) had PTSD. Of those, 21.4% (100/468) had major depression and 36.5% (171/468) had anxiety. Veterans with PTSD were younger (mean age 65.4 PTSD, 70.5 no PTSD, p < 0.0001) and had more VA hospitalizations and ER visits in the last 12 months of life (admissions: PTSD 2.8, no PTSD 2.4, p < 0.0001; ER visits: 3.2 vs 2.5, p < 0.0001). PTSD was associated with antipsychotic administration (OR 1.52, 95% CI 1.06-2.18). Major depression (333/5341, 6.2%) was associated with opioid administration (OR 1.348, 95% CI 1.129-1.609) and benzodiazepines (OR 1.489, 95% CI 1.141-1.943). Anxiety disorders (778/5341, 14.6%) were only associated with benzodiazepines (OR 1.598, 95% CI 1.194-2.138). CONCLUSIONS PTSD's association with increased end-of-life healthcare utilization and increased antipsychotic administration in the final days of life suggests increased symptom burden and potential for terminal delirium in individuals with PTSD. Understanding the burden of psychiatric illness and potential risks for delirium may facilitate the end-of-life care for these patients. TRIAL REGISTRATION NCT00234286.
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Affiliation(s)
- Kathleen E Bickel
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA.
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA.
| | - Richard Kennedy
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Cari Levy
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Rocky Mountain Veterans Affairs Medical Center, Aurora, USA
| | - Kathryn L Burgio
- The University of Alabama at Birmingham, Birmingham, Alabama, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - F Amos Bailey
- University of Colorado School of Medicine, Rocky Mountain VA Medical Center, Mail Stop B180, Academic Office One, 12631 E 17th Ave, Room 8407, Aurora, CO, 80045-2527, USA
- Birmingham Veterans Affairs Medical Center, Birmingham, Alabama, USA
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Mathew C, Hsu AT, Prentice M, Lawlor P, Kyeremanteng K, Tanuseputro P, Welch V. Economic evaluations of palliative care models: A systematic review. Palliat Med 2020; 34:69-82. [PMID: 31854213 DOI: 10.1177/0269216319875906] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Palliative care aims to improve quality of life by relieving physical, emotional, and spiritual suffering. Health system planning can be informed by evaluating cost and effectiveness of health care delivery, including palliative care. AIM The objectives of this article were to describe and critically appraise economic evaluations of palliative care models and to identify cost-effective models in improving patient-centered outcomes. DESIGN We conducted a systematic review and registered our protocol in PROSPERO (CRD42016053973). DATA SOURCES A systematic search of nine medical and economic databases was conducted and extended with reference scanning and gray literature. Methodological quality was assessed using the Drummond checklist. RESULTS We identified 12,632 articles and 5 were included. We included two modeling studies from the United States and England, and three economic evaluations from England, Australia, and Italy. Two studies compared home-based palliative care models to usual care, and one compared home-based palliative care to no care. Effectiveness outcomes included hospital readmission prevented, days at home, and palliative care symptom severity. All studies concluded that palliative care was cost-effective compared to usual care. The methodological quality was good overall, but three out of five studies were based on small sample sizes. CONCLUSION Applicability and generalizability of evidence is uncertain due to small sample sizes, short duration, and limited modeling of costs and effects. Further economic evaluations with larger sample sizes are needed, inclusive of the diversity and complexity of palliative care populations and using patient-centered outcomes.
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Affiliation(s)
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Insitute, Ottawa, ON, Canada.,Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Michelle Prentice
- Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Insitute, Ottawa, ON, Canada
| | - Peter Lawlor
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Vivian Welch
- Bruyère Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
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Byrne CM, Morgan DD. Patterns of Religiosity, Death Anxiety, and Hope in a Population of Community-Dwelling Palliative Care Patients in New Zealand—What Gives Hope If Religion Can’t? Am J Hosp Palliat Care 2019; 37:377-384. [DOI: 10.1177/1049909119891148] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study examines the prevalence of religiosity, death anxiety, and hope in a sample of New Zealand community hospice patients in the last 6 months of life. It explores the factors triggering distress or hope and examines whether religiosity is protective against death anxiety for this population. Early studies showed religious faith helps relieve death anxiety, but later work suggests this may only be the case in societies which are generally religious. Very little research has been conducted on this topic in New Zealand, from which recent censuses indicate is an increasingly secular country. If religion is not an important source of hope for dying, it is important to explore what factors do help relieve existential anxiety and to consider their clinical relevance. This study confirmed that organized religion was not a major support factor. Yet several people who declared themselves nonreligious scored highly for intrinsic religiosity and were among the most hopeful participants. This could suggest that spirituality may be more relevant than organized religion in relieving existential distress. The main source of hope for most participants was joyful memories and meaningful relationships. Fear of being a burden and of causing family suffering were the most significant causes of distress. Systematic spiritual assessment for all patients, not just those with a declared religious faith, a biography service, and psychotherapy, may all have a role in managing death anxiety at the end of life. Further work with larger and more diverse populations would be needed to confirm these findings.
