The palliative care needs of acute stroke patients: a prospective study of hospital admissions

The supportive care needs of stroke patients: A scoping review

The aims of the current review were to identify the current supportive care needs of stroke patients, categorize those needs according to the supportive care needs framework (SCNF), and to form a SCNF of stroke patients. Preferred Reporting Items for Systematic Reviews and Meta-Extension for Scoping Reviews (PRISMA-ScR) and Guidance for conducting systematic scoping reviews were followed. Ten databases were searched, including six English databases: PubMed, Embase, Web of Science, Cumulative Index to Nursing Allied Health Literature, Cochrane Library, and PsycINFO, and four Chinese databases: China National Knowledge Infrastructure, Wan Fang, China Biology Medicine Database and Chongqing VIP. The search period covers from the establishment of the database to December 31, 2022. Three thousand twenty-nine hits were screened resulting in the inclusion of 34 articles in the final literature review. The greatest need identified by stroke patients was information, followed by psychological, social, rehabilitation, practical, physical, emotional, and spiritual needs. The supportive care needs of stroke patients were identified. A preliminary SCNF of stroke patients was developed according to Fitch's SCNF. The multitude of existing needs of stroke patients need to be addressed. This review may represent the first time that SCNF for stroke patients has been developed. This work may lay the foundation for future research on the supportive care needs of stroke patients and provide a framework for the implementation of supportive care in clinical stroke units.

Palliative care needs of stroke patients at a tertiary care center in South India

Objectives

Stroke survivors have palliative care needs in multiple domains, which are overlooked. Accurate estimation of these is pivotal in ensuring proper rehabilitation and planning interventions to improve quality of life (QoL). We aimed to assess the palliative care needs of stroke patients in various domains in a structured manner at the neurology service of a tertiary care center in South India.

Materials and Methods

Seventy-five consecutive stroke patients presenting to the neurology service were recruited over six months with assessment across various domains including symptom burden, physical domain, activities of daily living (ADL), psychiatric/psychological domain, and QoL at baseline and with follow-up at one month and three months.

Results

Despite improvement in the conventional stroke impairment measures among stroke survivors, there were significant unmet needs across various domains; 98% were severely or entirely dependent on ADL at three-month follow-up; and pain and insomnia were the most frequent (33% incidence) troubling symptoms encountered. There were substantial mental health related issues. The QoL measurement tools employed were the stroke impact assessment questionnaire (SIAQ), a novel tool and the World Health Organization Quality Of Life Brief Version (WHO-QOL-BREF). SIAQ scores at one month showed that 19 patients (42.22%) had their QoL severely affected, and 36 patients (80%) showed the same trend at the three-month follow-up. WHO-BREF scores showed that 27 (62%) did not report good QoL, and 32 (73%) were found not to be satisfied with their health at a one-month follow-up.

Conclusion

There is a significant burden of unmet palliative care needs among stroke survivors in India across various domains.

Translation and linguistic validation of the Sheffield Profile for Assessment and Referral for Care (SPARC) to Colombian Spanish

OBJECTIVES

We aimed to translate and linguistically and cross-culturally validate Sheffield Profile for Assessment and Referral for Care (SPARC) in Spanish for Colombia (SPARC-Sp).

METHODS

The linguistic validation of SPARC followed a standard methodology. We conducted focus groups to assess the comprehensibility and feasibility. The acceptability was assessed using a survey study with potential users.

RESULTS

The comprehensibility assessment showed that additional adjustments to those made during the translation-back-translation process were required to apply SPARC-Sp in rural and low-schooled populations. It also identified the need for alternative administration mechanisms for illiterate people. The acceptability survey showed that potential users found SPARC-Sp as not only acceptable but also highly desirable. However, they desired to expand the number of items in all domains.

SIGNIFICANCE OF RESULTS

Beyond the semantic and conceptual validity attained through the back-translation process, actual cultural validity could be acquired thanks to the comprehensibility tests. Although extending the instrument is something potential users would like to do, it would make it less feasible to utilize the SPARC-Sp in clinical settings. Nonetheless, the instrument might benefit from the inclusion of a domain that evaluates challenges encountered when accessing the health-care system. For communities lacking literacy, alternate administration methods must also be considered.

Primary and Specialist Palliative Care in Neurosurgery: A Narrative Review and Bibliometric Analysis of Glioblastoma and Stroke

OBJECTIVE

Due to the increased demand for palliative care (PC) in recent years, a model has been proposed to divide PC into primary PC and specialist PC. This article aimed to delineate the indications for primary and specialist PC within 2 common neurosurgical conditions-glioblastoma (GBM) and stroke.

METHODS

A systematic review and bibliometric analysis was conducted to better appreciate the practice trends in PC utilization for GBM and stroke patients using several databases.

RESULTS

There were 70 studies on PC for GBM, the majority of which related to patient preference (22 [31%]). During 1999-2022, there was significant growth in publications per year on this topic at a rate of approximately 0.3 publications per year (P < 0.01). There were 44 studies on PC for stroke, the majority of which related to communication strategies (14 [32%]). During 1999-2022, there was no significant growth in stroke publications per year (P = 0.22).

CONCLUSIONS

Due to the progressively disabling neurological course of GBM, we suggest that a specialty PC team be used in conjunction with the neurosurgical team early in the disease trajectory while patients are still able to communicate their preferences, goals, and values. In contrast, short-term and long-term stages of management of stroke have differing implications for PC needs, with the short-term stage necessitating adept, time-sensitive communication between the patient, family, and care teams. Thus, we propose that primary PC should be included as a core competency in neurosurgery training, among other stroke specialists.

