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Pires L, Rosendo I, Seiça Cardoso C. [Palliative Care Needs in Primary Health Care: Characteristics of Patients with Advanced Cancer and Dementia]. ACTA MEDICA PORT 2024; 37:90-99. [PMID: 37579749 DOI: 10.20344/amp.20049] [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: 04/15/2023] [Accepted: 05/30/2023] [Indexed: 08/16/2023]
Abstract
INTRODUCTION The increase in life expectancy brought a higher prevalence of chronic diseases, with an emphasis on those who reached advanced stages and required palliative care. We aimed to characterize patients diagnosed with advanced neoplasms and/or dementia accompanied in primary health care and to test the sensitivity of two tools for identifying patients with palliative needs. METHODS We recruited three voluntary family physicians who provided data relative to 623 patients with active codification for neoplasm and/or dementia on the MIM@UF platform. We defined 'patient with palliative needs' as any patient with this codification in advanced stadium and made their clinical and sociodemographic characterization. Assuming the existence of advanced-stage disease as the gold standard, we calculated and compared the sensitivities of each of the tools under study: the surprise question, the question 'do you think this patient has palliative needs?' and an instrument that corresponded to identification by at least one of the questions. RESULTS Among the analyzed data, there were 559 (89.7%) active codifications of neoplasm and 64 (10.3%) of dementia; the prevalence of advanced neoplasm and dementia was 1.0% in the studied sample. The subgroup of patients with advanced dementia showed female sex predominance, an older age, and less access to health care. In both subgroups there was a scarcity of data related to education and income, and we observed polypharmacotherapy and multimorbidity. The sensitivity of the surprise question was 33.3% for neoplasia and 69.3% for dementia; of the new tool 50.0% for neoplasia and 92.3% for dementia; and, when used together, 55.6% for neoplasia and 92.3% for dementia. CONCLUSION Our results help characterize two subpopulations of patients in need of palliative care and advance with a possible tool for their identification, to be confirmed in a representative sample.
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Affiliation(s)
- Luís Pires
- Faculdade de Medicina. Universidade de Coimbra. Coimbra. Portugal
| | - Inês Rosendo
- Faculdade de Medicina. Universidade de Coimbra. Coimbra; Unidade de Saúde Familiar Coimbra Centro. Coimbra. Portugal
| | - Carlos Seiça Cardoso
- Faculdade de Medicina. Universidade de Coimbra. Coimbra; Unidade de Saúde Familiar Condeixa. Coimbra. Portugal
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2
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Sacca L, Lobaina D, Burgoa S, Rao M, Jhumkhawala V, Zapata SM, Issac M, Medina S. Using Patient-Centered Dissemination and Implementation Frameworks and Strategies in Palliative Care Settings for Improved Quality of Life and Health Outcomes: A Scoping Review. Am J Hosp Palliat Care 2023:10499091231214241. [PMID: 37956239 DOI: 10.1177/10499091231214241] [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: 11/15/2023] Open
Abstract
BACKGROUND There is a need for patient-provider dissemination and implementation frameworks, strategies, and protocols in palliative care settings for a holistic approach when it comes to addressing pain and other distressing symptoms affecting the quality of life, function, and independence of patients with chronic illnesses. The purpose of this scoping review is to explore patient-centered D&I frameworks and strategies that have been adopted in PC settings to improve behavioral and environmental determinants influencing health outcomes through evidence-based programs and protocols. METHODS The five step Arksey and O'Malley's (2005) York methodology was adopted as a guiding framework: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; and (5) collating, summarizing, and reporting results. RESULTS Only 6 out of the 38 (16%) included studies applied a D&I theory and/or framework. The RE-AIM framework was the most prominently cited (n = 3), followed by the Diffusion of Innovation Model (n = 2), the CONNECT framework (n = 1), and the Transtheoretical Stages of Change Model (n = 1). The most frequently reported ERIC strategy was strategy #6 "Develop and organize quality monitoring systems", as it identified in all 38 of the included studies. CONCLUSION This scoping review identifies D&I efforts to translate research into practice in U.S. palliative care settings. Results may contribute to enhancing future D&I initiatives for dissemination/adaptation, implementation, and sustainability efforts aiming to improve patient health outcomes and personal satisfaction with care received.