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Affiliation(s)
- Catherine M. Byrne
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Waipuna Hospice, IPU, Tauranga, New Zealand
| | - Deidre D. Morgan
- Palliative and Supportive Services, College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
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Abstract
Palliative care patients are predisposed to complex pain, including refractory pain, neuropathic pain, opioid-induced hyperalgesia, and opioid-induced neurotoxicity. Palliative care complex pain management can include use of subanesthetic parenteral ketamine. Support for subanesthetic ketamine exists from anecdotal experiences and nonrandomized studies, but there is a lack of statistically significant evidence to support or dismiss its use. Ketamine is sought for illegal, nonmedical purposes, so the lack of evidence coupled with potential for exploitation makes judicious and knowledgeable use critical. Palliative care nurse practitioners, as experts in symptom management, should evaluate and consider all potentially beneficial treatment strategies for complex pain, including novel strategies such as subanesthetic ketamine treatment. Several databases and clinical guideline repositories, along with inspection of germane articles' reference lists, were utilized to collect original research, retrospective studies, literature reviews, and case reports pertinent to the management of palliative care complex pain with parenteral ketamine. In conclusion, the evidence-based clinical decision-making process is engaged to outline a method to weigh the risks versus benefits of subanesthetic ketamine for this population of patients.
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Chambers E, Gardiner C, Thompson J, Seymour J. Patient and carer involvement in palliative care research: An integrative qualitative evidence synthesis review. Palliat Med 2019; 33:969-984. [PMID: 31250702 PMCID: PMC6691598 DOI: 10.1177/0269216319858247] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Patient/carer involvement in palliative care research has been reported as complex, difficult and less advanced compared to other areas of health and social care research. There is seemingly limited evidence on impact and effectiveness. AIM To examine the evidence regarding patient/carer involvement in palliative care research and identify the facilitators, barriers, impacts and gaps in the evidence base. DESIGN Qualitative evidence synthesis using an integrative review approach and thematic analysis. DATA SOURCES Electronic databases were searched up to March 2018. Additional methods included searching websites and ongoing/unpublished studies, author searching and contacting experts. Eligibility criteria were based on the SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) framework. Two quality assessments on methodology and involvement were undertaken. RESULTS A total of 93 records were included. Eight main themes were identified, mainly concerning facilitators and barriers to effective patient and carer involvement in palliative care research: definitions/roles, values/principles, organisations/culture, training/support, networking/groups, perspectives/diversity, relationships/communication and emotions/impact. Evidence on the impact of involvement was limited, but when carried out effectively, involvement brought positive benefits for all concerned, improving the relevance and quality of research. Evidence gaps were found in non-cancer populations and collaborative/user-led involvement. CONCLUSION Evidence identified suggests that involvement in palliative care research is challenging, but not dissimilar to that elsewhere. The facilitators and barriers identified relate mainly to the conduct of researchers at an individual level; in particular, there exists a reluctance among professionals to undertake involvement, and myths still perpetuate that patients/carers do not want to be involved. A developed infrastructure, more involvement-friendly organisational cultures and a strengthening of the evidence base would also be beneficial.