Palliative care interventions and end-of-life care as reported by patients' post-stroke and their families: a systematic review

AIMS

Internationally, there is an urgent need to implement guidelines supporting integration of palliative care into stroke clinical practice. Despite considerable advances in acute stroke management, ∼20% of all acute stroke patients die within the first 30 days. Palliative care is well established in diseases such as cancer or advanced heart failure, but evidence-based interventions of high quality are limited in stroke populations. This systematic review aims to identify and evaluate quantitative studies that describe palliative care interventions and end-of-life care as reported by patient's post-stroke and their families.

METHODS AND RESULTS

A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines was conducted in Cumulative Index to Nursing and Allied Health Literature, PubMed, Cochrane, Embase, Ovid, Proquest, and Scopus from 1990 to April 2021. The National Heart, Lung and Blood Institute standardized quality rating tools for quality assessment were used. Seven studies were identified, and all used descriptive quantitative designs. There were no interventional studies. The results were synthesized narratively according to the elements of palliative care interventions and end-of-life care: symptom burden and satisfaction, loss of autonomy at the end of life, and acknowledging uncertainty.

CONCLUSION

This review highlights the limited empirical evidence that describes palliative care interventions and end-of-life care as reported by patient's post-stroke and their families. Most of the current evidence focuses on the provision of care during the final days and hours of life, or end-of-life care, with little evidence to guide the integration of palliative care into post-stroke clinical care, especially for patients with an uncertain prognosis. Acute stroke is sudden, unexpected, and life-changing, and patients and families would benefit from well-designed targeted interventions to determine strategies that address the diverse palliative needs of this patient population.

REGISTRATION

PROSPERO CRD42021254536.

Attitudes of Canadian stroke physicians regarding palliative care for patients with acute severe stroke: A national survey

BACKGROUND

Palliative care (PC) aims to enhance the quality of life for patients and their families when confronted with serious illness.  As stroke continues to inflict high morbidity and mortality, the integration of palliative care within acute stroke care remains an important aspect of quality inpatient care.

AIM

This study aims to investigate the experiences and perceived barriers of PC integration for patients with acute severe stroke in Canadian stroke physicians.

METHODS

We conducted an anonymous, descriptive, cross-sectional web-based self-administered survey of stroke physicians in Canada who engage in acute severe stroke care. The questionnaire contained three sections related to stroke physician characteristics, practice attributes, and opinions about palliative care.  Descriptive statistics, univariate, and regression analysis were performed to ascertain relations between collected variables.

RESULTS

Of the 132 physician associate members, 120 were surveyed with a response rate of 69 (58%). Stroke physicians reported that PC services were consulted "sometimes" and that PC services were consulted rarely for prognostication and more often for end-of-life care which they agreed was better delivered off the stroke unit. Several barriers for early integration of palliative care services were identified including uncertainty in prognosis. Stroke physicians endorsed education of both families and physicians would be beneficial.

CONCLUSIONS

There remain perceived barriers for integration of palliative care within the acute stroke population. Challenges include consultation of PC services, uncertainty around patient prognosis, engagement, and educational barriers. There are opportunities for further integration and collaboration between palliative care physicians and stroke physicians.

Palliative and End-of-Life Care After Severe Stroke

BACKGROUND AND OBJECTIVES

The distinct illness trajectory after acute ischemic stroke demands a better understanding of the utilization of palliative care consultations (PCC) for this patient cohort. This study sought to determine the prevalence, predictors, and outcomes associated with PCC for patients hospitalized with severe ischemic stroke.

METHODS

This multicenter cohort study was conducted at four hospitals (2 comprehensive and 2 primary stroke centers) between January, 2016 and December, 2019. We included all patients with a discharge diagnosis of ischemic stroke and an initial National Institutes of Health Stroke Scale (NIHSS) of 10 or greater. We compared patient sociodemographic, clinical and care characteristics as well as hospital outcomes between patients who did and did not receive PCC.

RESULTS

The study included 1297 patients hospitalized with severe ischemic stroke. PCC occurred for 20% of all patients and this proportion varied across institutions from 11.9% to 43%. Less than half (43%) of patients who died in the hospital. In multivaraible analysis, PCC was less likely in female patients (OR .76, 95% CI .59, .99, P=0.04) but more likely in patients with higher NIHSS (OR1.95, 95% CI 1,13, 3.37, P=0.02). Patients with PCC had higher rates of moving to a plan focused on comfort measures (CMO) (P<0.01) and removal of artificial nutrition as part of a move to CMO (P<0.01). In a sub analysis of patients who died in the hospital and received PCC, patients who died on or before hospital day 3 were less likely to receive PCC than patients who died on or after hospital day 4 (24% v. 51%) (P=<0.01).

CONCLUSIONS

Most patients with severe stroke do not receive PCC, even among those who experience in-hospital death. The results of this study indicate there are missed opportunities for PCC to help reduce suffering after severe stroke.

A Systematic Review of the Development and Implementation of Needs-Based Palliative Care Tools in Heart Failure and Chronic Respiratory Disease

Background

The impetus to develop and implement tools for non-malignant patient groups is reflected in the increasing number of instruments being developed for heart failure and chronic respiratory diseases. Evidence syntheses of psychometric quality and clinical utility of these tools is required to inform research and clinical practice.

Aims

This systematic review examined palliative care needs tools for people diagnosed with advanced heart failure or chronic respiratory diseases, to determine their: (1) psychometric quality; and (2) acceptability, feasibility and clinical utility when implemented in clinical practice.

Methods

Systematic searches of MEDLINE, CINAHL, Embase, Cochrane and PsycINFO from database inception until June 2021 were undertaken. Additionally, the reference lists of included studies were searched for relevant articles. Psychometric properties of identified measures were evaluated against pre-determined and standard criteria.

