1
|
Minato M, Kosaka S, Higuchi M, Ouchi K. Palliative care screening tools in Japan: cross-sectional utility study. BMJ Support Palliat Care 2024:spcare-2023-004761. [PMID: 38395600 DOI: 10.1136/spcare-2023-004761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/05/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES In Japan's ageing society, the utility of US-based and UK-based palliative care screening tools in the inpatient setting is unknown. The purpose of this study is to identify the unmet palliative care needs of patients who are admitted to an acute care hospital using the US-based and UK-based screening tools. METHODS This single-centre, cross-sectional study included patients who were admitted to an acute care hospital in Tokyo, Japan, from November 2019 to January 2020. We used the Supportive and Palliative Care Indicator Tool and Palliative Care Screening Tool in the Emergency Department among admitted patients. RESULTS 126 patients (51.6%) were screened positive in total. Among these patients, the main comorbid conditions were dementia/frailty (85.7%) and neurological disease (50.8%). CONCLUSIONS One out of every two internal medicine inpatients at acute care hospitals may have palliative care needs. Given the lack of adequate palliative care workforce in Japan, a modified screening tool to capture the most high-risk patients may be necessary.
Collapse
Affiliation(s)
- Mami Minato
- Division of General Medicine, Itabashi Chuo Medical Center, Itabashi-ku, Japan
| | - Shintaro Kosaka
- Division of Internal Medicine, Nerima Hikarigaoka Hospital, Nerima-ku, Tokyo, Japan
| | - Masaya Higuchi
- Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kei Ouchi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Dang J, Yong ACW, Fong ZH, Ang K, Ng ASL. A Systematic Review of Palliative Care Needs in Young-Onset Dementia. J Am Med Dir Assoc 2024; 25:105219. [PMID: 39155044 DOI: 10.1016/j.jamda.2024.105219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND The distinctive differences in clinical needs and disease trajectory between people with young-onset (YOD) and late-onset dementia (LOD) make dementia palliative care unique. Limited studies have reported on the differences in palliative care needs between YOD and LOD, and the optimal time point to introduce palliative care in YOD remains controversial. We performed a systematic review to summarize key issues surrounding palliative care in YOD and highlight unmet needs in this pertinent area. METHODS Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched the PubMed database for all studies published between January 2000 and July 2022 that reported on palliative care in YOD. RESULTS Of 32 records identified, 8 articles were eligible for inclusion. The top 3 themes extracted centered around (1) clinical differences between YOD and LOD, (2) symptoms and causes of death in end-stage YOD, and (3) the importance of early advanced care planning (ACP). YOD diagnosis is often delayed and people with YOD have fewer somatic comorbidities but more neuropsychiatric symptoms, longer survival times, and a more malignant disease course. People with YOD and their families face unique psychosocial challenges when symptoms start at a younger age. End-stage YOD is not dissimilar to LOD where patients suffer from a broad spectrum of physical and psychological symptoms requiring palliation. Early initiation of ACP discussion is crucial in YOD given the more rapid progression of disease affecting cognition and decision-making capacity; however, rates of ACP completion in YOD remain low. CONCLUSIONS Given the complex care needs and more rapid disease trajectory in YOD, palliative care in YOD should be considered from the time of diagnosis, and to be incorporated into routine dementia care.
Collapse
Affiliation(s)
- Jiaojiao Dang
- Department of Neurology, National Neuroscience Institute, Singapore.
| | - Alisa Cui Wen Yong
- Department of Psychology, Faculty of Arts and Social Sciences, National University of Singapore, Singapore
| | - Zhi Hui Fong
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Kexin Ang
- Department of Neurology, National Neuroscience Institute, Singapore
| | - Adeline Su Lyn Ng
- Department of Neurology, National Neuroscience Institute, Singapore; Neuroscience and Behavioural Disorders Unit, Duke-NUS Medical School, Singapore
| |
Collapse
|
3
|
Donath C, Ostgathe C, Heckel M. Dementia patients in palliative care according to data from the German National Hospice and Palliative Care Register (2009-2021). BMC Palliat Care 2024; 23:185. [PMID: 39054518 PMCID: PMC11271063 DOI: 10.1186/s12904-024-01509-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 07/09/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND People with dementia are less in focus of palliative care research than other patient groups even though the awareness of their palliative and end-of-life care needs is rising. Empirical data analyses on people with dementia in palliative care services are lacking. AIM To explore the prevalence of dementia diagnoses as per the ICD criteria among users of various palliative care settings and to compare use of palliative services, care pathways, and outcomes in people with and without a dementia diagnosis. DESIGN We conducted retrospective analysis of dementia diagnoses as per ICD (F00-F03/G30) in the German National Hospice and Palliative Care Register between 2009 and 2021. The analysis used methods of descriptive and inferential statistics, including the Bonferroni correction for alpha error inflation. SETTING/PARTICIPANTS We limited the analysis to the subsample of people aged over 64. RESULTS The prevalence of dementia in the different settings of palliative care was lower than in the age-comparable population: Of the 69,116 data sets included in the analysis, a small minority (3.3%) was coded with dementia as the principal diagnosis. Among patients on inpatient palliative care wards, 0.8% (148 of 19,161) had a dementia diagnosis, as did 2.2% (52 of 2,380) of those under hospital palliative care support teams and 4.3% (2,014 of 46,803) of those receiving specialized palliative care at home. CONCLUSIONS The records of the German National Hospice and Palliative Care Register suggest that the prevalence of dementia is lower than one might expect from general population data, though numbers are in line with international studies on proportion of dementia patients receiving palliative care. Future research could usefully examine whether this discrepancy stems either from omissions in coding dementia as patients' principal diagnosis respectively from lapses in documentation of a dementia diagnosis previously made, or from barriers to accessing palliative care services or even displays being excluded from palliative care when trying to access it. TRIAL REGISTRATION No registration.
