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Mallon T, Schulze J, Dams J, Weber J, Asendorf T, Böttcher S, Sekanina U, Schade F, Schneider N, Freitag M, Müller C, König HH, Nauck F, Friede T, Scherer M, Marx G. Evaluating palliative care case conferences in primary care for patients with advanced non-malignant chronic conditions: a cluster-randomised controlled trial (KOPAL). Age Ageing 2024; 53:afae100. [PMID: 38783755 PMCID: PMC11116821 DOI: 10.1093/ageing/afae100] [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: 12/18/2023] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs. OBJECTIVE To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC. METHODS A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale. RESULTS A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51). CONCLUSIONS The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.
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Affiliation(s)
- Tina Mallon
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Josefine Schulze
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Judith Dams
- Department of Health Economics and Health Care Research, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Jan Weber
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Centre Göttingen, Humboldtallee 32, 37073 Göttingen, Germany
| | - Silke Böttcher
- Division of General Practice, Carl von Ossietzky University of Oldenburg, Ammerlaender Heerstraße 114-118, 26129 Oldenburg, Germany
| | - Uta Sekanina
- Department of General Practice, University Medical Centre Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| | - Franziska Schade
- Department of Palliative Medicine, University Medical Centre Göttingen, Von-Siebold-Str. 3, 37075 Göttingen and Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Nils Schneider
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Michael Freitag
- Division of General Practice, Carl von Ossietzky University of Oldenburg, Ammerlaender Heerstraße 114-118, 26129 Oldenburg, Germany
| | - Christiane Müller
- Department of General Practice, University Medical Centre Göttingen, Humboldtallee 38, 37073 Göttingen, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Care Research, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Centre Göttingen, Von-Siebold-Str. 3, 37075 Göttingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Centre Göttingen, Humboldtallee 32, 37073 Göttingen, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Gabriella Marx
- Department of General Practice and Primary Care, University Medical Centre Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
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van Baal K, Hemmerling M, Stahmeyer JT, Stiel S, Afshar K. End-of-life care in Germany between 2016 and 2020 - A repeated cross-sectional analysis of statutory health insurance data. BMC Palliat Care 2024; 23:105. [PMID: 38643167 PMCID: PMC11031961 DOI: 10.1186/s12904-024-01387-6] [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: 03/21/2023] [Accepted: 02/15/2024] [Indexed: 04/22/2024] Open
Abstract
BACKGROUND The Hospice and Palliative Care Act of 2015 aimed at developing and regulating the provision of palliative care (PC) services in Germany. As a result of the legal changes, people with incurable diseases should be enabled to experience their final stage of life including death according to their own wishes. However, it remains unknown whether the act has impacted end-of-life care (EoLC) in Germany. OBJECTIVE The present study examined trends in EoLC indicators for patients who died between 2016 and 2020, in the context of Lower Saxony, Germany. METHODS Repeated cross-sectional analysis was conducted on data from the statutory health insurance fund AOK Lower Saxony (AOK-LS), referring to the years 2016-2020. EoLC indicators were: (1) the number of patients receiving any form of outpatient PC, (2) the number of patients receiving generalist outpatient PC and (3) specialist outpatient PC in the last year of life, (4) the onset of generalist outpatient PC and (5) the onset of specialist outpatient PC before death, (6) the number of hospitalisations in the 6 months prior to death and (7) the number of days spent in hospital in the 6 months prior to death. Data for each year were analysed descriptively and a comparison between 2016 and 2020 was carried out using t-tests and chi-square tests. RESULTS Data from 160,927 deceased AOK-LS members were analysed. The number of patients receiving outpatient PC remained almost consistent over time (2016 vs. 2020 p = .077). The number of patients receiving generalist outpatient PC decreased from 28.4% (2016) to 24.5% (2020; p < .001), whereas the number of patients receiving specialist outpatient PC increased from 8.5% (2016) to 11.2% (2020; p < .001). The onset of generalist outpatient PC moved from 106 (2016) to 93 days (2020; p < .001) before death, on average. The onset of specialist outpatient PC showed the reverse pattern (2016: 55 days before death; 2020: 59 days before death; p = .041). CONCLUSION Despite growing needs for PC at the end of life, the number of patients receiving outpatient PC did not increase between 2016 and 2020. Furthermore, specialist outpatient PC is being increasingly prescribed over generalist outpatient PC. Although the early initiation of outpatient PC has been proven valuable for the majority of people at the end of life, generalist outpatient PC was not initiated earlier in the disease trajectory over the study period, as was found to be true for specialist outpatient PC. Future studies should seek to determine how existing PC needs can be optimally met within the outpatient sector and identify factors that can support the earlier initiation of especially generalist outpatient PC. TRIAL REGISTRATION The study "Optimal Care at the End of Life" was registered in the German Clinical Trials Register (DRKS00015108; 22 January 2019).