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Affiliation(s)
- Lea Sacca
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Diana Lobaina
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Sara Burgoa
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Meera Rao
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Vama Jhumkhawala
- Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
| | - Sheena M Zapata
- Symptom Management and Palliative Medicine, Baptist Health of South Florida, Miami Cancer Institute, Miami, FL, USA
| | - Michelle Issac
- Symptom Management and Palliative Medicine, Baptist Health of South Florida, Miami Cancer Institute, Miami, FL, USA
| | - Suleyki Medina
- Symptom Management and Palliative Medicine, Baptist Health of South Florida, Miami Cancer Institute, Miami, FL, USA
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Atreya S, Datta S, Salins N. Public Health Perspective of Primary Palliative Care: A Review through the Lenses of General Practitioners. Indian J Palliat Care 2022; 28:229-235. [PMID: 36072244 PMCID: PMC9443115 DOI: 10.25259/ijpc_9_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 01/30/2022] [Indexed: 11/04/2022] Open
Abstract
The rising trend of chronic life-threatening illnesses is accompanied by an exponential increase in serious health-related suffering. Palliative care is known to ameliorate physical and psychosocial suffering and restore quality of life. However, the contemporary challenges of palliative care delivery, such as changing demographics, social isolation, inequity in service delivery, and professionalisation of dying, have prompted many to adopt a public health approach to palliative care delivery. A more decentralised approach in which palliative care is integrated into primary care will ensure that the care is available locally to those who need it and at a cost that they can afford. General practitioners (GPs) play a pivotal role in providing primary palliative care in the community. They ensure that care is provided in alignment with patients’ and their families’ wishes along the trajectory of the life-threatening illness and at the patient’s preferred place. GPs use an interdisciplinary approach by collaborating with specialist palliative care teams and other healthcare professionals. However, they face challenges in providing end-of-life care in the community, which include identification of patients in need of palliative care, interpersonal communication, addressing patients’ and caregivers’ needs, clarity in roles and responsibilities between GPs and specialist palliative care teams, coordination of service with specialists and lack of confidence in providing palliative care in view of deficiencies in knowledge and skills in palliative care. Multiple training formats and learning styles for GPs in end-of-life care have been explored across studies. The research has yielded mixed results in terms of physician performance and patient outcomes. This calls for more research on GPs’ views on end-of-life care learning preferences, as this might inform policy and practice and facilitate future training programs in end-of-life care.
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Affiliation(s)
- Shrikant Atreya
- Department of Palliative Care and Psycho-oncology, Tata Medical Center, Kolkata, India,
| | - Soumitra Datta
- Department of Palliative Care and Psycho-oncology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India,
| | - Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India,
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Tan A, Spice R, Sinnarajah A. Family physicians supporting patients with palliative care needs within the patient medical home in the community: an appreciative inquiry study. BMJ Open 2021; 11:e048667. [PMID: 34857557 PMCID: PMC8640631 DOI: 10.1136/bmjopen-2021-048667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Canadians want to live and die in their home communities. Unfortunately, Canada has the highest proportion of deaths in acute care facilities as compared with other developed nations. This study aims to identify the essential components required to best support patients and families with palliative care needs in their communities to inform system changes and empower family physicians (FPs) in providing community-based palliative care for patients. DESIGN Appreciative inquiry (AI) methodology with individual interviews. Interview transcripts were analysed iteratively for emerging themes and used to develop 'possibility statements' to frame discussion in subsequent focus groups. A conceptual framework emerged to describe the 'destiny' state as per AI methods. SETTING FPs, palliative home care providers, patients and bereaved caregivers were recruited in the urban and surrounding rural health authority zones of Calgary, AB, Canada. PARTICIPANTS 9 females and 9 males FPs (range of practice years 2-42) in interviews; 8 bereaved caregivers, 1 patient, 26 palliative home care team members in focus groups. Interviews and focus groups were recorded digitally and transcribed with consent. RESULTS The identified themes that transcended all three groups created the foundation for the conceptual framework. Enhanced communication and fostering team relationships between all care providers with the focus on the patient and caregivers was the cornerstone concept. The FP/patient relationship must be protected and encouraged by all care providers, while more system flexibility is needed to respond more effectively to patients. These concepts must exist in the context that patients and caregivers need more education regarding the benefits of palliative care, while increasing public discourse about mortality. CONCLUSIONS Key areas were identified for how the patient's team can work together effectively to improve the patient and caregiver palliative care journey in the community with the cornerstone element of building on the trusting FP-patient longitudinal relationship.