Collapse
Affiliation(s)
- Carolin Donath
- Center for Health Services Research in Medicine, Department of Psychiatry and Psychotherapy, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Christoph Ostgathe
- Department of Palliative Medicine & Comprehensive Cancer Center, CCC Erlangen - EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Germany
| | - Maria Heckel
- Department of Palliative Medicine & Comprehensive Cancer Center, CCC Erlangen - EMN, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Krankenhausstraße 12, 91054, Erlangen, Germany.
| |
Collapse
|
4
|
Bonares M, Fisher S, Quinn K, Wentlandt K, Tanuseputro P. Study protocol for the development and validation of a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. Diagn Progn Res 2024; 8:5. [PMID: 38500236 PMCID: PMC10949607 DOI: 10.1186/s41512-024-00168-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/05/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Patients with dementia and their caregivers could benefit from advance care planning though may not be having these discussions in a timely manner or at all. A prognostic tool could serve as a prompt to healthcare providers to initiate advance care planning among patients and their caregivers, which could increase the receipt of care that is concordant with their goals. Existing prognostic tools have limitations. We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. METHODS The derivation cohort will include approximately 235,000 patients with dementia, who were admitted to hospital in Ontario from April 1st, 2009, to December 31st, 2017. Predictor variables will be fully prespecified based on a literature review of etiological studies and existing prognostic tools, and on subject-matter expertise; they will be categorized as follows: sociodemographic factors, comorbidities, previous interventions, functional status, nutritional status, admission information, previous health care utilization. Data-driven selection of predictors will be avoided. Continuous predictors will be modelled as restricted cubic splines. The outcome variable will be mortality within 1 year of admission, which will be modelled as a binary variable, such that a logistic regression model will be estimated. Predictor and outcome variables will be derived from linked population-level healthcare administrative databases. The validation cohort will comprise about 63,000 dementia patients, who were admitted to hospital in Ontario from January 1st, 2018, to March 31st, 2019. Model performance, measured by predictive accuracy, discrimination, and calibration, will be assessed using internal (temporal) validation. Calibration will be evaluated in the total validation cohort and in subgroups of importance to clinicians and policymakers. The final model will be based on the full cohort. DISCUSSION We seek to develop and validate a clinical prediction tool to estimate the risk of 1-year mortality among hospitalized patients with dementia. The model would be integrated into the electronic medical records of hospitals to automatically output 1-year mortality risk upon hospitalization. The tool could serve as a trigger for advance care planning and inform access to specialist palliative care services with prognosis-based eligibility criteria. Before implementation, the tool will require external validation and study of its potential impact on clinical decision-making and patient outcomes. TRIAL REGISTRATION NCT05371782.
Collapse
Affiliation(s)
- Michael Bonares
- Department of Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
- Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Stacey Fisher
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
| | - Kieran Quinn
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Sinai Health System, Toronto, ON, Canada
- ICES Toronto, Toronto, ON, Canada
| | - Kirsten Wentlandt
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- ICES Ottawa, Ottawa, ON, Canada
| |
Collapse
|
5
|
Ribeiro AF, Martins Pereira S, Nunes R, Hernández-Marrero P. What are the triggers for palliative care referral in burn intensive care units? Results from a qualitative study based on healthcare professionals' views, clinical experiences and practices. Palliat Med 2024; 38:297-309. [PMID: 38372020 PMCID: PMC10955784 DOI: 10.1177/02692163241229962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND Burns are a global public health problem, accounting for around 300,000 deaths annually. Burns have significant consequences for patients, families, healthcare teams and systems. Evidence suggests that the integration of palliative care in burn intensive care units improves patients' comfort, decision-making processes and family care. Research is needed on how to optimise palliative care referrals. AIM To identify triggers for palliative care referral in critically burned patients based on professionals' views, experiences and practices. DESIGN Qualitative study using in-depth interviews. SETTING/PARTICIPANTS All five Burn Intensive Care Units reference centres across Portugal were invited; three participated. Inclusion criteria: Professionals with experience/working in these settings. A total of 15 professionals (12 nurses and 3 physicians) participated. Reflexive thematic analysis was performed. RESULTS Three main triggers for palliative care referral were identified: (i) Burn severity and extension, (ii) Co-morbidities and (iii) Multiorgan failure. Other triggers were also generated: (i) Rehabilitative palliative care related to patients' suffering and changes in body image, (ii) Family suffering and/or dysfunctional and complex family processes, (iii) Long stay in the burn intensive care unit and (iv) Uncontrolled pain. CONCLUSIONS This study identifies triggers for palliative care in burn intensive care units based on professionals' views, clinical experiences and practices. The systematisation and use of triggers could help streamline referral pathways and strengthen the integration of palliative care in burn intensive care units. Research is needed on the use of these triggers in clinical practice to enhance decision-making processes, early and high-quality integrated palliative care and proportionate patient and family centred care.