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Affiliation(s)
- Katharina van Baal
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Melissa Hemmerling
- AOK Lower Saxony, Department for Health Services Research, Hildesheimer Str. 273, 30519, Hannover, Germany
| | - Jona Theodor Stahmeyer
- AOK Lower Saxony, Department for Health Services Research, Hildesheimer Str. 273, 30519, Hannover, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Kambiz Afshar
- Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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3
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Colquhoun-Flannery E, Goodwin D, Walshe C. How clinicians recognise people who are dying: An integrative review. Int J Nurs Stud 2024; 151:104666. [PMID: 38134558 DOI: 10.1016/j.ijnurstu.2023.104666] [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: 07/01/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Timely recognition of dying is important for high quality end-of-life care however, little is known about how clinicians recognise dying. Late recognition is common and can lead to futile treatment that can prolong or increase suffering and prevent a change in the focus of care. AIM To explore how clinicians caring for dying people recognise that they are in the last days or hours of life, as well as the factors that influence the recognition of dying. DESIGN A systematically constructed integrative review of the literature. METHODS Medline, Scopus, Cumulative Index to Nursing and Allied Health Literature, PsycInfo and Allied and Complementary Medicine were searched in July 2022. Papers were included if they were original research, discussed how clinicians recognise dying, available in English language and published in 2012 or later. A constant comparison approach was applied to the analysis and synthesis of the literature. RESULTS 24 papers met the inclusion criteria. There were 3 main categories identified: 'Clues and signals' refers to prompts and signs that lead a clinician to believe a person is dying, incorporating the sub-categories 'knowing the patient over time', and 'intuition and experience'. 'Recognition by others' is where clinicians come to recognise someone is dying through others. This can be through a change in the context of care such as a tool or care plan or by communication with the team. 'Culture, system and practice' refers to the cultural beliefs of a setting that influences awareness of dying and denial of death as a possibility and avoidance of naming death and dying directly. System and practice of the setting also impact on recognition of dying. This involves work pace and intensity, shift systems and timing of senior reviews of patients. Uncertainty and its impact on recognition of dying are evident throughout the findings of this review. The seeking of certainty and the absence of the possibility of dying contributes to late recognition of dying. DISCUSSION Recognition of dying is a complex process that occurs over time, involving a combination of intuition and gathering of information, that is influenced by contextual factors. A culture where dying is not openly acknowledged or even named explicitly contributes to late recognition of dying. A shared language and consistent terminology for explicitly naming dying are needed. Uncertainty is intrinsic to the recognition of dying and therefore a shift to recognising the possibility of dying rather than seeking certainty is needed. REGISTRATION (PROSPERO) CRD42022360900. Registered September 2022.
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Affiliation(s)
- Elizabeth Colquhoun-Flannery
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK.
| | - Dawn Goodwin
- Lancaster Medical School, Lancaster University, Lancaster, UK.
| | - Catherine Walshe
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK.
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4
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Bowers SP, Black P, McCheyne L, Wilson D, Mills SEE, Agrawal U, Williams L, Quirk F, Bowden J. Current definitions of advanced multimorbidity: a protocol for a scoping review. BMJ Open 2023; 13:e076903. [PMID: 38035744 PMCID: PMC10689385 DOI: 10.1136/bmjopen-2023-076903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 10/25/2023] [Indexed: 12/02/2023] Open
Abstract
INTRODUCTION People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice. METHODS AND ANALYSIS Scoping review methodology, based on Arksey and O'Malley's framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of 'multimorbidity', 'end of life' and 'palliative care'. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions. ETHICS AND DISSEMINATION Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB's PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination.