Results

Eighteen tools met inclusion criteria: 11 were developed to assess unmet patient palliative care needs. Of those, 6 were generic, 4 were developed for heart failure and 1 was developed for interstitial lung disease. Seven tools identified those who may benefit from palliative care and include general and disease-specific indicators. The psychometric qualities of the tools varied. None met all of the accepted criteria for psychometric rigor in heart failure or respiratory disease populations. There is limited implementation of needs assessment tools in practice.

Conclusion

Several tools were identified, however further validation studies in heart failure and respiratory disease populations are required. Rigorous evaluation to determine the impact of adopting a systematic needs-based approach for heart failure and lung disease on the physical and psychosocial outcomes of patients and carers, as well as the economic costs and benefits to the healthcare system, is required.

Quality of dying after acute stroke

Introduction

There is a lack of evidence concerning the palliative needs of patients with acute stroke during end-of-life care. We interviewed relatives of patients who deceased in our stroke unit about the quality of dying and compared their experiences with those of nurses.

Patients and Methods

Relatives of 59 patients were interviewed approximately 6 weeks after the patient had died. The primary outcome was a score assessing the overall quality of dying on a scale ranging from 0 to 10, with 0 representing the worst quality and 10 the best quality. We investigated the frequency and appreciation of specific aspects of the dying phase with an adapted version of the Quality of Death and Dying Questionnaire. The nurse who was most frequently involved in the end-of-life care of the patient completed a similar questionnaire.

Results

Family members were generally satisfied with the quality of dying (median overall score 8; interquartile range, 6–9) as well as with the care provided by nurses (9; 8–10) and doctors (8; 7–9). Breathing difficulties were frequently reported (by 46% of the relatives), but pain was not. Unsatisfactory experiences were related to feeding (69% unsatisfactory), inability to say goodbye to loved ones (51%), appearing not to have control (47%), and not retaining a sense of dignity (41%). Two-thirds of the relatives reported that palliative medication adequately resolved discomfort. There was a good correlation between the experiences of relatives and nurses.

Discussion and Conclusion

Most relatives were satisfied with the overall quality of dying. Negative experiences concerned feeding problems, not being able to say goodbye to loved ones, sense of self control and dignity, and breathing difficulties. Experiences of nurses may be a reasonable and practical option when evaluating the quality of dying in acute stroke patients.

The experience of uncertainty for patients, families and healthcare providers in post-stroke palliative and end-of-life care: a qualitative meta-synthesis

PURPOSE

recent data show that there is limited evidence and guidance regarding the best practices for the integration of palliative care (PC) and end-of-life (EOL) post-stroke. The purpose of this meta-synthesis is to understand the PC/EOL experiences after a stroke.

METHODS

a meta-synthesis was conducted to answer the following research question-What are post-stroke PC/EOL experiences from the perspectives of patients, families and healthcare professionals (HCPs)? This approach was completed through two main phases-a systematic search and appraisal of the literature and reciprocal translation with interpretive triangulation of the extracted data. Databases searched were MEDLINE, EMBASE, PsycINFO, Joanna Briggs Institute and CINAHL databases (from their inception to April 2020). After data were extracted, a qualitative exploratory design was used to evaluate the PC/EOL in post-stroke experiences.

RESULTS

the search identified 696 studies. A total of 14 studies were included in this meta-synthesis as they satisfied our eligibility criteria. Uncertainty post-stroke was the overarching main theme that emerged across post-stroke PC/EOL experiences. Within this theme of uncertainty, opportunities to decrease uncertainty emerged from two interdependent themes-presence of cohesive communication and shared dynamic decision process for both families and HCPs.

CONCLUSIONS

to mitigate the degree of uncertainty post-stroke, HCPs should be present, provide clear direct communication and incorporate the value-based goals of care within their medical treatment plan. These findings suggest that future research is needed to focus on how PC approaches can be integrated into stroke care programmes.

Family Perceptions of Quality of End-of-Life Care in Stroke

Background: Most end-of-life decisions after stroke are made by a surrogate decision maker, yet there has been limited study of surrogate assessment of the quality of end-of-life stroke care. Objective: To assess surrogate perceptions of quality of end-of-life care (QEOLC) in stroke and explore factors associated with quality. Design: Cross-sectional analysis of interviewer-administered survey. Settings/subjects: Surrogate decision makers for deceased stroke patients in a population-based study. Measurements: The primary outcome was the validated 10-item family version of the QEOLC scale. The univariate association between prespecified patient and surrogate factors and dichotomized QEOLC score (high: 8-10, low: 0-7) was explored with logistic regression fit using generalized estimating equations. Results: Seventy-nine surrogates for 66 deceased stroke cases were enrolled (median patient age: 76, female patient: 53%, Mexican American patient: 59%, median time from stroke to death: seven days, median surrogate age: 59, and female surrogate: 72%). The overall QEOLC was generally high (median 8.3, quartiles 6.1, 9.6) although several individual items had a high proportion (∼30%-50%) of surrogates who felt that the questions did not apply to the patient's situation. No hypothesized factors were associated with QEOLC score, including demographics, stroke type, location/timing of death, advance directives, health literacy, or understanding of patient wishes. Conclusions: Surrogates reported generally high QEOLC. Although this finding is encouraging, modifications to the QEOLC may be needed in stroke as some surrogates were unable to provide a valid response for certain items.

Nursing care (palliative medicine) in patients with neuropsychiatric disorders

BACKGROUND AND PURPOSE

Palliative medicine is a special status focusing on the quality of life of patients suffering from special or advanced diseases. Palliative medicine can be helpful at any stage of the disease, including the diagnosis. Thus, the present study aims at reviewing the application of palliative care in mental disorders.