Collapse
Affiliation(s)
- André Filipe Ribeiro
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Centro Hospitalar de Entre o Douro e Vouga, Santa Maria da Feira, Portugal
| | - Sandra Martins Pereira
- Universidade Católica Portuguesa, CEGE: Research Center in Management and Economics – Ethics and Sustainability Research Area, Católica Porto Business School, Porto, Portugal
| | - Rui Nunes
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- International Network UNESCO Chair in Bioethics, Porto, Portugal
| | - Pablo Hernández-Marrero
- Universidade Católica Portuguesa, CEGE: Research Center in Management and Economics – Ethics and Sustainability Research Area, Católica Porto Business School, Porto, Portugal
- Portuguese Nurses Association for Long-Term and Palliative Care (AECCP), Lisbon, Portugal
| |
Collapse
|
6
|
Shalev D, Brenner K, Carlson RL, Chammas D, Levitt S, Noufi PE, Robbins-Welty G, Webb JA. Palliative Care Psychiatry: Building Synergy Across the Spectrum. Curr Psychiatry Rep 2024; 26:60-72. [PMID: 38329570 DOI: 10.1007/s11920-024-01485-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 02/09/2024]
Abstract
PURPOSE OF REVIEW Palliative care (PC) psychiatry is a growing subspecialty focusing on improving the mental health of those with serious medical conditions and their caregivers. This review elucidates the current practice and ongoing evolution of PC psychiatry. RECENT FINDINGS PC psychiatry leverages training and clinical practices from both PC and psychiatry, addressing a wide range of needs, including enhanced psychiatric care for patients with serious medical illness, PC access for patients with medical needs in psychiatric settings, and PC-informed psychiatric approaches for individuals with treatment-refractory serious mental illness. PC psychiatry is practiced by a diverse workforce comprising hospice and palliative medicine-trained psychiatrists, psycho-oncologists, geriatric psychiatrists, other mental health professionals, and non-psychiatrist PC clinicians. As a result, PC psychiatry faces challenges in defining its operational scope. The manuscript outlines the growth, current state, and prospects of PC psychiatry. It examines its roles across various healthcare settings, including medical, integrated care, and psychiatric environments, highlighting the unique challenges and opportunities in each. PC psychiatry is a vibrant and growing subspecialty of psychiatry that must be operationalized to continue its developmental trajectory. There is a need for a distinct professional identity for PC psychiatry, strategies to navigate administrative and regulatory hurdles, and greater support for novel clinical, educational, and research initiatives.
Collapse
Affiliation(s)
- Daniel Shalev
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 East 68thStreet, Box 39, New York, NY, 10065, USA.