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Affiliation(s)
- Sarah P Bowers
- University of St Andrews School of Medicine, St Andrews, UK
| | - Polly Black
- University of St Andrews School of Medicine, St Andrews, UK
| | | | | | - Sarah E E Mills
- University of St Andrews School of Medicine, St Andrews, UK
- NHS Fife, Kirkcaldy, UK
| | - Utkarsh Agrawal
- University of Oxford Nuffield Department of Primary Care Health Sciences, Oxford, UK
| | | | - Frances Quirk
- University of St Andrews School of Medicine, St Andrews, UK
- NHS Fife, Kirkcaldy, UK
| | - Jo Bowden
- University of St Andrews School of Medicine, St Andrews, UK
- NHS Fife, Kirkcaldy, UK
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5
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Felber SJ, Guffi T, Brem BG, Schmitz FM, Schnabel KP, Guttormsen Schär S, Eychmüller S, Zambrano SC. Talking about dying and death: Essentials of communicating about approaching death from the perspective of major stakeholders. Palliat Support Care 2023:1-10. [PMID: 37927127 DOI: 10.1017/s1478951523001621] [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: 11/07/2023]
Abstract
OBJECTIVES Although caring for dying patients and their family caregivers (FC) is integral to patient care, training in communication about approaching death is almost inexistent in medical and nursing curricula. Consequently, many health professionals have insufficient knowledge about conducting these conversations. In order to gain a broader insight into essential aspects of this communication from different perspectives, we conducted focus groups with key stakeholders. METHODS Medical specialists, nurses, medical students, bereaved FC and patient representatives participated in five focus groups (n = 30). Following a focus group schedule, we elicited relevant aspects of communication about approaching death, associated emotions, and appropriate communication frameworks. We analyzed data thematically. RESULTS Four main themes were central to conversations about approaching death: (1) embracing care within medical expertise, (2) preparing the conversation while remaining open to the unexpected, (3) recognizing and reflecting on own emotions and reactions, and (4) establishing a meaningful connection with others. SIGNIFICANCE OF RESULTS Communicating about approaching death with dying patients and their FC can be complex and challenging at a professional and personal level. With the recognition of the dying phase, a process is initiated for which health professionals need solid clinical knowledge about but also effective communication skills, constant self-reflection and self-care strategies. Comprehensive training and supervision while dealing with the challenges of communicating approaching death to dying patients and their FC are key, particularly for trainees, less experienced physicians and nurses. The essential components identified in this study can help health professionals to master these conversations.
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Affiliation(s)
- Sibylle J Felber
- University Centre for Palliative Care, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Tommaso Guffi
- University Centre for Palliative Care, Inselspital, University Hospital Bern, Bern, Switzerland
- Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland
| | - Beate G Brem
- Institute for Medical Education (IML), University of Bern, Bern, Switzerland
| | - Felix M Schmitz
- Institute for Medical Education (IML), University of Bern, Bern, Switzerland
| | - Kai P Schnabel
- Institute for Medical Education (IML), University of Bern, Bern, Switzerland
| | | | - Steffen Eychmüller
- University Centre for Palliative Care, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Sofia C Zambrano
- Institute for Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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6
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Erard M. Beyond Last Words: Patterns of Linguistic and Interactional Behavior in a Historical Sample of Dying Hospital Patients. OMEGA-JOURNAL OF DEATH AND DYING 2023; 86:1089-1107. [PMID: 33722079 PMCID: PMC9810827 DOI: 10.1177/00302228211000938] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patterns of linguistic and interactional behavior by people at the very end of their lives are not well described, partly because data is difficult to obtain. This paper analyzes descriptions of 486 deaths gathered from 1900 to 1904 in the first-ever clinical study of dying by noted Canadian physician, Sir William Osler. Only 16 patients were noted speaking, and only four canonical last words were reported. The most frequent observation by medical staff was that the deaths were quiet (n = 30), though range of other behaviors were noted (e.g., moaning, delirium, seeming intention to speak). Osler's problematic study left behind data whose analysis is a small step toward empirically characterizing the linguistic and interactional details of a previously under-described phenomena as well as the importance of the social context in which they occur.
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Affiliation(s)
- Michael Erard
- Institute of Data Science,
Maastricht University, Maastricht, the Netherlands,Michael Erard, Institute of Data Science,
Maastricht University, Paul Henri Spaklaan 1, 6229 GT Maastricht, the
Netherlands.