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Affiliation(s)
- Eleni Chambers
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Clare Gardiner
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Jill Thompson
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Jane Seymour
- The School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
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Murdoch S. ‘How can patient and carers’ experiences shape services?’ The Royal Society of Medicine palliative care competition. BMJ Support Palliat Care 2019; 9:164-166. [DOI: 10.1136/bmjspcare-2018-001619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/15/2018] [Indexed: 11/03/2022]
Abstract
Quality improvement can be difficult to assess and monitor in palliative care due to the nature of the specialty. This essay investigates ways in which this is currently carried out by assessing the benefits of patient-centred outcome measures. Potential technological improvements which could be implemented in the future are also discussed. This is an award-winning essay which subsequently complemented a separate project which analysed the use of the Integrated Palliative Care Outcome Scale in an inpatient palliative care unit.
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Geerse OP, Lakin JR, Berendsen AJ, Alfano CM, Nekhlyudov L. Cancer survivorship and palliative care: Shared progress, challenges, and opportunities. Cancer 2018; 124:4435-4441. [DOI: 10.1002/cncr.31723] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 07/19/2018] [Accepted: 07/23/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Olaf P. Geerse
- Department of Pulmonary Diseases University Medical Center Groningen, University of Groningen Groningen the Netherlands
- Ariadne Labs Brigham and Women’s Hospital, Harvard T. H. Chan School of Public Health Boston Massachusetts
| | - Joshua R. Lakin
- Ariadne Labs Brigham and Women’s Hospital, Harvard T. H. Chan School of Public Health Boston Massachusetts
- Department of Medicine Brigham and Women’s Hospital Boston Massachusetts
- Department of Psychosocial Oncology and Palliative Care Dana‐Farber Cancer Institute Boston Massachusetts
| | - Annette J. Berendsen
- Department of General Practice and Elderly Medicine University Medical Center Groningen, University of Groningen Groningen the Netherlands
| | | | - Larissa Nekhlyudov
- Department of Medicine Brigham and Women’s Hospital Boston Massachusetts
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Bellido-Pérez M, Crespo I, Wilson KG, Porta-Sales J, Balaguer A, Monforte-Royo C. Assessment of the wish to hasten death in patients with advanced cancer: A comparison of 2 different approaches. Psychooncology 2018; 27:1538-1544. [DOI: 10.1002/pon.4689] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 02/19/2018] [Accepted: 02/19/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Mercedes Bellido-Pérez
- Department of Nursing; School of Medicine and Health Sciences; Universitat Internacional de Catalunya; Barcelona Spain
- Primary Health Care Center Esparreguera; Institut Català de la Salut; Barcelona Spain
| | - Iris Crespo
- School of Medicine and Health Sciences; Universitat Internacional de Catalunya; Barcelona Spain
| | - Keith G. Wilson
- Department of Psychology; Ottawa Hospital Rehabilitation Centre; Ottawa Ontario Canada
| | - Josep Porta-Sales
- School of Medicine and Health Sciences; Universitat Internacional de Catalunya; Barcelona Spain
- Palliative Care Service, Institut Català d'Oncologia; l'Hospitalet de Llobregat; Barcelona Spain
| | - Albert Balaguer
- School of Medicine and Health Sciences; Universitat Internacional de Catalunya; Barcelona Spain
| | - Cristina Monforte-Royo
- Department of Nursing, School of Medicine and Health Sciences; Universitat Internacional de Catalunya; Barcelona Spain
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Perez-Cruz PE, Shamieh O, Paiva CE, Kwon JH, Muckaden MA, Bruera E, Hui D. Factors Associated With Attrition in a Multicenter Longitudinal Observational Study of Patients With Advanced Cancer. J Pain Symptom Manage 2018; 55:938-945. [PMID: 29155290 PMCID: PMC5834396 DOI: 10.1016/j.jpainsymman.2017.11.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 11/06/2017] [Accepted: 11/07/2017] [Indexed: 12/13/2022]
Abstract
CONTEXT Attrition is common in longitudinal observational studies in palliative care. Few studies have examined predictors of attrition. OBJECTIVES To identify patient characteristics at enrollment associated with attrition in palliative oncology outpatient setting. METHODS In this longitudinal observational study, advanced cancer patients enrolled in an outpatient multicenter study were assessed at baseline and two to five weeks later. We compared baseline characteristics between patients who returned for follow-up and those who dropped out. RESULTS Seven hundred forty-four patients were enrolled from Jordan, Brazil, Chile, Korea, and India. Attrition rate was 33%, with variation among countries (22%-39%; P = 0.023). In univariate analysis, baseline predictors for attrition were cognitive failure (odds ratio [OR] 1.23 per point in Memorial Delirium Assessment Scale; P < 0.01), functional status (OR 1.55 per 10-point decrease in Karnofsky Performance Status; P < 0.01), Edmonton Symptom Assessment Scale [ESAS] physical score (OR 1.03 per point; P < 0.01), ESAS emotional score (OR 1.05 per point; P < 0.01), and shorter duration between cancer diagnosis and palliative care referral in months (OR 0.89 per log; P = 0.028). In multivariate analysis, cognitive failure (OR 1.12 per point; P = 0.007), ESAS physical score (OR 1.18 per point; P = 0.027), functional status (OR 1.35 per 10-point decrease; P < 0.001), and shorter duration from cancer diagnosis (OR 0.86 per log; P = 0.01) remained independent predictors of attrition. CONCLUSION Advanced cancer patients with cognitive failure, increased physical symptoms, poorer performance status, and shorter duration from cancer diagnosis were more likely to dropout. These results have implications for research design, patient selection, and data interpretation in longitudinal observational studies.
