Identifying patients who could benefit from palliative care by making use of the general practice information system: the Surprise Question versus the SPICT

Screening instruments for early identification of unmet palliative care needs: a systematic review and meta-analysis

BACKGROUND

The early detection of individuals who require palliative care is essential for the timely initiation of palliative care services. This systematic review and meta-analysis aimed to (1) Identify the screening instruments used by health professionals to promote early identification of patients who may benefit from palliative care; and (2) Assess the psychometric properties and clinical performance of the instruments.

METHODS

A comprehensive literature search was conducted in PubMed, Embase, CINAHL, Scopus, CNKI and Wanfang from inception to May 2023. We used the COnsensus-based Standards for the Selection of Health Measurement INstruments to assess the methodological quality of the development process for the instruments. The clinical performance of the instruments was assessed by narrative summary or meta-analysis. Subgroup analyses were conducted where necessary. The quality of included studies was assessed using the Newcastle-Ottawa Scale and the Cochrane Collaboration's risk of bias assessment tool.

RESULTS

We included 31 studies that involved seven instruments. Thirteen studies reported the development and validation process of these instruments and 18 studies related to assessment of clinical performance of these instruments. The content validity of the instruments was doubtful or inadequate because of very low to moderate quality evidence. The pooled sensitivity (Se) ranged from 60.0% to 73.8%, with high heterogeneity (I2 of 88.15% to 99.36%). The pooled specificity (Sp) ranges from 70.4% to 90.2%, with high heterogeneity (I2 of 96.81% to 99.94%). The Supportive and Palliative Care Indicators Tool (SPICT) had better performance in hospitals than in general practice settings (Se=79.8% vs 45.3%, p=0.004; Sp=59.1% vs 97.0%, p=0.000).

CONCLUSION

The clinical performance of existing instruments in identifying patients with palliative care needs early ranged from poor to reasonable. The SPICT is used most commonly, has better clinical performance than other instruments but performs better in hospital settings than in general practice settings.

Evaluating the Utility of the Surprise Question Among General Physicians for Appropriate Palliative Care Indication in Brazil

Objectives

This study aimed to assess the agreement between established tools, such as the Palliative Performance Scale (PPS) and Brazilian version of the Supportive and Palliative Care Indicators Tool (SPICT-BR), and the subjective assessment of palliative care (PC) need using the Surprise Question (SQ) administered by resident physicians. This assessment was conducted among hospitalized patients, with and without cancer, to determine the efficacy of these tools in indicating the need for PC.

Methods

A six-month cross-sectional study in 2019 of medical records of patients hospitalized in a single center in IAMSPE-Brazil. The SPICT-BR and PPS were applied to the medical record data, and the SQ was posed to each resident physician. Comparisons for categorical data were made using the chi-square test, with p < 0.05 considered statistically significant.

Results

Of 203 patients evaluated, 57.6% were male and 81.2% were older adults (≥60 years). The mean age was 67.40 ± 9.72 years. Chronic disease was nonneoplastic in 78.32% of patients, and 56.65% had not been hospitalized in the preceding year. The PPS score was <70% in 69.4% of patients, and 51.2% met at least one SPICT-BR criterion. Among patients with cancer, 40.9% had over two positive SPICT-BR criteria; 97.5% of these patients received NO responses to SQ by residents (p < 0.0001). Similarly, 90.6% of patients with one SPICT-BR criterion received NO responses to SQ, with no significant difference between groups.

Conclusion

The SQ proved to be a valuable tool for PC indication, particularly when administered by untrained professionals. Consistent with SPICT-BR findings, our study highlights the SQ's role in facilitating early identification of patients in need of PC.

The Surprise Question and clinician-predicted prognosis: systematic review and meta-analysis

BACKGROUND

The Surprise Question, 'Would you be surprised if this person died within the next year?' is a simple tool that can be used by clinicians to identify people within the last year of life. This review aimed to determine the accuracy of this assessment, across different healthcare settings, specialties, follow-up periods and respondents.