| | - Keri Brenner
- Department of Medicine, Stanford University, Palo Alto, CA, USA
| | - Rose L Carlson
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, 525 East 68thStreet, Box 39, New York, NY, 10065, USA
| | - Danielle Chammas
- Department of Medicine, University of California: San Francisco, San Francisco, CA, USA
| | - Sarah Levitt
- Department of Psychiatry, University of Toronto, Toronto, Canada
| | - Paul E Noufi
- Department of Medicine, Georgetown University, Baltimore, MD, USA
| | | | - Jason A Webb
- Department of Medicine, Oregon Health and Sciences University, Portland, OR, USA
| |
Collapse
|
7
|
Triandafilidis Z, Carr S, Davis D, Chiu S, Leigh L, Jeong S, Wong D, Hensby J, Lewis S, Attia J, Goodwin N. What care do people with dementia receive at the end of life? Lessons from a retrospective clinical audit of deaths in hospital and other settings. BMC Geriatr 2024; 24:40. [PMID: 38195437 PMCID: PMC10775581 DOI: 10.1186/s12877-023-04449-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 11/01/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND The need for better end-of-life care for people with dementia has been acknowledged. Existing literature suggests that people dying with dementia have less access to palliative care, yet little is known about the care provided to people with dementia at the end of life. This study aimed to establish evidence related to end-of-life care for people dying with dementia in hospital compared to other settings. METHODS A retrospective clinical audit of people who had a diagnosis of dementia and had accessed services within a local health district, who died between 2015 and 2019, was conducted. A total of 705 people were identified, and a subset of 299 people randomly selected for manual audit. Chi-square p-values were used to compare the place of death, and a t-test or non-parametric test was used to assess the significance of the difference, as appropriate. Measures of functional decline within one month of death were assessed using mixed effects logistic regression models. RESULTS The characteristics of people differed by place of death, with people who died in hospital more likely to be living at home and to not have a spouse. Less than 1 in 5 people had advance care directives or plans. Many were still being actively treated at the time of death: almost half of people who died in hospital had an investigation in their final 72 hours, less than half of people were coded as receiving palliative care at death, and more than 2 in 3 people did not get access to specialist palliative care. Declining function was associated with the terminal phase. CONCLUSION This study provides novel insights for those providing end-of-life care for people with dementia. Healthcare professionals and policy makers should consider how demographic characteristics relate to the places people with dementia receive end-of-life care. The care provided to people with dementia in the last year of their life highlights the need for more support to prepare advance care documentation and timely consideration for palliative care. Changes in markers of nutritional status and function in people with advanced dementia may help with identification of terminal phases.
Collapse
Affiliation(s)
- Zoi Triandafilidis
- Central Coast Research Institute (CCRI) for Integrated Care, Gosford, NSW, Australia.
- The University of Newcastle, Gosford, NSW, Australia.
| | - Sally Carr
- Central Coast Local Health District, Gosford, NSW, Australia
| | - Daneill Davis
- Central Coast Local Health District, Gosford, NSW, Australia
| | - Simon Chiu
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Lucy Leigh
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Sarah Jeong
- Central Coast Local Health District, Gosford, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Daniel Wong
- The University of Newcastle, Gosford, NSW, Australia
- Central Coast Local Health District, Gosford, NSW, Australia
| | - Jacinta Hensby
- Central Coast Local Health District, Gosford, NSW, Australia
| | - Suzanne Lewis
- Central Coast Research Institute (CCRI) for Integrated Care, Gosford, NSW, Australia
- The University of Newcastle, Gosford, NSW, Australia
| | - John Attia
- The University of Newcastle, Gosford, NSW, Australia
- Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Nicholas Goodwin
- Central Coast Research Institute (CCRI) for Integrated Care, Gosford, NSW, Australia
- The University of Newcastle, Gosford, NSW, Australia
- Central Coast Local Health District, Gosford, NSW, Australia
| |
Collapse
|
8
|
Collins A, Hui D, Davison SN, Ducharlet K, Murtagh F, Chang YK, Philip J. Referral Criteria to Specialist Palliative Care for People with Advanced Chronic Kidney Disease: A Systematic Review. J Pain Symptom Manage 2023; 66:541-550.e1. [PMID: 37507095 DOI: 10.1016/j.jpainsymman.2023.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 07/30/2023]
Abstract
CONTEXT People with advanced chronic kidney disease (CKD) have significant morbidity, yet for many, access to palliative care occurs late, if at all. OBJECTIVES This study sought to examine criteria for referral to specialist palliative care for adults with advanced CKD with a view to improving use of these essential services. METHODS Systematic review of studies detailing referral criteria to palliative care in advanced CKD conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA) guideline and registered (PROSPERO: CRD42021230751). DATA SOURCES Electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed) were used to identify potential studies, which were subjected to double review, data extraction, thematic coding, and descriptive analyses. RESULTS Searches yielded 650 unique titles ultimately resulting in 56 studies addressing referral criteria to specialist palliative care in advanced CKD. Of 10 categories of referral criteria, most commonly discussed were: Critical times of treatment decision making (n = 23, 41%); physical or emotional symptoms (n = 22, 39%); limited prognosis (n = 18, 32%); patient age and comorbidities (n = 18, 32%); category of CKD/ biochemical criteria (n = 13, 23%); functional decline (n = 13, 23); psychosocial needs (n = 9, 16%); future care planning (n = 9, 16%); anticipated decline in illness course (n = 8, 14%); and hospital use (n = 8, 14%). CONCLUSION Clinicians consider referral to specialist palliative care for a wide range of reasons, with many related to care needs. As palliative care continues to integrate with nephrology, our findings represent a key step towards developing consensus criteria to standardize referral for patients with chronic kidney diseases.