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Affiliation(s)
- Amy Tan
- Palliative Care, The University of British Columbia, Victoria, British Columbia, Canada
- Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Ronald Spice
- Family Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Palliative Care, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Aynharan Sinnarajah
- Palliative Care, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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Role of GPs in shared decision making with patients about palliative cancer treatment: a qualitative study in the Netherlands. Br J Gen Pract 2021; 72:e276-e284. [PMID: 34990389 PMCID: PMC8843392 DOI: 10.3399/bjgp.2021.0446] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 10/21/2021] [Indexed: 11/12/2022] Open
Abstract
Background GPs are well placed to enhance shared decision making (SDM) about treatment for patients with advanced cancer. However, to date, little is known about GPs’ views about their contribution to SDM. Aim To explore GPs’ perspectives on their role in SDM about palliative cancer treatment and the requirements they report to fulfil this role. Design and setting Qualitative interview study among Dutch GPs. Method GPs were sampled purposefully and conveniently. In-depth, semi-structured interviews were conducted, recorded, and transcribed verbatim. Transcripts were analysed by thematic analysis. Results Fifteen GPs took part in this study. Most of them reported practices that potentially support SDM: checking the quality of a decision, complementing SDM, and enabling SDM. Even though most of the GPs believed that decision making about systemic cancer treatment is primarily the oncologist’s responsibility, they did recognise their added value in the SDM process because of their gatekeeper position, the additional opportunity they offer patients to discuss treatment decisions, and their knowledge and experience as primary healthcare providers at the end of life. Requirements for them to support the SDM process were described as: good collaboration with oncologists; sufficient information about the disease and its treatment; time to engage in conversations about treatment; a trusting relationship with patients; and patient-centred communication. Conclusion GPs may support SDM by checking the quality of a decision and by complementing and enabling the SDM process to reach high-quality decisions. This conceptualisation of the GP’s supporting role in SDM may help us to understand how SDM is carried out through interprofessional collaboration and provide tools for how to adopt a role in the interprofessional SDM process.