METHODS

Searches were conducted of Medline, Embase, AMED, PubMed and the Cochrane Central Register of Controlled Trials, from inception until 01 January 2024. Studies were included if they reported original data on the ability of the Surprise Question to predict survival. For each study (including subgroups), sensitivity, specificity, positive and negative predictive values and accuracy were determined.

RESULTS

Our dataset comprised 56 distinct cohorts, including 68 829 patients. In a pooled analysis, the sensitivity of the Surprise Question was 0.69 ((0.64 to 0.74) I2=97.2%), specificity 0.69 ((0.63 to 0.74) I2=99.7%), positive predictive value 0.40 ((0.35 to 0.45) I2=99.4%), negative predictive value 0.89 ((0.87 to 0.91) I2=99.7%) and accuracy 0.71 ((0.68 to 0.75) I2=99.3%). The prompt performed best in populations with high event rates, shorter timeframes and when posed to more experienced respondents.

CONCLUSIONS

The Surprise Question demonstrated modest accuracy with considerable heterogeneity across the population to which it was applied and to whom it was posed. Prospective studies should test whether the prompt can facilitate timely access to palliative care services, as originally envisioned.

PROSPERO REGISTRATION NUMBER

CRD32022298236.

Use of the supportive and palliative care indicators tool (SPICT™) for end-of-life discussions: a scoping review

BACKGROUND

In order to mitigate the distress associated with life limiting conditions it is essential for all health professionals not just palliative care specialists to identify people with deteriorating health and unmet palliative care needs and to plan care. The SPICT™ tool was designed to assist with this.

AIM

The aim was to examine the impact of the SPICT™ on advance care planning conversations and the extent of its use in advance care planning for adults with chronic life-limiting illness.

METHODS

In this scoping review records published between 2010 and 2024 reporting the use of the SPICT™, were included unless the study aim was to evaluate the tool for prognostication purposes. Databases searched were EBSCO Medline, PubMed, EBSCO CINAHL, APA Psych Info, ProQuest One Theses and Dissertations Global.

RESULTS

From the search results 26 records were reviewed, including two systematic review, two theses and 22 primary research studies. Much of the research was derived from primary care settings. There was evidence that the SPICT™ assists conversations about advance care planning specifically discussion and documentation of advance care directives, resuscitation plans and preferred place of death. The SPICT™ is available in at least eight languages (many versions have been validated) and used in many countries.

CONCLUSIONS

Use of the SPICT™ appears to assist advance care planning. It has yet to be widely used in acute care settings and has had limited use in countries beyond Europe. There is a need for further research to validate the tool in different languages.

The contribution of generalist community nursing to palliative care: a retrospective case note review

Background: There is a paucity of evidence regarding the contribution of generalist community nursing to palliative care. Aim: The aim of this study was to identity the proportion of patients referred to a generalist community nursing service who meet the criteria for palliative care need and explore key aspects of their management. Methods: A retrospective case note review of people known to a generalist community nursing service was undertaken to identify people with palliative care needs. Results: Of the 1284 people enrolled in the community nursing service, 21.1% (n=271) were identified as having palliative care needs, of which most (82.7%; n=224) had a non-cancer illness. However, palliative care need was largely unrecognised in the referrals to community nursing and there was little evidence of a palliative approach being integrated into nursing care. Conclusions: Nursing has a significant role in the provision of generalist palliative care in the community. However, research is needed to identify the barriers community nurses experience identifying needs and providing palliative care. A focus on education and support in implementing screening tools, which may assist community nurses in recognising needs and delivering palliative in the generalist setting, is urgently needed.

External Validation and User Experiences of the ProPal-COPD Tool to Identify the Palliative Phase in COPD

Background

Difficulty predicting prognosis is a major barrier to timely palliative care provision for patients with COPD. The ProPal-COPD tool, combining six clinical indicators and the Surprise Question (SQ), aims to predict 1-year mortality as a proxy for palliative care needs. It appeared to be a promising tool for healthcare providers to identify patients with COPD who could benefit from palliative care.