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7
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Afshar K, van Baal K, Wiese B, Schleef T, Stiel S, Müller-Mundt G, Schneider N. Structured implementation of the Supportive and Palliative Care Indicators Tool in general practice - A prospective interventional study with follow-up. Palliat Care 2022; 21:214. [PMID: 36451172 PMCID: PMC9714240 DOI: 10.1186/s12904-022-01107-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 11/15/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND General practitioners (GPs) play a key role in the provision of primary palliative care (PC). The identification of patients who might benefit from PC and the timely initiation of patient-centred PC measures at the end of life are essential, yet challenging. Although different tools exist to support these key tasks, a structured approach is often missing. OBJECTIVE The study aimed at implementing the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE™) in general practices, following a structured and regional approach, in order to evaluate the effects of this tool on the identification of patients with potential PC needs and the initiation of patient-centred PC measures. METHODS The intervention of this mixed-methods study comprised a standardised training of 52 GPs from 34 general practices in two counties in Lower Saxony, Germany, on the use of the SPICT-DE™. The SPICT-DE™ is a clinical tool which supports the identification of patients with potential PC needs. Subsequently, over a period of 12 months, GPs applied the SPICT-DE™ in daily practice with adult patients with chronic, progressive diseases, and completed a follow-up survey 6 months after the initial patient assessment. The outcome parameters were alterations in the patient's clinical situation, and the type and number of initiated patient-centred PC measures during the follow-up interval. Additionally, 12 months after the standardised training, GPs provided feedback on their application of the SPICT-DE™. RESULTS A total of 43 GPs (n = 15 female, median age 53 years) out of an initial sample of 52 trained GPs assessed 580 patients (n = 345 female, median age 84 years) with mainly cardiovascular (47%) and cancer (33%) diseases. Follow-up of 412 patients revealed that 231 (56%) experienced at least one critical incident in their disease progression (e.g. acute crisis), 151 (37%) had at least one hospital admission, and 141 (34%) died. A review of current treatment/medication (76%) and a clarification of treatment goals (53%) were the most frequently initiated patient-centred PC measures. The majority of GPs deemed the SPICT-DE™ practical (85%) and stated an intention to continue applying the tool in daily practice (66%). CONCLUSIONS The SPICT-DE™ is a practical tool that supports the identification of patients at risk of deterioration or dying and promotes the initiation of patient-centred PC measures. TRIAL REGISTRATION The study was registered in the German Clinical Trials Register (N° DRKS00015108; 22/01/2019).
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Affiliation(s)
- Kambiz Afshar
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Katharina van Baal
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Birgitt Wiese
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Tanja Schleef
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Stephanie Stiel
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Gabriele Müller-Mundt
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Nils Schneider
- grid.10423.340000 0000 9529 9877Institute for General Practice and Palliative Care, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
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8
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van Baal K, Wiese B, Müller-Mundt G, Stiel S, Schneider N, Afshar K. Quality of end-of-life care in general practice – a pre–post comparison of a two-tiered intervention. BMC PRIMARY CARE 2022; 23:90. [PMID: 35443614 PMCID: PMC9022313 DOI: 10.1186/s12875-022-01689-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/04/2022] [Indexed: 11/14/2022]
Abstract
Background General practitioners (GPs) play a crucial role in the provision of end-of-life care (EoLC). The present study aimed at comparing the quality of GPs’ EoLC before and after an intervention involving a clinical decision aid and a public campaign. Methods The study was part of the larger interventional study ‘Optimal care at the end of life’ (OPAL) (Innovation Fund, Grant No. 01VSF17028). The intervention lasted 12 months and comprised two components: (1) implementation of the Supportive and Palliative Care Indicators Tool (SPICT-DE™) in general practice and (2) a public campaign in two German counties to inform and connect regional health care providers and stakeholders in EoLC. Participating GPs completed the General Practice End of Life Care Index (GP-EoLC-I) pre- (t0) and post- (t1) intervention. The GP-EoLC-I (25 items, score range: 14–40) is a self-assessment questionnaire that measures the quality of GPs’ EoLC. It includes two subscales: practice organisation and clinical practice. Data were analysed descriptively, and a paired t-test was applied for the pre–post comparison. Results Forty-five GPs (female: 29%, median age: 57 years) from 33 general practices participated in the intervention and took part in the survey at both times of measurement (t0 and t1). The mean GP-EoLC-I score (t0 = 27.9; t1 = 29.8) increased significantly by 1.9 points between t0 and t1 (t(44) = − 3.0; p = 0.005). Scores on the practice organisation subscale (t0 = 6.9; t1 = 7.6) remained almost similar (t(44) = -2.0; p = 0.057), whereas those of the clinical practice subscale (t0 = 21.0; t1 = 22.2) changed significantly between t0 and t1 (t(44) = -2.6; p = 0.011). In particular, items regarding the record of care plans, patients’ preferred place of care at the end of life and patients’ preferred place of death, as well as the routine documentation of impending death, changed positively. Conclusions GPs’ self-assessed quality of EoLC seemed to improve after a regional intervention that involved both the implementation of the SPICT-DE™ in daily practice and a public campaign. In particular, improvement related to the domains of care planning and documentation. Trial registration The study was registered in the German Clinical Trials Register (DRKS00015108; 22/01/2019).