Collapse
Affiliation(s)
- Anna Collins
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia
| | - David Hui
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sara N Davison
- Division of Nephrology & Immunology (S.N.D.), Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Kathryn Ducharlet
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Department of Nephrology (K.D.), St Vincent's Hospital, Melbourne, Australia; Eastern Health Clinical School (K.D.), Monash University, Melbourne, Australia; Eastern Health Integrated Renal Services (K.D.), Melbourne, Australia
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre (F.M.), Hull York Medical School, University of Hull, UK
| | - Yuchieh Kathryn Chang
- Department of Palliative Care (D.H., Y.K.C.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Philip
- Department of Medicine (A.C., K.D., J.P.), St Vincent's Hospital, University of Melbourne, Australia; Palliative Care Service (J.P.), Royal Melbourne Hospital, Parkville, Australia; Palliative Care Service (J.P.), Peter MacCallum Cancer Centre, Melbourne, Australia.
| |
Collapse
|
9
|
Blum M, Zeng L, Chai E, Morrison RS, Gelfman LP. Using Functional Status at the Time of Palliative Care Consult to Identify Opportunities for Earlier Referral. J Palliat Med 2023; 26:1398-1400. [PMID: 37440176 PMCID: PMC10541928 DOI: 10.1089/jpm.2023.0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2023] [Indexed: 07/14/2023] Open
Abstract
Background: In order to improve early access to palliative care, strategies for monitoring referral practices in real-time are needed. Objective: To evaluate how Australia-Modified Karnofsky Performance Status (AKPS) at the time of initial palliative care consult differs between serious illnesses and could be used to identify opportunities for earlier referral. Methods: We retrospectively evaluated data from an inpatient palliative care consult registry. Serious illnesses were classified using ICD-10 codes. AKPS was assessed by palliative care clinicians during consult. Results: The AKPS distribution varied substantially between the different serious illnesses (p < 0.001). While patients with cancer and heart disease often had preserved functional status, the majority of patients with dementia, neurological, lung, liver, and renal disease were already completely bedbound at the time of initial palliative care consult. Conclusion: Measuring functional status at the time of palliative care referral could be helpful for monitoring referral practices and identifying opportunities for earlier referral.
Collapse
Affiliation(s)
- Moritz Blum
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Li Zeng
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emily Chai
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - R. Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC), Bronx, New York, USA
| | - Laura P. Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC), Bronx, New York, USA
| |
Collapse
|
10
|
Grądalski T, Kochan K. Quality of referrals to specialist palliative care and remote patient triage - a cross-sectional study. Support Care Cancer 2023; 31:551. [PMID: 37658942 PMCID: PMC10474992 DOI: 10.1007/s00520-023-08025-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 08/27/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE Choosing the optimal moment for admission to palliative care remains a serious challenge, as it requires a systematic identification of persons with supportive care needs. Despite the screening tools available for referring physicians, revealing the essential information for preliminary admission triage is crucial for an undisturbed qualification process. The study was aimed at analysing the eligibility criteria for specialist palliative care disclosed within provided referrals, expanded when necessary by documentation and/or interview. METHODS Referral forms with the documentation of 300 patients consecutively referred to the non-profit in-patient ward and home-care team in Poland were analysed in light of prognosis, phase of the disease and supportive needs. RESULTS Half of the referrals had the sufficient information to make a justified preliminary qualification based solely on the delivered documentation. The majority lacked performance status or expected prognosis. Where some information was revealed, two-thirds were in a progressing phase of the disease, with a within-weeks life prognosis. In 53.7%, no particular reason for admission was given. Social problems were signalled as the only reason for the admission in 7.7%. Twenty-eight percent were labelled as "urgent"; however, 52.4% of them were triaged as "stable" or disqualified. Patients referred to a hospice ward received complete referral forms more often, containing all necessary information. CONCLUSIONS General physicians need practical tips to facilitate timely referrals and unburden the overloaded specialist palliative care. Dedicated referral forms extended by a checklist of typical patients' concerns should be disseminated for better use of these resources.
Collapse
Affiliation(s)
- Tomasz Grądalski
- Chair of Palliative Medicine, Andrzej Frycz Modrzewski Krakow University, Kraków, Poland.
- St. Lazarus Hospice, Fatimska 17, 31-831, Kraków, Poland.
| | | |
Collapse
|
11
|
Roach P, Lovell MR, Macfarlane S. Dying with behavioral and psychological symptoms of dementia in Australian nursing homes: a retrospective case-control study. Front Psychiatry 2023; 14:1091771. [PMID: 37255681 PMCID: PMC10225542 DOI: 10.3389/fpsyt.2023.1091771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 04/27/2023] [Indexed: 06/01/2023] Open
Abstract
Objectives To identify predictors of mortality in people with active and challenging behavioral and psychological symptoms of dementia (BPSD). Design A retrospective case-control study was designed to compare those referred to Dementia Support Australia (DSA) who died in the 12 months to November 2016, with an equal number of controls who did not die. An audit tool was designed after literature review and expert opinion from the service. Odds ratio calculations and the Mann-Whitney U test were used to assess for difference. Setting Residents of Australian residential aged care facilities with BPSD referred to the DSA service. Participants Of 476 patients referred to DSA during the study period, 44 died. 44 controls were randomly selected from those remaining matched for age and sex. Results Significant differences included higher rates of benzodiazepine use, drowsiness, delirium, reduced oral intake and discussions about goals of care in those who died. Those who died were referred to the service for a shorter period and had more frequent contact between DSA and nurses at the nursing homes. Increase in opioid use and loss of skin integrity in those who died approached significance. The overall end of life course demonstrated a complex set of needs with frequent delirium, pain and frailty. Conclusion Further study is required to determine the optimal care for those with BPSD at the end of their lives. This study would indicate complex end of life care needs and point to a role for palliative care support.