Objective

To externally validate the ProPal-COPD tool and to assess user experiences.

Methods

Patients admitted with an acute exacerbation COPD were recruited across 10 hospitals. Demographics, clinical characteristics and survival status were collected. Sensitivity, specificity, positive and negative predictive values of the tool using two cut-off values were calculated. Also, predictive properties of the SQ were calculated. In monitoring meetings and interviews, healthcare providers shared their experiences with the tool. Transcripts were deductively coded using six user experience domains: Acceptability, Satisfaction, Credibility, Usability, User-reported adherence and Perceived impact.

Results

A total of 523 patients with COPD were included between May 2019 and August 2020, of whom 100 (19.1%) died within 12 months. The ProPal-COPD tool had an AUC of 0.68 and a low sensitivity (55%) and moderate specificity (74%) for predicting 1-year all-cause mortality. Using a lower cut-off value, sensitivity was higher (74%), but specificity lower (46%). Sensitivity and specificity of the SQ were 56% and 73%, respectively (AUC 0.65). However, healthcare providers generally appreciated using the tool because it increased awareness of the palliative phase and provided a shared understanding of prognosis, although they considered its outcome not always correct.

Conclusion

The accuracy of the ProPal-COPD tool to predict 1-year mortality is limited, although screening patients with its indicators increases healthcare providers' awareness of palliative care needs and encourages them to timely initiate appropriate care.

Palliative care outpatients in a German comprehensive cancer center-identifying indicators for early and late referral

PURPOSE

Despite that early integration of palliative care is recommended in advanced cancer patients, referrals to outpatient specialised palliative care (SPC) frequently occur late. Well-defined referral criteria are still missing. We analysed indicators associated with early (ER) and late referral (LR) to SPC of an high volume outpatient unit of a comprehensive cancer center.

METHODS

Characteristics, laboratory parameters and symptom burden of 281 patients at first SPC referral were analysed. Timing of referral was categorized as early, intermediate and late (> 12, 3-12 and < 3 months before death). Ordinal logistic regression analysis was used to identify factors related to referral timing. Kruskal-Wallis test was used to determine symptom severity and laboratory parameter in each referral category.

RESULTS

LRs (50.7%) had worse scores of weakness, loss of appetite, drowsiness, assistance of daily living (all p < 0.001) and organisation of care (p < 0.01) in contrast to ERs. The mean symptom sum score was significantly higher in LRs than ERs (13.03 vs. 16.08; p < 0.01). Parameters indicative of poor prognosis, such as elevated LDH, CRP and neutrophil-to-lymphocyte ratio (NLR) (p < 0.01) as well as the presence of ascites (p < 0.05), were significantly higher (all p < 0.001) in LRs. In univariable analyses, psychological distress (p < 0.05) and female gender (p < 0.05) were independently associated with an ER.

CONCLUSION

A symptom sum score and parameters of poor prognosis like NLR or LDH might be useful to integrate into palliative care screening tools.

The utility of the surprise question: A useful tool for identifying patients nearing the last phase of life? A systematic review and meta-analysis

BACKGROUND

The surprise question is widely used to identify patients nearing the last phase of life. Potential differences in accuracy between timeframe, patient subgroups and type of healthcare professionals answering the surprise question have been suggested. Recent studies might give new insights.

AIM

To determine the accuracy of the surprise question in predicting death, differentiating by timeframe, patient subgroup and by type of healthcare professional.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Electronic databases PubMed, Embase, Cochrane Library, Scopus, Web of Science and CINAHL were searched from inception till 22nd January 2021. Studies were eligible if they used the surprise question prospectively and assessed mortality. Sensitivity, specificity, negative predictive value, positive predictive value and c-statistic were calculated.