METHOD

In the present study, as many as 1,149 studies were found in the period of 1985 to 2018 by searching on different websites including Medline, Embase, ProQuest, Global Health, GoogleScholar, and Scopus. As many as 53 studies having to do with mental disorders were found, and more specifically, as many as 36 articles related to palliative medicine were applied.

FINDINGS

Reviewing the related literature indicates that the care needs of mental disorders patients are quite complicated. The findings indicated that predicting the complications of the disease, as well as advanced planning in terms of caring for these patients, are of significant importance. The findings indicated that over the last decade two palliative care models have been developed: integrative and consultative.

CONCLUSION

With the growth development of palliative care in developed countries, the knowledge of palliative care can be shared with the nurses and practitioners of neurological diseases, and this knowledge can be applied to palliate and reduce the pains and sufferings of the patients and their families.

Use of Hospital Referral Regions in Evaluating End-of-Life Care

Background: Hospital referral regions (HRRs) are often used to characterize inpatient referral patterns, but it is unknown how well these geographic regions are aligned with variation in Medicare-financed hospice care, which is largely provided at home. Objective: Our objective was to characterize the variability in hospice use rates among elderly Medicare decedents by HRR and county. Methods: Using 2014 Master Beneficiary File for decedents 65 and older from North and South Carolina, we applied Bayesian mixed models to quantify variation in hospice use rates explained by HRR fixed effects, county random effects, and residual error among Medicare decedents. Results: We found HRRs and county indicators are significant predictors of hospice use in NC and SC; however, the relative variation within HRRs and associated residual variation is substantial. On average, HRR fixed effects explained more variation in hospice use rates than county indicators with a standard deviation (SD) of 10.0 versus 5.1 percentage points. The SD of the residual error is 5.7 percentage points. On average, variation within HRRs is about half the variation between regions (52%). Conclusions: The magnitude of unexplained residual variation in hospice use for NC and SC suggests that novel, end-of-life-specific service areas should be developed and tested to better capture geographic differences and inform research, health systems, and policy.

Palliative Care for Stroke Patients and Their Families: Barriers for Implementation

Stroke is a leading cause of death, disability and is a symptom burden worldwide. It impacts patients and their families in various ways, including physical, emotional, social, and spiritual aspects. As stroke is potentially lethal and causes severe symptom burden, a palliative care (PC) approach is indicated in accordance with the definition of PC published by the WHO in 2002. Stroke patients can benefit from a structured approach to palliative care needs (PCN) and the amelioration of symptom burden. Stroke outcome is uncertain and outlook may change rapidly. Regarding these challenges, core competencies of PC include the critical appraisal of various treatment options, and openly and respectfully discussing therapeutic goals with patients, families, and caregivers. Nevertheless, PC in stroke has to date mainly been restricted to short care periods for dying patients after life-limiting complications. There is currently no integrated concept for PC in stroke care addressing the appropriate moment to initiate PC for stroke patients, and the question of how to screen for symptoms remains unanswered. Therefore, PC for stroke patients is often perceived as a stopgap in cases of unfavorable prognosis and very short survival times. In contrast, PC can provide much more for stroke patients and support a holistic approach, improve quality of life and ensure treatment according to the patient's wishes and values. In this short review we identify key aspects of PC in stroke care and current barriers to implementation. Additionally, we provide insights into our approach to PC in stroke care.

Palliative care after stroke

Stroke is the leading cause of disability and one of the most common reasons of death around the world. Information is not sufficient on the palliative care (PC) needs of stroke patients and factors affecting their prognosis. In this study, we have investigated the demographics and comorbidities of stroke patients followed-up in a PC center (PCC), and the factors efficient on their prognosis. Medical records of 132 patients followed-up in PCC with stroke diagnosis between years 2016 and 2017 were reviewed retrospectively. Patients diagnosed with stroke were grouped as ischemic stroke, intracerebral hematoma (ICH) and subarachnoid hemorrhage (SAH). Age, gender, PCC hospitalization period (LOS), Glasgow Coma Scale, comorbidities such as percutaneous endoscopic gastrostomy, tracheostomy, pressure ulcer (PU), and discharge status (home, intensive care unit, exitus) have been compared for the patients included in the study. While average age was 72.41 ± 16.03 and hospitalization period was 35.47 ± 36.13 days, 92 patients (69.7%) were diagnosed with ischemic stroke, 20 patients (15.2%) with ICH, and 20 patients (15.2%) were diagnosed with SAH. The rate of exitus in patients diagnosed with ischemic stroke was significantly higher than patients diagnosed with ICH and SAH (p = 0.02), and hypertension rate was higher in patients with ischemic stroke than patients diagnosed with SAH (p = 0.007). The age of patients with exitus were found to be significantly higher (p = 0.001). Length of stay (LOS) in PC was determined to be significantly higher in patients with tracheostomy and patients diagnosed with ICH compared to patients with SAH. Furthermore, PU rate was significantly higher in patients diagnosed with ICH than patients with SAH (p = 0.007). Patients who experienced stroke and their families need comprehensive palliative care for psychosocial support, determination of patient-focused care objectives, and symptom management. There is a need for studies on larger populations to eliminate prognostic uncertainties and provide successful symptom management in patients following stroke.

Palliative approach in acute neurological events: a five-year study

INTRODUCTION

Acute neurological illness often results in severe disability. Five-year life expectancy is around 40%; half the survivors become completely dependent on outside help.

OBJECTIVE

Evaluate the symptoms of patients admitted to a Hospital ward with a diagnosis of stroke, subarachnoid hemorrhage or subdural hematoma, and analyze the role of an In-Hospital Palliative Care Support Team.

MATERIAL AND METHODS

Retrospective, observational study with a sample consisting of all patients admitted with acute neurological illness and with a guidance request made to the In-Hospital Palliative Care Support Team of a tertiary Hospital, over 5 years (2012-2016).