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Carlini J, Bahudin D, Michaleff ZA, Plunkett E, Shé ÉN, Clark J, Cardona M. Discordance and concordance on perception of quality care at end of life between older patients, caregivers and clinicians: a scoping review. Eur Geriatr Med 2021; 13:87-99. [PMID: 34386928 PMCID: PMC8359918 DOI: 10.1007/s41999-021-00549-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Accepted: 07/26/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND This scoping review aimed to investigate the presence of discordance or concordance in the perceptions of end-of-life (EOL) care quality between consumers (i.e. patients aged over 60 in their last years of life and/or their informal caregivers) and clinicians, to inform further improvements in end-of-life care service delivery. METHODS A scoping review of qualitative and quantitative studies was systematically undertaken by searching for English language publications in MEDLINE database and manual reference search of eligible articles. Thematic analysis was employed to identify and extract common concordance and discordance themes leading to the development of analytical constructs. Articles were eligible for inclusion if they reported on consumers' (i.e. older patients aged 60 + years in their final years of life and/or their informal caregivers) and clinicians' (doctors, nurses, social workers, etc.) perspectives on quality of medical, surgical or palliative/supportive care administered to older adults in the last year of life across all healthcare settings. RESULTS Of the 2736 articles screened, 21 articles were included. Four themes identified concordance between consumers' and clinicians' perceptions of care quality: holistic patient care; coordinated care that facilitated EOL; the role of family at EOL; and impact of prognostic uncertainty on care planning. Three themes emerged for discordance of perceptions: understanding the patient needs at EOL; capacity of healthcare system/providers to accommodate family needs; and knowledge and communication of active or palliative care at EOL. CONCLUSIONS While progress has been made on promoting patient autonomy and respecting the family role in representing patient's best interest, gaps remain in terms of care coordination, communication of prognosis, public understanding of the meaning of goals of care including de-escalation of management and enactment of advance care directives by clinicians for people with diminished decision capacity. Public understanding of the meaning of "comfort" care and the need to prevent over-treatment are essential for their satisfaction with care and their ability to embrace the concept of a good death.
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Affiliation(s)
- Joan Carlini
- School of Business, Griffith University, Southport, QLD Australia
- Gold Coast University Hospital Consumer Advisory Group, Southport, QLD Australia
| | - Danial Bahudin
- Faculty of Health Sciences and Medicine, Bond University, Robina, QLD Australia
| | - Zoe A. Michaleff
- Institute for Evidence Based Healthcare, Bond University, Robina, QLD Australia
| | - Emily Plunkett
- Palliative Care Service, Robina Hospital, Robina, QLD Australia
| | - Éidín Ní Shé
- School of Population Health, University of New South Wales, Kensington, NSW Australia
| | - Justin Clark
- Institute for Evidence Based Healthcare, Bond University, Robina, QLD Australia
| | - Magnolia Cardona
- Institute for Evidence Based Healthcare, Bond University, Robina, QLD Australia
- Evidence Based Practice Professorial Unit, Gold Coast University Hospital, Level 2, PED building, 1 Hospital Boulevard, Southport, QLD 4215 Australia
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McCallan T, Daudt H. Engaging Family Physicians in the Provision of Palliative and End-of-Life Care: Can We Do Better? Palliat Med Rep 2021; 2:207-211. [PMID: 34318299 PMCID: PMC8310740 DOI: 10.1089/pmr.2021.0021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2021] [Indexed: 11/12/2022] Open
Abstract
Background: Evidence shows the benefits of having a family physician (FP) at the heart of a care team that delivers palliative and end-of-life care (PEoLC). However, FPs have limitations on their ability to provide PEoLC. Objectives: We conducted a quality improvement study to (1) explore the barriers FPs encounter in providing PEoLC in our metropolitan context and (2) identify potential strategies to overcome these challenges. Methods: We interviewed a cohort of FPs from 10 different clinical practices within a metropolitan area (British Columbia [BC], Canada); this cohort is not regularly engaged with our Specialist Palliative Care Team. Verbatim transcripts were examined using inductive thematic analysis. Results: All FPs identified home visits as a critical aspect of being able to provide PEoLC. Despite this consensus, work-life balance, time, and compensation are major barriers to providing home visits and PEoLC. Local healthcare system awareness (available resources, why and how to access them) was identified as a barrier that can potentially be addressed through education sessions. Although 5 out of 10 FPs had not had formal palliative care education or training, clinical education was not considered a barrier to provide PEoLC. Conclusion: Providing FPs with tools and resources through education, including why and how to access them, and adjusting the BC compensation model to address home visit's travel time and time modifiers may better support FPs to provide PEoLC.