RESULTS

Fifty-nine studies met the inclusion criteria, including 88.268 assessments. The meta-analysis resulted in an estimated sensitivity of 71.4% (95% CI [66.3-76.4]) and specificity of 74.0% (95% CI [69.3-78.6]). The negative predictive value varied from 98.0% (95% CI [97.7-98.3]) to 88.6% (95% CI [87.1-90.0]) with a mortality rate of 5% and 25% respectively. The positive predictive value varied from 12.6% (95% CI [11.0-14.2]) with a mortality rate of 5% to 47.8% (95% CI [44.2-51.3]) with a mortality rate of 25%. Seven studies provided detailed information on different healthcare professionals answering the surprise question.

CONCLUSION

We found overall reasonable test characteristics for the surprise question. Additionally, this study showed notable differences in performance within patient subgroups. However, we did not find an indication of notable differences between timeframe and healthcare professionals.

Readiness of Advance Care Planning Among Patients With Cardiovascular Disease

Background

Advance care planning (ACP) is a widely advocated strategy to improve outcomes at end-of-life care for patients suffering from heart failure (HF). However, finding the right time to start ACP is challenging for healthcare providers because it is often a sensitive issue for patients with HF and their families. We interviewed patients with cardiovascular diseases regarding ACP readiness and investigated the relationship between the ACP desire and multiple clinical prognostic parameters.

Method

Eighty-one patients (average age 81.8 ± 10.3 years old, 42 men, 62 cases of HF) who introduced cardiac rehabilitation were inquired about previous ACP experience, a desire for ACP, understanding of their cardiovascular diseases, and lifestyle-associated questionnaires. Multiple logistic regression analyses were employed to identify the clinical parameters associated with ACP desire. Patients who desired ACP were also asked about their preferences for medical care at the end-of-life.

Results

Nine patients (11.1%) had previous experience with ACP, and 28 (34.6%) preferred to implement ACP. Patients who did not want to implement ACP were 54.3%. Patients with HF showed a higher acceptance rate of ACP (odds ratio [OR] 5.56, p = 0.015). Interestingly, patients harboring skeletal muscle frailty showed lower ACP acceptance, while patients with non-frailty rather positively wanted to implement ACP. Two types of prognosis evaluation scales, such as the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) risk score and the Japanese Version of Supportive and Palliative Care Indicators Tool (SPICT-JP), identified 31 patients (38.3%) needing ACP; however, 19 (61.3%) did not want ACP. The wish not to attempt resuscitation and life-prolonging treatment at the end-of-life reached approximately 70% among patients who requested ACP.

Conclusions

Although patients with HF tended to be ready for implementing ACP, the presence of skeletal muscle frailty was negatively associated with ACP preference. Indeed, patients who should be considered ACP were not carried out and did not desire it. Earlier introduction of ACP into patients before having skeletal muscle frailty may be considered.

Supportive and palliative care indicators tool (SPICT™) in a Danish healthcare context: translation, cross-cultural adaptation, and content validation

BACKGROUND

Early identification of patients who require palliative and supportive care at the general palliative care level is challenging. The Supportive & Palliative Care Indicators Tool (SPICT™) might provide a helpful framework for this process.

AIM

To translate, culturally adapt and content validate SPICT™-DK in hospital, primary care, and general practice and within the broader Danish health care context.

METHODS

SPICT™-DK was translated and cross-culturally validated by using the TRAPD-model (Translation, Review, adjudication, pretesting, and documentation) as well as the EORTC- translation guide (European Organisation for Research and Treatment of Cancer). In the pre-(pilot) testing phase, six focus group interviews and five individual interviews were conducted involving n = 29 health care professionals from general practice, primary care, and hospital. The qualitative data were analyzed through thematic analysis and the SPICT™-DK was then revised and published.

RESULTS

The interviews revealed that SPICT™-DK can be used to identify people with palliative care needs. Three themes were derived from the analysis and showed SPICT™-DK provides a linguistic framework but must be used as an interdisciplinary tool as that SPICT™-DK requires competencies and collaboration.