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Affiliation(s)
- Pedro E Perez-Cruz
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Omar Shamieh
- Department of Palliative Care, King Hussein Cancer Center, Amman, Jordan
| | | | - Jung Hye Kwon
- Department of Medical Oncology, Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | | | - Eduardo Bruera
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care and Rehabilitation Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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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: 27] [Impact Index Per Article: 4.5] [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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Barbato M, Barclay G, Potter J, Yeo W. Sedation and Analgesia in Unconscious Palliative Care Patients: Can Bispectral Index monitoring add to our understanding? J Palliat Care 2017; 31:57-9. [DOI: 10.1177/082585971503100109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Barbato
- Palliative Care Unit, Port Kembla Hospital, 89–91 Cowper Street, Warrawong, New South Wales 2505, Australia
| | - Greg Barclay
- Palliative Care Services, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Port Kembla Hospital, Warrawong, New South Wales, Australia
| | - Jan Potter
- Geriatric Medicine, Aged Care, Rehabilitation and Palliative Care, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia; Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Wilf Yeo
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia; Clinical Research and Trial Unit, Illawarra Health and Medical Research Institute, University of Wollongong Campus, Wollongong, New South Wales, Australia
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Snowden A, Young J. A screening tool for predicting gatekeeping behaviour. Nurs Open 2017; 4:187-199. [PMID: 29085645 PMCID: PMC5653390 DOI: 10.1002/nop2.83] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 03/28/2017] [Indexed: 11/30/2022] Open
Abstract
AIM To develop a typology and screening tool for gatekeeping behaviours by nurses responsible for recruitment in palliative care research. DESIGN Concurrent analysis. METHOD Two focus groups were conducted in 2015 with nine qualified hospice community nurses involved in recruitment to a trial in palliative care. The literature was searched for research into gatekeeping from 2000-2016. All narrative examples of gatekeeping activity were coded using gerunds. Common codes were then grouped and interpreted as a social process. RESULTS Gatekeeping is normal and should be expected. A continuum typology emerged, ranging from unintentional to active disengagement. Justification ranged from forgetting to deliberately not mentioning the study for fear of burdening patients. Viewing gatekeeping as a continuum allowed for the creation of a screening tool designed to collaboratively discuss and hence mitigate specific types of gatekeeping behaviour before they occur. This is a unique international contribution to this persistent issue.