RESULTS

A total of 66 patients were evaluated, with an age median of 83 years old. Amongst them, there were 41 ischaemic strokes, 12 intracranial bleedings, 12 subdural hematomas, and 5 subarachnoid hemorrhages. The median of delay between admission and guidance request was 14 days. On the first evaluation by the team, the GCS score median was 6/15 and the Palliative Performance Scale (PPS) median 10%. Dysphagia (96.8%) and bronchorrhea (48.4%) were the most prevalent symptoms. A total of 56 patients had a feeding tube (84.8%), 33 had vital sign monitoring (50.0%), 24 were hypocoagulated (36.3%), 25 lacked opioid or anti-muscarinic therapy for symptom control (37,9%); 6 patients retained orotracheal intubation, which was removed. In-hospital mortality was 72.7% (n=48).

DISCUSSION AND CONCLUSION

Patients were severely debilitated, in many cases futile interventions persisted, yet several were under-medicated for symptom control. The delay between admission and collaboration request was high. Due to the high morbidity associated with acute neurological illness, palliative care should always be timely provided.

Outcomes, experiences and palliative care in major stroke: a multicentre, mixed-method, longitudinal study

BACKGROUND

Case fatality after total anterior circulation stroke is high. Our objective was to describe the experiences and needs of patients and caregivers, and to explore whether, and how, palliative care should be integrated into stroke care.

METHODS

From 3 stroke services in Scotland, we recruited a purposive sample of people with total anterior circulation stroke, and conducted serial, qualitative interviews with them and their informal and professional caregivers at 6 weeks, 6 months and 1 year. Interviews were transcribed for thematic and narrative analysis. The Palliative Care Outcome Scale, EuroQol-5D-5L and Caregiver Strain Index questionnaires were completed after interviews. We also conducted a data linkage study of all patients with anterior circulation stroke admitted to the 3 services over 6 months, which included case fatality, place of death and readmissions.

RESULTS

Data linkage (n = 219) showed that 57% of patients with total anterior circulation stroke died within 6 months. The questionnaires recorded that the patients experienced immediate and persistent emotional distress and poor quality of life. We conducted 99 interviews with 34 patients and their informal and professional careers. We identified several major themes. Patients and caregivers faced death or a life not worth living. Those who survived felt grief for a former life. Professionals focused on physical rehabilitation rather than preparation for death or limited recovery. Future planning was challenging. "Palliative care" had connotations of treatment withdrawal and imminent death.

INTERPRETATION

Major stroke brings likelihood of death but little preparation. Realistic planning with patients and informal caregivers should be offered, raising the possibility of death or survival with disability. Practising the principles of palliative care is needed, but the term "palliative care" should be avoided or reframed.

Changes in the Use of Intensive and Supportive Procedures for Patients With Stroke in Taiwan in the Last Month of Life Between 2000 and 2010

CONTEXT

Stroke is the second leading cause of death and the primary cause of disability worldwide. It is uncertain what care patients with stroke receive in their end of life and what trends in care are in recent years.

OBJECTIVES

The objective of this study was to investigate the changes in the use of intensive and supportive procedures for Taiwanese patients with stroke in their last month of life during 2000-2010.

METHODS

Analysis of claims data of 55,930 patients with stroke obtained from the National Health Insurance Research Database was performed to investigate the changes in the use of intensive and supportive procedures for Taiwanese patients with stroke in their last month of life during 2000-2010.

RESULTS

Over the whole study period, 25.4% of patients with stroke were admitted to intensive care units in their last month of life. The percentages of patients receiving mechanical ventilation (77.4%-67.9%), cardiopulmonary resuscitation (53.8%-35.8%), and inotropic agents (73.5%-64.3%) decreased over time. The percentages of patients receiving artificial hydration and nutrition (65.9%-73.3%) and sedative or analgesic agents (34.7%-38.6%) increased over time. Patients under 85 years old were more likely to be admitted to intensive care units. Men were more likely to receive mechanical ventilation and cardiopulmonary resuscitation than women.

CONCLUSION

Over time, the use of supportive procedures increased, and the use of intensive procedures decreased in patients with stroke in the last month of life. This study highlights a need for research, guidelines, and training in how to provide palliative care for end-stage patients with stroke.

Palliative Care in Neurology

Palliative medicine is a specialty that focuses on improving the quality of life for patients with serious or advanced medical conditions, and it is appropriate at any stage of disease, including at the time of diagnosis. Neurologic conditions tend to have high symptom burdens, variable disease courses, and poor prognoses that affect not only patients but also their families and caregivers. Patients with a variety of neurologic conditions such as Parkinson disease, dementia, amyotrophic lateral sclerosis, brain tumors, stroke, and acute neurologic illnesses have substantial unmet needs that can be addressed through a combination of primary and specialty palliative care. The complex needs of these patients are ideally managed with a comprehensive approach to care that addresses the physical, psychological, social, and spiritual aspects of care in an effort to reduce suffering. Early discussions about prognosis, goals of care, and advance care planning are critical as they can provide guidance for treatment decisions and allow patients to retain a sense of autonomy despite progressive cognitive or functional decline. With the rapid growth in palliative care across the United States, there are opportunities to improve the palliative care knowledge of neurology trainees, the delivery of palliative care to patients with neurologic disease by both neurologists and nonneurologists, and the research agenda for neuropalliative care.

[Functional decline and presence of symptoms in palliative care: Cause or consequence?]

INTRODUCTION

Several publications have related functional decline to the appearance of symptoms, especially psychiatric or psychological ones, such as anxiety and depression. Moreover, an initial depressive disorder or prior to functional decline usually worsens it. It was decided to investigate the relationship between the presence of functional decline, measured by a decrease in the Barthel index (BI), and the presence of symptoms.