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Affiliation(s)
- Tara McCallan
- Moss Rock Medical, Island Health Palliative and End of Life Program and Victoria Hospice, Victoria, British Columbia, Canada
- UBC Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Helena Daudt
- Department of Education and Research, Victoria Hospice, Victoria, British Columbia, Canada
- School of Nursing, University of Victoria, Victoria, British Columbia, Canada
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Howard M, Hafid A, Isenberg SR, Hsu AT, Scott M, Conen K, Webber C, Bronskill SE, Downar J, Tanuseputro P. Intensity of outpatient physician care in the last year of life: a population-based retrospective descriptive study. CMAJ Open 2021; 9:E613-E622. [PMID: 34088732 PMCID: PMC8191591 DOI: 10.9778/cmajo.20210039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories. METHODS We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory. RESULTS Decedents (n = 359 559) had a median age of 78 (interquartile range 66-86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians. INTERPRETATION Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care.
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Affiliation(s)
- Michelle Howard
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont.
| | - Abe Hafid
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Sarina R Isenberg
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Amy T Hsu
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Mary Scott
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Katrin Conen
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Colleen Webber
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Susan E Bronskill
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - James Downar
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
| | - Peter Tanuseputro
- Department of Family Medicine (Howard, Hafid), McMaster University, Hamilton, Ont.; Bruyère Research Institute (Isenberg, Hsu, Scott, Webber, Tanuseputro); Department of Medicine (Isenberg), University of Ottawa; Ottawa Hospital Research Institute (Hsu, Scott, Webber), Ottawa, Ont.; Department of Medicine (Conen), McMaster University, Hamilton, Ont.; ICES (Bronskill); Institute of Health Policy, Management and Evaluation (Bronskill), University of Toronto, Toronto, Ont.; Division of Palliative Care, Department of Medicine (Downar), University of Ottawa; Department of Medicine (Tanuseputro), University of Ottawa, Ottawa, Ont
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9
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Gallagher E, Carter-Ramirez D, Boese K, Winemaker S, MacLennan A, Hansen N, Hafid A, Howard M. Frequency of providing a palliative approach to care in family practice: a chart review and perceptions of healthcare practitioners in Canada. BMC FAMILY PRACTICE 2021; 22:58. [PMID: 33773579 PMCID: PMC8005234 DOI: 10.1186/s12875-021-01400-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 02/23/2021] [Indexed: 12/01/2022]
Abstract
Background Most patients nearing the end of life can benefit from a palliative approach in primary care. We currently do not know how to measure a palliative approach in family practice. The objective of this study was to describe the provision of a palliative approach and evaluate clinicians’ perceptions of the results. Methods We conducted a descriptive study of deceased patients in an interprofessional team family practice. We integrated conceptual models of a palliative approach to create a chart review tool to capture a palliative approach in the last year of life and assessed a global rating of whether a palliative approach was provided. Clinicians completed a questionnaire before learning the results and after, on perceptions of how often they believed a palliative approach was provided by the team. Results Among 79 patients (mean age at death 73 years, 54% female) cancer and cardiac diseases were the top conditions responsible for death. One-quarter of patients were assessed as having received a palliative approach. 53% of decedents had a documented discussion about goals of care, 41% had nurse involvement, and 15.2% had a discussion about caregiver well-being. These indicators had the greatest discrimination between a palliative approach or not. Agreement that elements of a palliative approach were provided decreased significantly on the clinician questionnaire from before to after viewing the results. Conclusions This study identified measurable indicators of a palliative approach in family practice, that can be used as the basis for quality improvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01400-4.
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Affiliation(s)
- Erin Gallagher
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Daniel Carter-Ramirez
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Kaitlyn Boese
- Division of Palliative Care, Department of Medicine, University of Ottawa, 451 Smyth, Road Ottawa, Ottawa, ON, K1H 8M5, Canada.,Department of Palliative Care, Bruyere Continuing Care, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada
| | - Samantha Winemaker
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Amanda MacLennan
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.,Division of Palliative Care, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Nicolle Hansen
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Abe Hafid
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, David Braley Health Sciences Centre 100 Main Street West, 5th Floor, Hamilton, ON, L8P 1H6, Canada.