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Affiliation(s)
| | - Jenny Young
- Edinburgh Napier UniversityEdinburghEH11 4BNUK
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Bellido-Pérez M, Monforte-Royo C, Tomás-Sábado J, Porta-Sales J, Balaguer A. Assessment of the wish to hasten death in patients with advanced disease: A systematic review of measurement instruments. Palliat Med 2017; 31:510-525. [PMID: 28124578 PMCID: PMC5405817 DOI: 10.1177/0269216316669867] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with advanced conditions may present a wish to hasten death. Assessing this wish is complex due to the nature of the phenomenon and the difficulty of conceptualising it. AIM To identify and analyse existing instruments for assessing the wish to hasten death and to rate their reported psychometric properties. DESIGN Systematic review based on PRISMA guidelines. The COnsensus-based Standards for the selection of health Measurement INstruments checklist was used to evaluate the methodological quality of validation studies and the measurement properties of the instrument described. DATA SOURCES The CINAHL, PsycINFO, Pubmed and Web of Science databases were searched from inception to November 2015. RESULTS A total of 50 articles involving assessment of the wish to hasten death were included. Eight concerned instrument validation and were evaluated using COnsensus-based Standards for the selection of health Measurement INstruments criteria. They reported data for between two and seven measurement properties, with ratings between fair and excellent. Of the seven instruments identified, the Desire for Death Rating Scale or the Schedule of Attitudes toward Hastened Death feature in 48 of the 50 articles. The Schedule of Attitudes toward Hastened Death is the most widely used and is the instrument whose psychometric properties have been most often analysed. Versions of the Schedule of Attitudes toward Hastened Death are available in five languages other than the original English. CONCLUSION This systematic review has analysed existing instruments for assessing the wish to hasten death. It has also explored the methodological quality of studies that have examined the measurement properties of these instruments and offers ratings of the reported properties. These results will be useful to clinicians and researchers with an interest in a phenomenon of considerable relevance to advanced patients.
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Affiliation(s)
- Mercedes Bellido-Pérez
- 1 Department of Nursing, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain.,2 Hospital Sagrat Cor, Barcelona, Spain
| | - Cristina Monforte-Royo
- 1 Department of Nursing, School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Joaquín Tomás-Sábado
- 3 Escola Universitària d'Infermeria Gimbernat, Autonomous University of Barcelona, Barcelona, Spain
| | - Josep Porta-Sales
- 4 School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain.,5 Palliative Care Service, Institut Català d'Oncologia, Barcelona, Spain
| | - Albert Balaguer
- 4 School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
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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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Schreibeis-Baum HC, Xenakis LE, Chen EK, Hanson M, Ahluwalia S, Ryan G, Lorenz KA. A Qualitative Inquiry on Palliative and End-of-Life Care Policy Reform. J Palliat Med 2017; 19:400-7. [PMID: 27035522 DOI: 10.1089/jpm.2015.0296] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND There is increasing recognition of the role of palliative care (PC) in health care delivery, but priorities for state and federal policy to support PC are unclear and have sometimes engendered controversy. We canvassed experts to shed light on general recommendations for improving PC. OBJECTIVE The study objective was to identify challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC. METHODS Semistructured telephone interviews were used to solicit challenges to and potential solutions for promoting, adopting, and implementing policies that would support or expand high-quality PC. Interviews were analyzed using qualitative methods. The subjects were a purposive sample of 22 professional state and federal-level advocates who work in the field of aging and/or PC. RESULTS Respondents identified four central challenges to advancing PC policies: (1) knowledge about PC in the health care setting, (2) cultural beliefs about PC, (3) payment/reimbursement for PC services, and (4) public understanding of PC. Of the wide range of solutions proposed by respondents, we present the eight most frequently discussed solutions to these challenges targeted towards policymakers, health care professionals, research, and the general public. Respondents' understanding of the relationships between problems and solutions revealed many dependencies and interconnectedness. CONCLUSIONS A qualitative approach of querying experts identified multiple significant challenges to improving and expanding PC, most of which are acknowledged in existing consensus statements. Proposed solutions were more numerous and diffuse than descriptions of the problems, signaling the need for further consensus building around actionable policy, and better understanding of how to advance a PC policy agenda.