MATERIAL AND METHODS

A prospective analytical study conducted on patients referred to a Home Care Support Team (HCST).

RESULTS

The study included 638 cases, of which 53.9% (N=344) were male, 56% (N=357) with cancer and 44% (N=281) geriatric. The mean age was 79.64 years+- 10.8. Significant differences (P<.001) were found in functional decline measured by mean decline in the BI between cancer (34.4) and non-cancer patients (12.12). Significant differences (P<.001) were also found in all recorded symptoms (pain, dyspnoea, anorexia, nausea, anxiety, depression, and insomnia), more frequently in cancer patients, except psychomotor agitation. A higher presence of symptoms was detected in patients with greater functional decline, with decreases in BI above 20 points. There were no differences in previous treatments, except in certain analgesics. Differences were found in the different treatments prescribed by HCST.

CONCLUSIONS

The presence of functional decline and its level may be related to the appearance of symptoms, especially in cancer patients.

Post-Acute Care Facility as a Discharge Destination for Patients in Need of Palliative Care in Brazil

Patients with complex palliative care needs can experience delayed discharge, which causes an inappropriate occupancy of hospital beds. Post-acute care facilities (PACFs) have emerged as an alternative discharge destination for some of these patients. The aim of this study was to investigate the frequency of admissions and characteristics of palliative care patients discharged from hospitals to a PACF. We conducted a retrospective analysis of PACF admissions between 2014 and 2016 that were linked to hospital discharge reports and electronic health records, to gather information about hospital-to-PACF transitions. In total, 205 consecutive patients were discharged from 6 different hospitals to our PACF. Palliative care patients were involved in 32% (n = 67) of these discharges. The most common conditions were terminal cancer (n = 42, 63%), advanced dementia (n = 17, 25%), and stroke (n = 5, 8%). During acute hospital stays, patients with cancer had significant shorter lengths of stay (13 vs 99 days, P = .004), a lower use of intensive care services (2% vs 64%, P < .001) and mechanical ventilation (2% vs 40%, P < .001), when compared to noncancer patients. Approximately one-third of discharges from hospitals to a PACF involved a heterogeneous group of patients in need of palliative care. Further studies are necessary to understand the trajectory of posthospitalized patients with life-limiting illnesses and what factors influence their decision to choose a PACF as a discharge destination and place of death. We advocate that palliative care should be integrated into the portfolio of post-acute services.

End-of-life decisions in acute stroke patients: an observational cohort study

Background

Crucial issues of modern stroke care include best practice end-of-life-decision (EOLD)-making procedures and the provision of high-quality palliative care for dying stroke patients.

Methods

We retrospectively analyzed records of those patients who died over a 4-year period (2011–2014) on our Stroke Unit concerning EOLD, focusing on the factors that most probably guided decisions to induce limitation of life-sustaining therapy and subsequently end-of-life-care procedures thereafter.

Results

Of all patients treated at our Stroke Unit, 120 (2.71 %) died. In 101 (86.3 %), a do-not-resuscitate-order (DNRO) was made during early treatment. A decision to withdraw/withhold further life supportive therapy was made in 40 patients (34.2 %) after a mean of 5.0 days (range 0–29). Overall patient death occurred after a mean time of 7.0 days (range 1–30) and 2.6 days after therapy restrictions. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke were possible indicators of decisions to therapeutic withdrawing/withholding. Proceedings of EOL care in these patients were heterogeneous; in most cases monitoring (95 %), medical procedures (90 %), oral medication (88 %), parenteral nutrition (98 %) and antibiotic therapy (86 %) were either not ordered or withdrawn, however IV fluids were continued in all patients.

Conclusions

A high percentage of stroke patients were rated as terminally ill and died in the course of caregiving. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke facilitated decisions to change therapeutic goals thus initiating end-of-life-care. However, there is further need to foster research on this field in order to ameliorate outcome prognostication, to understand the dynamics of EOLD-making procedures and to educate staff to provide high-quality patient-centred palliative care in stroke medicine.

Electronic supplementary material

The online version of this article (doi:10.1186/s12904-016-0113-8) contains supplementary material, which is available to authorized users.

A Pilot Randomized Controlled Trial of a Holistic Needs Assessment Questionnaire in a Supportive and Palliative Care Service

CONTEXT

At present, there is no widely used systematic evidence-based holistic approach to assessment of patients' supportive and palliative care needs.

OBJECTIVES

To determine whether the use of a holistic needs assessment questionnaire, Sheffield Profile for Assessment and Referral for Care (SPARC), will lead to improved health care outcomes for patients referred to a palliative care service.

METHODS

This was an open, pragmatic, randomized controlled trial. Patients (n = 182) referred to the palliative care service were randomized to receive SPARC at baseline (n = 87) or after a period of two weeks (waiting-list control n = 95). Primary outcome measure is the difference in score between Measure Yourself Concerns and Wellbeing (MYCAW) patient-nominated Concern 1 on the patient self-scoring visual analogue scale at baseline and the two-week follow-up. Secondary outcomes include difference in scores in the MYCAW, EuroQoL (EQ-5D), and Patient Enablement Instrument (PEI) scores at Weeks 2, 4, and 6.

RESULTS

There was a significant association between change in MYCAW score and whether the patients were in the intervention or control group (χ(2)trend = 5.51; degrees of freedom = 1; P = 0.019). A higher proportion of patients in the control group had an improvement in MYCAW score from baseline to Week 2: control (34 of 70 [48.6%]) vs. intervention (19 of 66 [28.8%]). There were no significant differences (no detectable effect) between the control and intervention groups in the scores for EQ-5D and Patient Enablement Instrument at 2-, 4-, or 6-week follow-up.