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How do physicians and nurses in family practice describe their care for patients with progressive life-limiting illness? A qualitative study of a 'palliative approach'. Prim Health Care Res Dev 2019; 20:e95. [PMID: 32800001 PMCID: PMC6609973 DOI: 10.1017/s1463423619000252] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
AIM To explore how a palliative approach to care is operationalized in primary care, through the description of clinical practices used by primary care clinicians to identify and care for patients with progressive life-limiting illness (PLLI). BACKGROUND Increasing numbers of people are living with PLLI but are often not recognized as needing a palliative approach to care. To meet growing needs, generalists such as family physicians will need to adopt a palliative approach to care in their own setting. Practical descriptions of a palliative approach in non-specialist settings have been lacking. METHODS We conducted a qualitative descriptive study design using in-depth semi-structured interviews with 11 key informant participants (6 physicians, 3 nurse practitioners, 1 registered nurse, and 1 registered practical nurse) known to be providing comprehensive care to patients with PLLI in family practices in Ontario, Canada. We asked about their approach to identifying patients with PLLI and the strategies used in their care. We employed content analysis to develop themes. FINDINGS Participants identified patients by functional decline, change in needs, increased acuity, and the specifics of a condition/diagnosis. Care strategies included concretizing commitment to care, eliciting goals of care, shifting care to the home, broadening team members including leveraging the support of family and community resources, and shifting to a 'proactive' approach involving increased follow-up, flexibility, and intensity. CONCLUSION Primary care providers articulated strategies for identifying and providing care to patients with PLLI that illuminate an upstream approach tailored to their setting.
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Sellars M, Chung O, Nolte L, Tong A, Pond D, Fetherstonhaugh D, McInerney F, Sinclair C, Detering KM. Perspectives of people with dementia and carers on advance care planning and end-of-life care: A systematic review and thematic synthesis of qualitative studies. Palliat Med 2019; 33:274-290. [PMID: 30404576 PMCID: PMC6376607 DOI: 10.1177/0269216318809571] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND: Advance care planning aims to ensure that care received during serious and chronic illness is consistent with the person’s values, preferences and goals. However, less than 40% of people with dementia undertake advance care planning internationally. AIM: This study aims to describe the perspectives of people with dementia and their carers on advance care planning and end-of-life care. DESIGN: Systematic review and thematic synthesis of qualitative studies. DATA SOURCES: Electronic databases were searched from inception to July 2018. RESULTS: From 84 studies involving 389 people with dementia and 1864 carers, five themes were identified: avoiding dehumanising treatment and care (remaining connected, delaying institutionalisation, rejecting the burdens of futile treatment); confronting emotionally difficult conversations (signifying death, unpreparedness to face impending cognitive decline, locked into a pathway); navigating existential tensions (accepting inevitable incapacity and death, fear of being responsible for cause of death, alleviating decisional responsibility); defining personal autonomy (struggling with unknown preferences, depending on carer advocacy, justifying treatments for health deteriorations); and lacking confidence in healthcare settings (distrusting clinicians’ mastery and knowledge, making uninformed choices, deprived of hospice access and support at end of life). CONCLUSION: People with dementia and their carers felt uncertain in making treatment decisions in the context of advance care planning and end-of-life care. Advance care planning strategies that attend to people’s uncertainty in decision-making may help to empower people with dementia and carers and strengthen person-centred care in this context.