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Affiliation(s)
- Hannah C Schreibeis-Baum
- 1 Health Services Research and Development, Center for Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles , Los Angeles, California
| | - Lea E Xenakis
- 2 RAND Health, RAND Corporation , Santa Monica, California
| | - Emily K Chen
- 2 RAND Health, RAND Corporation , Santa Monica, California
| | - Mark Hanson
- 2 RAND Health, RAND Corporation , Santa Monica, California
| | | | - Gery Ryan
- 2 RAND Health, RAND Corporation , Santa Monica, California
| | - Karl A Lorenz
- 2 RAND Health, RAND Corporation , Santa Monica, California.,3 Center for Innovation to Implementation (Ci2i), VA Palo Alto , Palo Alto, California.,4 Section of Palliative Medicine, Stanford University School of Medicine , Stanford, California
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Kars MC, van Thiel GJ, van der Graaf R, Moors M, de Graeff A, van Delden JJ. A systematic review of reasons for gatekeeping in palliative care research. Palliat Med 2016; 30:533-48. [PMID: 26577927 DOI: 10.1177/0269216315616759] [Citation(s) in RCA: 99] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND When healthcare professionals or other involved parties prevent eligible patients from entering a trial as a research subject, they are gatekeeping. This phenomenon is a persistent problem in palliative care research and thought to be responsible for the failure of many studies. AIM To identify potential gatekeepers and explore their reasons for gatekeeping in palliative care research. DESIGN A 'Review of Reasons' based on the systematic Preferred Reporting Items for Systematic Reviews and Meta-Analyses approach and a thematic synthesis. DATA SOURCE PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO from 2000 to May 20 2015 were searched. Studies in children (aged <18 years) and patients with dementia were excluded. RESULTS Thirty papers on gatekeeping in palliative care research were included. Five groups of potential gatekeepers were identified: healthcare professionals, research ethics committees, management, relatives and researchers. The fear of burdening vulnerable patients was the most reported reason for gatekeeping. Other reasons included 'difficulty with disclosure of health status', 'fear of burdening the patient's relatives', 'doubts about the importance or quality of the study', 'reticent attitude towards research and (research) expertise' and 'logistics'. In hospice and homecare settings, the pursuit of comfort care may trigger a protective attitude. Gatekeeping is also rooted in a (perceived) lack of skills to recruit patients with advanced illness. CONCLUSION Gatekeeping is motivated by the general assumption of vulnerability of patients, coupled with an emphasis on the duty to protect patients. Research is easily perceived as a threat to patient well-being, and the benefits appear to be overlooked. The patients' perspective concerning study participation is needed to gain a full understanding and to address gatekeeping in palliative care research.
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Affiliation(s)
- Marijke C Kars
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ghislaine Jmw van Thiel
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marleen Moors
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alexander de Graeff
- Department of Medical Oncology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Johannes Jm van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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McCaffrey N, Fazekas B, Cutri N, Currow DC. How Accurately Do Consecutive Cohort Audits Predict Phase III Multisite Clinical Trial Recruitment in Palliative Care? J Pain Symptom Manage 2016; 51:748-755. [PMID: 26732730 DOI: 10.1016/j.jpainsymman.2015.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 11/23/2015] [Accepted: 11/27/2015] [Indexed: 11/16/2022]
Abstract
CONTEXT Audits have been proposed for estimating possible recruitment rates to randomized controlled trials (RCTs), but few studies have compared audit data with subsequent recruitment rates. OBJECTIVES To compare the accuracy of estimates of potential recruitment from a retrospective consecutive cohort audit of actual participating sites and recruitment to four Phase III multisite clinical RCTs. METHODS The proportion of potentially eligible study participants estimated from an inpatient chart review of people with life-limiting illnesses referred to six Australian specialist palliative care services was compared with recruitment data extracted from study prescreening information from three sites that participated fully in four Palliative Care Clinical Studies Collaborative RCTs. The predominant reasons for ineligibility in the audit and RCTs were analyzed. RESULTS The audit overestimated the proportion of people referred to the palliative care services who could participate in the RCTs (pain 17.7% vs. 1.2%, delirium 5.8% vs. 0.6%, anorexia 5.1% vs. 0.8%, and bowel obstruction 2.8% vs. 0.5%). Approximately 2% of the referral base was potentially eligible for these effectiveness studies. Ineligibility for general criteria (language, cognition, and geographic proximity) varied between studies, whereas the reasons for exclusion were similar between the audit and pain and anorexia studies but not for delirium or bowel obstruction. CONCLUSION The retrospective consecutive case note audit in participating sites did not predict realistic recruitment rates, mostly underestimating the impact of study-specific inclusion criteria. These findings have implications for the applicability of the results of RCTs. Prospective pilot studies are more likely to predict actual recruitment.
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Affiliation(s)
- Nikki McCaffrey
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia.