CONCLUSION

SPICT™-DK is now translated and culturally validated in a Danish healthcare setting. The tool is useful to identify people with palliative care needs but must be implemented as an interdisciplinary collaborative intervention. SPICT™ -DK cannot be used by all healthcare professionals as it requires disease-specific competencies. However, it provides a common language for early palliative care interventions which can form the basis for interdisciplinary planning of future treatment and care.

Measurement Properties of ID-PALL, A New Instrument for the Identification of Patients With General and Specialized Palliative Care Needs

CONTEXT

To improve access to palliative care, identification of patients in need of general or specialized palliative care is necessary. To our knowledge, no available identification instrument makes this distinction. ID-PALL is a screening instrument developed to differentiate between these patient groups.

OBJECTIVE

To assess the structural and criterion validity and the inter-rater agreement of ID-PALL.

METHODS

In this multicenter, prospective, cross-sectional study, nurses and physicians assessed medical patients hospitalized for 2 to 5 days in two tertiary hospitals in Switzerland using ID-PALL. For the criterion validity, these assessments were compared to a clinical gold standard evaluation performed by palliative care specialists. Structural validity, internal consistency and inter-rater agreement were assessed.

RESULTS

2232 patients were assessed between January and December 2018, 97% by nurses and 50% by physicians. The variances for ID-PALL G and S are explained by two factors, the first one explaining most of the variance in both cases. For ID-PALL G, sensitivity ranged between 0.80 and 0.87 and specificity between 0.56 and 0.59. ID-PALL S sensitivity ranged between 0.82 and 0.94, and specificity between 0.35 and 0.64. A cut-off value of 1 delivered the optimal values for patient identification. Cronbach's alpha was 0.78 for ID-PALL G and 0.67 for ID-PALL S. The agreement rate between nurses and physicians was 71.5% for ID-PALL G and 64.6% for ID-PALL S.

CONCLUSION

ID-PALL is a promising screening instrument allowing the early identification of patients in need of general or specialized palliative care. It can be used by nurses and physicians without a specialized palliative care training. Further testing of the finalized clinical version appears warranted.

Last Year of Life Study-Cologne (LYOL-C) (Part II): study protocol of a prospective interventional mixed-methods study in acute hospitals to analyse the implementation of a trigger question and patient question prompt sheets to optimise patient-centred care

INTRODUCTION

The Last Year of Life Study-Cologne Part I (LYOL-C I) has identified general hospital units as the most important checkpoints for transitions in the last year of life of patients. Yet, satisfaction with hospitals, as reported by bereaved relatives, is the lowest of all health service providers. Thus, the LYOL-C Part II (LYOL-C II) focuses on optimising patient-centred care in acute hospitals for patients identified to be in their last year of life. LYOL-C II aims to test an intervention for hospitals by using a two-sided (healthcare professionals (HCPs) and patients) trigger question-based intervention to 'shake' the system in a minimally invasive manner.

METHODS AND ANALYSIS

Prospective interventional mixed-methods study following a two-phase approach: phase I, individual interviews with HCPs and patient representatives to design the intervention to maximise ease of implementation and phase II, exploratory study with two arms and a prepost design with patients in their last year of life. The intervention will consist of the Surprise Question and the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for HCPs to identify patients and provide patient-centred care, plus question prompt sheets for patients, encouraging them to initiate discussions with their HCPs. Data on transitions, changes in therapy, quality of care, palliative care integration and death of patients will be analysed. Furthermore, a staff survey (pre/post) and guided interviews with staff, patients and relatives (post) will be conducted. Finally, a formative socioeconomic impact assessment to provide evidence regarding the sustainability of the intervention will be performed.

ETHICS AND DISSEMINATION

The study was approved by the Ethics Committee of the Faculty of Medicine of the University of Cologne (#20-1431). Results will be published in peer-reviewed journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00022378.