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Affiliation(s)
- Marcus Sellars
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia.,2 Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Olivia Chung
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia
| | - Linda Nolte
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia
| | - Allison Tong
- 3 Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia
| | - Dimity Pond
- 4 School of Medicine and Public Health (General Practice), The University of Newcastle, Callaghan, NSW, Australia
| | - Deirdre Fetherstonhaugh
- 5 Australian Centre for Evidence Based Aged Care, La Trobe University, Melbourne, VIC, Australia
| | - Fran McInerney
- 6 Wicking Dementia Research and Education Centre, College of Health and Medicine, University of Tasmania, Hobart, TAS, Australia
| | - Craig Sinclair
- 7 Rural Clinical School of Western Australia, University of Western Australia, Albany, WA, Australia
| | - Karen M Detering
- 1 Advance Care Planning Australia, Austin Health, Melbourne, VIC, Australia.,8 Faculty of Medicine, Dentistry and Health Science, University of Melbourne, Melbourne, VIC, Australia
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12
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Bartley MM, Suarez L, Shafi RMA, Baruth JM, Benarroch AJM, Lapid MI. Dementia Care at End of Life: Current Approaches. Curr Psychiatry Rep 2018; 20:50. [PMID: 29936639 DOI: 10.1007/s11920-018-0915-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW Dementia is a progressive and life-limiting condition that can be described in three stages: early, middle, and late. This article reviews current literature on late-stage dementia. RECENT FINDINGS Survival times may vary across dementia subtypes. Yet, the overall trajectory is characterized by progressive decline until death. Ideally, as people with dementia approach the end of life, care should focus on comfort, dignity, and quality of life. However, barriers prevent optimal end-of-life care in the final stages of dementia. Improved and earlier advanced care planning for persons with dementia and their caregivers can help delineate goals of care and prepare for the inevitable complications of end-stage dementia. This allows for timely access to palliative and hospice care, which ultimately improves dementia end-of-life care.
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Affiliation(s)
| | - Laura Suarez
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Reem M A Shafi
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Joshua M Baruth
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Amanda J M Benarroch
- Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Maria I Lapid
- Center for Palliative Medicine, Mayo Clinic, Rochester, MN, USA. .,Department of Psychiatry and Psychology, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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Scheerens C, Deliens L, Van Belle S, Joos G, Pype P, Chambaere K. "A palliative end-stage COPD patient does not exist": a qualitative study of barriers to and facilitators for early integration of palliative home care for end-stage COPD. NPJ Prim Care Respir Med 2018; 28:23. [PMID: 29925846 PMCID: PMC6010468 DOI: 10.1038/s41533-018-0091-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/28/2018] [Accepted: 06/04/2018] [Indexed: 11/09/2022] Open
Abstract
Early integration of palliative home care (PHC) might positively affect people with chronic obstructive pulmonary disease (COPD). However, PHC as a holistic approach is not well integrated in clinical practice at the end-stage COPD. General practitioners (GPs) and community nurses (CNs) are highly involved in primary and home care and could provide valuable perspectives about barriers to and facilitators for early integrated PHC in end-stage COPD. Three focus groups were organised with GPs (n = 28) and four with CNs (n = 28), transcribed verbatim and comparatively analysed. Barriers were related to the unpredictability of COPD, a lack of disease insight and resistance towards care of the patient, lack of cooperation and experience with PHC for professional caregivers, lack of education about early integrated PHC, insufficient continuity of care from hospital to home, and lack of communication about PHC between professional caregivers and with end-stage COPD patients. Facilitators were the use of trigger moments for early integrating PHC, such as after a hospital admission or when an end-stage COPD patient becomes oxygen-dependent or housebound, positive attitudes towards PHC in informal caregivers, more focus on early integration of PHC in professional caregivers' education, implementing advance care planning in healthcare and PHC systems, and enhancing communication about care and PHC. The results provide insights for clinical practice and the development of key components for successful practice in a phase 0-2 Early Integration of PHC for end-stage COPD (EPIC) trial, such as improving care integration, patients' disease insight and training PHC nurses in care for end-stage COPD.
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Affiliation(s)
- Charlotte Scheerens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium.
- Department of Internal Medicine, Ghent University, Ghent, Belgium.
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
| | - Simon Van Belle
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Guy Joos
- Department of Internal Medicine, Ghent University, Ghent, Belgium
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Peter Pype
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Family Medicine and Primary Health Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel (VUB), Ghent, Belgium
- Department of Internal Medicine, Ghent University, Ghent, Belgium
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