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Natalie Cutri
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
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McCaffrey N, Hardy J, Fazekas B, Agar M, Devilee L, Rowett D, Currow D. Potential economic impact on hospitalisations of the Palliative Care Clinical Studies Collaborative (PaCCSC) ketamine randomised controlled trial. AUST HEALTH REV 2016; 40:100-105. [DOI: 10.1071/ah15012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 04/20/2015] [Indexed: 11/23/2022]
Abstract
Objective The aim of the present study was to estimate the potential healthcare cost savings associated with reduced prescribing of subcutaneous ketamine for the treatment of chronic cancer pain after publication of the Palliative Care Clinical Studies Collaborative (PaCCSC) ketamine randomised controlled trial (RCT), to provide further reasons to modify ketamine prescribing practice in this setting. Methods Potential cost savings in this setting were estimated from a health system perspective using a 1-year impact model. The model was populated with estimates derived using an epidemiological approach informed by morbidity and prevalence data, the PaCCSC feasibility study, ketamine RCT and national ketamine utilisation survey results, as well as clinical opinion. Results The total estimated annual hospitalisation costs associated with subcutaneous ketamine prescribing were A$3 899 600 (2605 bed-days). A 17% reduction in ketamine prescribing lowered hospitalisation costs to A$3 236 668 (2162 bed-days), a reduction of A$662 932 (443 bed-days) because of reduced in-patient stays associated with ketamine toxicity and prescribing process. Conclusions The findings from the modelled impact analysis suggest that dissemination of the PaCCSC ketamine RCT results may have saved the Australian healthcare system approximately A$663 000 in annual hospitalisation costs and freed up 443 in-patient bed-days, although there was high uncertainty within the study. Wider dissemination over time and targeted, local de-adoption strategies could result in further savings.
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50
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Daveson BA, de Wolf-Linder S, Witt J, Newson K, Morris C, Higginson IJ, Evans CJ. Results of a transparent expert consultation on patient and public involvement in palliative care research. Palliat Med 2015; 29:939-49. [PMID: 25931336 PMCID: PMC4668913 DOI: 10.1177/0269216315584875] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Support and evidence for patient, unpaid caregiver and public involvement in research (user involvement) are growing. Consensus on how best to involve users in palliative care research is lacking. AIM To determine an optimal user-involvement model for palliative care research. DESIGN We hosted a consultation workshop using expert presentations, discussion and nominal group technique to generate recommendations and consensus on agreement of importance. A total of 35 users and 32 researchers were approached to attend the workshop, which included break-out groups and a ranking exercise. Descriptive statistical analysis to establish consensus and highlight divergence was applied. Qualitative analysis of discussions was completed to aid interpretation of findings. SETTING/PARTICIPANTS Participants involved in palliative care research were invited to a global research institute, UK. RESULTS A total of 12 users and 5 researchers participated. Users wanted their involvement to be more visible, including during dissemination, with a greater emphasis on the difference their involvement makes. Researchers wanted to improve productivity, relevance and quality through involvement. Users and researchers agreed that an optimal model should consist of (a) early involvement to ensure meaningful involvement and impact and (b) diverse virtual and face-to-face involvement methods to ensure flexibility. CONCLUSION For involvement in palliative care research to succeed, early and flexible involvement is required. Researchers should advertise opportunities for involvement and promote impact of involvement via dissemination plans. Users should prioritise adding value to research through enhancing productivity, quality and relevance. More research is needed not only to inform implementation and ensure effectiveness but also to investigate the cost-effectiveness of involvement in palliative care research.
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Affiliation(s)
- Barbara A Daveson
- Department of Palliative Care, Policy & Rehabilitation; Cicely Saunders Institute; King's College London, London, UK
| | - Susanne de Wolf-Linder
- Department of Palliative Care, Policy & Rehabilitation; Cicely Saunders Institute; King's College London, London, UK
| | - Jana Witt
- Department of Palliative Care, Policy & Rehabilitation; Cicely Saunders Institute; King's College London, London, UK
| | - Kirstie Newson
- Department of Palliative Care, Policy & Rehabilitation; Cicely Saunders Institute; King's College London, London, UK Psychosocial Oncology and Consumer Liaison Groups, UK
| | - Carolyn Morris
- Department of Palliative Care, Policy & Rehabilitation; Cicely Saunders Institute; King's College London, London, UK
| | - Irene J Higginson
- Department of Palliative Care, Policy & Rehabilitation; Cicely Saunders Institute; King's College London, London, UK
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