CONCLUSION

This trial result identifies a potential negative effect of SPARC in specialist palliative care services, raising questions that standardized holistic needs assessment questionnaires may be counterproductive if not integrated with a clinical assessment that informs the care plan.

Life-and-death decision-making in the acute phase after a severe stroke: Interviews with relatives

BACKGROUND

Decision-making in the acute phase after a severe stroke is complex and may involve life-and-death decisions. Apart from the medical condition and prognosis, quality of life and the deliberation of palliative care should be part of the decision-making process. Relatives play an important role by informing physicians about the patient's values and preferences. However, little is known about how the patients' relatives experience the decision-making process.

AIM

To elicit the perspective of relatives of severe stroke patients with regard to the decision-making process in the acute phase in order to understand how they participate in treatment decisions.

DESIGN

An exploratory qualitative interview approach guided by the principles of grounded theory.

SETTINGS/PARTICIPANTS

Relatives of severe stroke patients (n = 15) were interviewed about their experiences in the decision-making process in the acute phase.

RESULTS

Four categories reflecting relatives' experiences were identified: (1) making decisions under time pressure, (2) the feeling of 'who am I' to decide, (3) reluctance in saying 'let her die' and (4) coping with unexpected changes. Following the treatment proposal of the physician was found to be the prevailing tendency of relatives in the decision-making process.

CONCLUSION

A better understanding of the latent world of experiences of relatives that influence the decision-making process may help physicians and other health-care providers to better involve relatives in decision-making and enhance the care, including palliative care, for patients with severe stroke in line with their values and preferences. Communication between physician and relatives seems vital in this process.

Impact of a clinical pathway on end-of-life care following stroke: a mixed methods study

BACKGROUND

Death after stroke is common, but little is known about end-of-life care processes in acute stroke units.

AIM

(1) To identify family and health-care worker perceptions of an end-of-life care pathway for patients who die after acute stroke. (2) To determine whether patients with fatal stroke judged to require an end-of-life care pathway differ from patients with fatal stroke who die without introduction of such a pathway.

DESIGN

Mixed methods study integrating qualitative semistructured interviews with quantitative casenote review.

SETTING/PARTICIPANTS

In four Scottish acute stroke units, 17 relatives of deceased stroke patients and 23 health-care professionals were interviewed. Thematic analysis used a modified grounded theory approach. Multivariate analysis was performed on casenote data, identified prospectively from 100 consecutive stroke deaths.

RESULTS

Deciding pathway use was a consultative process, occurring within normal working hours. Families were commonly involved and could veto or trigger aspects of end-of-life care. Families sometimes felt responsible for decisions such as pathway use, resuscitation or hydration. Families were often led to expect their relative's death early in the post-stroke period. Prolonged dying processes, particularly where patients had severe dysphagia, added to distress for families. Preferences for place of care were discussed infrequently. No link was found between demographic or clinical characteristics and care pathway use.

CONCLUSION

Distressing stroke-related clinical problems dominated relatives' concerns rather than use of the end-of-life care pathway. At times, relatives felt primarily responsible for key aspects of decision-making. Relatives often felt unprepared for a prolonged dying process after stroke, particularly where patients had persistent major swallowing difficulties.

The study protocol of: 'Initiating end of life care in stroke: clinical decision-making around prognosis'

BACKGROUND

The initiation of end of life care in an acute stroke context should be focused on those patients and families with greatest need. This requires clinicians to synthesise information on prognosis, patterns (trajectories) of dying and patient and family preferences. Within acute stroke, prognostic models are available to identify risks of dying, but variability in dying trajectories makes it difficult for clinicians to know when to commence palliative interventions. This study aims to investigate clinicians' use of different types of evidence in decisions to initiate end of life care within trajectories typical of the acute stroke population.

METHODS/DESIGN

This two-phase, mixed methods study comprises investigation of dying trajectories in acute stroke (Phase 1), and the use of clinical scenarios to investigate clinical decision-making in the initiation of palliative care (Phase 2). It will be conducted in four acute stroke services in North Wales and North West England. Patient and public involvement is integral to this research, with service users involved at each stage.

DISCUSSION

This study will be the first to examine whether patterns of dying reported in other diagnostic groups are transferable to acute stroke care. The strengths and limitations of the study will be considered. This research will produce comprehensive understanding of the nature of clinical decision-making around end of life care in an acute stroke context, which in turn will inform the development of interventions to further build staff knowledge, skills and confidence in this challenging aspect of acute stroke care.

Life after stroke - is palliative care relevant? A better understanding of illness trajectories after stroke may help clinicians identify patients for a palliative approach to care

Only about 50% of people who have a stroke survive to five-years. Clinicians should identify those most at risk of dying, and gradually integrate palliative care. Such holistic and anticipatory care will be of benefit to patients and their family carers; should reduce futile treatments, medications, or unsuccessful resuscitation attempts; and help more people die how and where they choose. Research is exploring how best to provide palliative and end-of-life care in acute stroke units, but how best to improve holistic, ongoing care in the community is poorly understood. The concept of fluctuating illness trajectories might help clinicians meet the multidimensional needs of stroke survivors at different time points. 'Illness trajectory' research in cancer has suggested that social decline mirrors the physical decline, while psychological and existential distress tended to be most acute at diagnosis, returning home after treatment, disease recurrence, and in the last days. Further research is needed to explore how best to provide palliative care at different stages of the 'stroke journey', and the nature of illness trajectories after stroke.