Collapse
Affiliation(s)
- Peter Roach
- Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
- Mona Vale Hospital, Northern Sydney Local Health District, Mona Vale, NSW, Australia
| | - Melanie R. Lovell
- Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
- Northern Clinical School, Sydney Medical School, University of Sydney, St Leonards, NSW, Australia
| | - Stephen Macfarlane
- The Dementia Centre, HammondCare, St Leonards, NSW, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| |
Collapse
|
12
|
Kawashima A, Evans CJ. Needs-based triggers for timely referral to palliative care for older adults severely affected by noncancer conditions: a systematic review and narrative synthesis. BMC Palliat Care 2023; 22:20. [PMID: 36890522 PMCID: PMC9996955 DOI: 10.1186/s12904-023-01131-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 02/01/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Older people with noncancer conditions are less likely to be referred to palliative care services due to the inherent uncertain disease trajectory and a lack of standardised referral criteria. For older adults with noncancer conditions where prognostic estimation is unpredictable, needs-based criteria are likely more suitable. Eligibility criteria for participation in clinical trials on palliative care could inform a needs-based criteria. This review aimed to identify and synthesise eligibility criteria for trials in palliative care to construct a needs-based set of triggers for timely referral to palliative care for older adults severely affected by noncancer conditions. METHODS A systematic narrative review of published trials of palliative care service level interventions for older adults with noncancer conditions. Electronic databases Medline, Embase, CINAHL, PsycINFO, CENTRAL, and ClinicalTrials.gov. were searched from inception to June 2022. We included all types of randomised controlled trials. We selected trials that reported eligibility criteria for palliative care involvement for older adults with noncancer conditions, where > 50% of the population was aged ≥ 65 years. The methodological quality of the included studies was assessed using a revised Cochrane risk-of-bias tool for randomized trials. Descriptive analysis and narrative synthesis provided descriptions of the patterns and appraised the applicability of included trial eligibility criteria to identify patients likely to benefit from receiving palliative care. RESULTS 27 randomised controlled trials met eligibility out of 9,584 papers. We identified six major domains of trial eligibility criteria in three categories, needs-based, time-based and medical history-based criteria. Needs-based criteria were composed of symptoms, functional status, and quality of life criteria. The major trial eligibility criteria were diagnostic criteria (n = 26, 96%), followed by medical history-based criteria (n = 15, 56%), and physical and psychological symptom criteria (n = 14, 52%). CONCLUSION For older adults severely affected by noncancer conditions, decisions about providing palliative care should be based on the present needs related to symptoms, functional status, and quality of life. Further research is needed to examine how the needs-based triggers can be operationalized as referral criteria in clinical settings and develop international consensus on referral criteria for older adults with noncancer conditions.
Collapse
Affiliation(s)
- Arisa Kawashima
- Department of Nursing for Advanced Practice, Division of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan.,King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, London, UK. .,Sussex Community NHS Foundation Trust, Brighton, UK.
| |
Collapse
|
13
|
Brennan F, Chapman M, Gardiner MD, Narasimhan M, Cohen J. Our dementia challenge: arise palliative care. Intern Med J 2023; 53:186-193. [PMID: 36822608 DOI: 10.1111/imj.16011] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 12/13/2022] [Indexed: 02/25/2023]
Abstract
While many of the maladies of the 20th century are steadily coming under control, the march of neurodegenerative disorders continues largely unchecked. Dementias are an exemplar of such disorders; their incidence and prevalence continue to rise, in large part due to a steadily ageing population worldwide. They represent a group of chronic, progressive and, ultimately, fatal neurodegenerative diseases. Dementia has remained therapeutically recalcitrant. It is not a single disease, and because of that, we cannot expect a single panacea. While primary prevention rightly gains prominence, those with established disease currently require a shift in focus from curative intent towards improved quality of life. Enter palliative care. The sheer number and complexity of needs of patients with dementia, from the physical to the psychosocial and spiritual, necessitates the engagement of a wide range of medical disciplines, nursing and allied health professionals. One of those disciplines, as highlighted in the recent Australian Royal Commission into Aged Care Quality and Safety, is palliative care. This paper shall expand upon that role in the overall context of care for those with dementia.
Collapse
Affiliation(s)
- Frank Brennan
- Department of Palliative Care, Calvary Hospital, Kogarah, New South Wales, Australia.,Department of Palliative Care, The St George Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of NSW Sydney, Sydney, New South Wales, Australia
| | - Michael Chapman
- Department of Palliative Care, Canberra Hospital, ACT, Canberra, Australian Capital Territory, Australia.,Medical School, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Matthew D Gardiner
- Department of Palliative Care, Calvary Hospital, Kogarah, New South Wales, Australia.,Faculty of Medicine, The University of NSW Sydney, Sydney, New South Wales, Australia
| | - Manisha Narasimhan
- Department of Neurology, The Sutherland Hospital, Sydney, New South Wales, Australia.,Brain and Mind Centre, University of Sydney, Sydney, New South Wales, Australia
| | - Joshua Cohen
- Department of Palliative Care, Calvary Hospital, Kogarah, New South Wales, Australia
| |
Collapse
|
14
|
Sullivan SS, Bo W, Li CS, Xu W, Chang YP. Predicting Hospice Transitions in Dementia Caregiving Dyads: An Exploratory Machine Learning Approach. Innov Aging 2022; 6:igac051. [PMID: 36452051 PMCID: PMC9701063 DOI: 10.1093/geroni/igac051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Indexed: 10/19/2023] Open
Abstract
Background and Objectives Hospice programs assist people with serious illness and their caregivers with aging in place, avoiding unnecessary hospitalizations, and remaining at home through the end-of-life. While evidence is emerging of the myriad of factors influencing end-of-life care transitions among persons living with dementia, current research is primarily cross- sectional and does not account for the effect that changes over time have on hospice care uptake, access, and equity within dyads. Research Design and Methods Secondary data analysis linking the National Health and Aging Trends Study to the National Study of Caregiving investigating important social determinants of health and quality-of-life factors of persons living with dementia and their primary caregivers (n = 117) on hospice utilization over 3 years (2015-2018). We employ cutting-edge machine learning approaches (correlation matrix analysis, principal component analysis, random forest [RF], and information gain ratio [IGR]). Results IGR indicators of hospice use include persons living with dementia having diabetes, a regular physician, a good memory rating, not relying on food stamps, not having chewing or swallowing problems, and whether health prevents them from enjoying life (accuracy = 0.685; sensitivity = 0.824; specificity = 0.537; area under the curve (AUC) = 0.743). RF indicates primary caregivers' age, and the person living with dementia's income, census division, number of days help provided by caregiver per month, and whether health prevents them from enjoying life predicts hospice use (accuracy = 0.624; sensitivity = 0.713; specificity = 0.557; AUC = 0.703). Discussion and Implications Our exploratory models create a starting point for the future development of precision health approaches that may be integrated into learning health systems that prompt providers with actionable information about who may benefit from discussions around serious illness goals-for-care. Future work is necessary to investigate those not considered in this study-that is, persons living with dementia who do not use hospice care so additional insights can be gathered around barriers to care.
Collapse
Affiliation(s)
| | - Wei Bo
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Chin-Shang Li
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Wenyao Xu
- Department of Computer Science Engineering, University at Buffalo, Buffalo, New York, USA
| | - Yu-Ping Chang
- School of Nursing, University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
15
|
Nishimura M, Dening KH, Sampson EL, de Oliveira Vidal EI, de Abreu WC, Kaasalainen S, Eisenmann Y, Dempsey L, Moore KJ, Davies N, Bolt SR, Meijers JMM, Dekker NL, Miyashita M, Nakanishi M, Nakayama T, van der Steen JT. Cross-cultural conceptualization of a good end of life with dementia: a qualitative study. Palliat Care 2022; 21:106. [PMID: 35676673 PMCID: PMC9175529 DOI: 10.1186/s12904-022-00982-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 05/19/2022] [Indexed: 09/25/2023] Open
Abstract
Background Research on the nature of a “good death” has mostly focused on dying with cancer and other life-limiting diseases, but less so on dementia. Conceptualizing common cross-cultural themes regarding a good end of life in dementia will enable developing international care models. Methods We combined published qualitative studies about end of life with dementia, focus group and individual interviews with the researchers, and video-conferencing and continuous email discussions. The interviews were audio-recorded and transcribed verbatim. The data were analyzed thematically, and the researchers developed common themes referring to their original studies. Results Fourteen qualitative researchers representing 14 cross-cultural studies covering qualitative data of 121 people with dementia and 292 family caregivers. The researchers and data were from eight countries UK, The Netherlands, Japan, Portugal, Germany, Canada, Brazil, and Ireland. Three focus groups, five individual interviews, and video-conferencing were conducted and feedback on multiple iterations was gained by 190 emails between May 2019 and April 2020 until consensus was achieved. Nine cross-culturally common themes emerged from the discussions and shared interpretation of the data of persons with dementia and family caregivers. Three represent basic needs: “Pain and Symptoms Controlled,” “Being Provided Basic Care,” and “A Place like Home.” Other themes were “Having Preferences Met,” “Receiving Respect as a Person,” “Care for Caregivers,” “Identity Being Preserved,” “Being Connected,” and “Satisfaction with Life and Spiritual Well-being.” “Care for Caregivers” showed the greatest difference in emphasis across cultures. Good relationships were essential in all themes. Conclusions The common cross-cultural themes comprise a framework underpinned by value placed on personhood and dignity, emphasizing that interdependency through relationships is essential to promote a good end of life with dementia. These themes and valuing the importance of relationships as central to connecting the themes could support care planning and further development of a dementia palliative care model. Trial registration The Graduate School and Faculty of Medicine Kyoto University (R1924–1). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-022-00982-9.