Care of the dying neurologic patient

The causes of death in patients with neurodegenerative diseases are important information for patients and relatives because misleading information causes additional burdens. Early and frank discussion about disease progression, the causes of death, and end-of-life decisions might support the patient's and family's acceptance of the dying process and also helps physicians to frame treatment goals more explicitly. These goals include the place of death as well as medication administered at the end of life. The Liverpool Care Pathway provides a useful tool to standardize the care at the end of life that contributes to individual decisions and care plans. The prescription of medication at the end of life in various neurodegenerative diseases differs from treatment during the earlier phases of the diseases, not only because of swallowing difficulties but also in terms of symptom control.

Provision of palliative and end-of-life care in stroke units: a qualitative study

BACKGROUND

Stroke is a leading cause of death; between 20% and 30% of people die within 30 days of a stroke. High-quality palliative and end-of-life care are advocated for patients not expected to recover from stroke.

AIM

To explore the perspectives of health professionals regarding the provision of palliative and end-of-life care in UK stroke units.

DESIGN AND SETTING

Qualitative focus groups and individual interviews were held with 66 health professionals working in UK specialist stroke units. Data were analysed thematically.

RESULTS

Three themes emerged from the data. Palliative care was recognised as an important component of stroke care; however, there was uncertainty when initiating transitions to palliative care in stroke, and issues were identified with the integration of acute stroke care and palliative care.

CONCLUSIONS

The findings provide encouraging evidence that palliative and end-of-life care have been adopted as key components of specialist stroke care in UK stroke units. However, many patients stand to benefit from earlier identification of palliative care need and a consideration of quality-of-life approaches during active care. Encouraging collaboration and partnership when working with specialist palliative care services would optimise palliative care service delivery and may provide patients and their families with greater opportunities for documenting and achieving preferences for care and achieving a better quality of death.

Symptom burden, palliative care need and predictors of physical and psychological discomfort in two UK hospitals

BACKGROUND

The requirement to meet the palliative needs of acute hospital populations has grown in recent years. With increasing numbers of frail older people needing hospital care as a result of both malignant and non-malignant conditions, emphasis is being placed upon understanding the physical, psychological and social burdens experienced by patients. This study explores the extent of burden in two large UK hospitals, focusing upon those patients who meet palliative care criteria. Furthermore, the paper explores the use of palliative services and identifies the most significant clinical diagnostic and demographic factors which determine physical and psychological burden.

METHODS

Two hospital surveys were undertaken to identify burden using the Sheffield Profile for Assessment and Referral to Care (SPARC). The Gold Standards Framework (GSF) is used to identify those patients meeting palliative care criteria. Participants were identified as being in-patients during a two-week data collection phase for each site. Data was gathered using face-to-face interviews or self-completion by patients or a proxy. Descriptive analyses highlight prevalence and use of palliative care provision. Binary logistic regression assesses clinical diagnostic predictor variables of physical and psychological burden.

RESULTS

The sample consisted of 514 patients and elevated physical, psychological and social burden is identified amongst those meeting palliative care criteria (n = 185). Tiredness (34.6%), pain (31.1%), weakness (28.8%) and psychological discomfort (low mood 19.9%; anxiety 16.1%) are noted as being prevalent. A small number of these participants accessed Specialist Palliative Care (8.2%). Dementia was identified as a predictor of physical (OR 3.94; p < .05) and psychological burden (OR 2.88; p < .05), being female was a predictor of psychological burden (OR 2.00; p < .05).

CONCLUSION

The paper highlights elevated levels of burden experienced by patients with palliative care requirements. Moreover, the paper also indicates that a large proportion of such patients are not in receipt of palliative approaches to their care. Furthermore, the paper identifies that those with non-malignant illnesses, especially dementia, may experience high levels of physical and psychological burden.

Integrating palliative care within acute stroke services: developing a programme theory of patient and family needs, preferences and staff perspectives

BACKGROUND

Palliative care should be integrated early into the care trajectories of people with life threatening illness such as stroke. However published guidance focuses primarily on the end of life, and there is a gap in the evidence about how the palliative care needs of acute stroke patients and families should be addressed. Synthesising data across a programme of related studies, this paper presents an explanatory framework for the integration of palliative and acute stroke care.

METHODS

Data from a survey (n=191) of patient-reported palliative care needs and interviews (n=53) exploring experiences with patients and family members were explored in group interviews with 29 staff from 3 United Kingdom stroke services. A realist approach to theory building was used, constructed around the mechanisms that characterise integration, their impacts, and mediating, contextual influences.

RESULTS

The framework includes two cognitive mechanisms (the legitimacy of palliative care and individual capacity), and behavioural mechanisms (engaging with family; the timing of intervention; working with complexity; and the recognition of dying) through which staff integrate palliative and stroke care. A range of clinical (whether patients are being 'actively treated', and prognostic uncertainty) and service (leadership, specialty status and neurological focus) factors appear to influence how palliative care needs are attended to.

CONCLUSIONS

Our framework is the first, empirical explanation of the integration of palliative and acute stroke care. The specification in the framework of factors that mediate integration can inform service development to improve the outcomes and experiences of patients and families.

Rehabilitation after stroke

BACKGROUND

Stroke is becoming more common in Germany as the population ages. Its long-term sequelae can be alleviated by early reperfusion in stroke units and by complication management and functional restoration in early-rehabilitation and rehabilitation centers.

METHODS

Selective review of the literature.

RESULTS

Successful rehabilitation depends on systematic treatment by an interdisciplinary team of experienced specialists. In the area of functional restoration, there has been major progress in our understanding of the physiology of learning, relearning, training, and neuroenhancement. There have also been advances in supportive pharmacotherapy and robot technology.

CONCLUSION

Well-organized acute and intermediate rehabilitation after stroke can provide patients with the best functional results attainable on the basis of our current scientific understanding. Further experimental and clinical studies will be needed to expand our knowledge and improve the efficacy of rehabilitation.