Collapse
Affiliation(s)
- Mayumi Nishimura
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Sakyo-ku, Yoshida Konoe-cho, Kyoto, 606-8501, Japan.
| | | | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK
| | - Edison Iglesias de Oliveira Vidal
- Botucatu Medical School, Sao Paulo State University (UNESP), Av. Prof. Mario Rubens Guimaraes Montenegro, Botucatu, SP, 18618-687, Brazil
| | - Wilson Correia de Abreu
- Center for Health Technology and Services Research, University of Porto (ESEP/CINTESIS), R. Dr. Plácido da Costa, 4200-450, Porto, Portugal
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4K1, Canada
| | - Yvonne Eisenmann
- Department of Palliative Medicine, University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Laura Dempsey
- Department of Nursing and Healthcare, Technological University of the Shannon: Midlands Midwest, Dublin Road, Athlone, Co Westmeath, N37 HD68, Ireland
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK.,National Ageing Research Institute Inc., Royal Melbourne Hospital, Royal Park Campus, Gate 4, Building 8, 34-54 Poplar Rd, Parkville, VIC, 3052, Australia
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, University College London, Gower Street, London, WC1E 6BT, UK.,Research Department of Primary Care and Population Health, University College London, Gower Street, London, WC1E 6BT, UK
| | - Sascha R Bolt
- Department of Health Services Research, Care and Public Health Research Institute, Living Lab in Ageing and Long-Term Care, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands
| | - Judith M M Meijers
- Department of Health Services Research, Care and Public Health Research Institute, Living Lab in Ageing and Long-Term Care, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200, MD, Maastricht, The Netherlands.,Zuyderland Care, Zuyderland Medical Center, Dr. H. van der Hoffplein 1, 6162, BG, Sittard-Geleen, The Netherlands
| | - Natashe Lemos Dekker
- Institute of Cultural Anthropology and Development Sociology, Leiden University, Pieter de la Court Wassenaarseweg 52, 2333, AK, Leiden, The Netherlands
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miharu Nakanishi
- Department of Psychiatric Nursing, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Takeo Nakayama
- Department of Health Informatics, School of Public Health, Graduate School of Medicine, Kyoto University, Sakyo-ku, Yoshida Konoe-cho, Kyoto, 606-8501, Japan
| | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Hippocratespad 21, 2333, ZD, Leiden, The Netherlands.,Department of Primary and Community Care, Radboud University Medical Center, Nijmegen, the Netherlands
| |
Collapse
|
16
|
Tan LF, Ho Wei Fen S. Comment on: Referral criteria to specialist palliative care for patients with dementia: A systematic review. J Am Geriatr Soc 2021; 69:2037-2038. [PMID: 33939834 DOI: 10.1111/jgs.17197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/06/2023]
Affiliation(s)
- Li Feng Tan
- Division of Healthy Ageing, Alexandra Hospital, Singapore
| | - Sara Ho Wei Fen
- Department of Medicine, National University Hospital, Singapore
| |
Collapse
|
17
|
Mo L, Hui D. Reply to comment on: Referral criteria to specialist palliative care for patients with dementia-A systematic review. J Am Geriatr Soc 2021; 69:2038-2039. [PMID: 33939835 DOI: 10.1111/jgs.17199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 04/03/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Li Mo
- The Center of Gerontology and Geriatrics, National Clinical Research Center of Geriatrics, Sichuan University West China Hospital, Chengdu, China.,Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| |
Collapse
|
18
|
Blackstone KA, Cobbs EL. Palliative care for persons with dementia. J Am Geriatr Soc 2021; 69:1461-1462. [PMID: 33894063 DOI: 10.1111/jgs.17166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 03/08/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Karen A Blackstone
- Department of Geriatrics, Extended Care and Palliative Care, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, USA.,Department of Medicine, George Washington University, Washington, District of Columbia, USA
| | - Elizabeth L Cobbs
- Department of Geriatrics, Extended Care and Palliative Care, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia, USA.,Department of Medicine, George Washington University, Washington, District of Columbia, USA
| |
Collapse
|