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9
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Hodge A, Manson J, McTague L, Kyeremateng S, Taylor P. Creating virtual communities of practice for ambulance paramedics: a qualitative evaluation of the use of Project ECHO in end-of-life care. Br Paramed J 2022; 7:51-58. [PMID: 36531799 PMCID: PMC9730191 DOI: 10.29045/14784726.2022.12.7.3.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023] Open
Abstract
Introduction Ambulance services play a key role in the recognition and care of patients nearing their end of life, yet are expected to recognise and manage these complex presentations often with limited education. Paramedics operate across large geographical areas, meaning education delivery is challenging. Yorkshire Ambulance Service implemented Project Extension for Community Healthcare Outcomes (ECHO), which is the creation of virtual communities of practice to address this problem and increase access to specialist supervision, education and sharing of practice. We undertook a service evaluation of the programme and interviewed paramedics about their experiences with ECHO. Methods Semi-structured interviews were conducted with eight ambulance clinicians who took part in the end-of-life care (EoLC) ECHO programme. Thematic analysis and coding was undertaken to identify and develop the emerging themes. Results This study identified three key themes: programme structure, factors influencing engagement and professional impact. The provision of a virtual community of practice through Project ECHO was a unique and highly valued experience, which was accessible and allowed for networking, peer support and sharing of practice. The concept of a ripple effect was reported in disseminating learning across the wider team. Conclusion The development of virtual communities of practice as a novel educational intervention has the potential to transform clinical supervision and ongoing education for ambulance clinicians who are often isolated by the nature of ambulance services that cover large regions.
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Affiliation(s)
- Andrew Hodge
- Yorkshire Ambulance Service NHS Trust ORCID iD: https://orcid.org/0000-0002-2632-2249
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10
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Schüttengruber G, Großschädl F, Lohrmann C. A Consensus Definition of End of Life from an International and Interdisciplinary Perspective: A Delphi Panel Study. J Palliat Med 2022; 25:1677-1685. [PMID: 35549439 DOI: 10.1089/jpm.2022.0030] [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: 12/14/2022] Open
Abstract
Background: Those working in the field of palliative care have recognized that many terms are being used synonymously and that clear definitions (or any definitions) for many of these terms are lacking. The synonymous use of the terms palliative and end of life (EOL) can especially lead to conflicts in clinical practice, such as a tardy referral to palliative care. Such conflicts may then result in poorer treatment of patients, for instance, pain management. In research, the lack of clear definitions or even of any established definition for central concepts, such as EOL, weakens study validity and research outcomes. Objective: The aim of this study was to establish a concise definition for the EOL phase. Design: A modified Delphi study design was chosen. A structured questionnaire based on a previously conducted concept analysis about the EOL was used. Setting: A panel of international and interdisciplinary experts was established. Between 34 (1st round) and 21 (4th round) individuals participated in the anonymous online expert panel. Results: After four panel rounds, we were able to provide a definition which covers physical and psychosocial aspects that should be considered at the beginning of the EOL phase and possible predictions about the remaining time. The definition also covers aspects of EOL care, such as considerations related to the individual's dignity, spirituality, and maintenance of relationships. Conclusion: EOL is a term which is defined by considering multiple aspects that affect the process of identifying the EOL phase, the EOL phase itself and the resulting care options.
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Affiliation(s)
| | | | - Christa Lohrmann
- Medical University of Graz/Institute of Nursing Science, Graz, Austria
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11
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Prado E, Marcon S, Kalinke L, da Silva M, Barreto M, Takemoto A, Birolim M, Laranjeira C. Meanings and Experiences of End-of-Life Patients and Their Family Caregivers in Hospital-to-Home Transitions: A Constructivist Grounded Theory Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:12987. [PMID: 36293568 PMCID: PMC9602127 DOI: 10.3390/ijerph192012987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 06/16/2023]
Abstract
This study explored the meanings and experiences of patients with terminal chronic diseases and their caregivers, who face the imminence of death in the home environment after hospital discharge. The qualitative study used constructivist grounded theory. The participants were individuals with a terminal chronic illness, discharged to home, and their family caregivers. Data were gathered from in-depth interviews and field notes, and a comparative analysis was conducted to identify categories and codes, according to Charmaz's theory. The sample consisted of 21 participants. Three inter-related data categories emerged: "Floating between acceptance and resistance: Perceiving the proximity of death", "Analysing the end from other perspectives: it is in the encounter with death that life is understood" and "Accepting the path: between the love of letting go and the love of wanting to stay". The categories translate the reconstruction of those facing end-of-life occurring in the home environment. It is amid the imminence of death that life gains intensity and talking about the finitude of life configures an opportunity to see life from other perspectives. Giving voice to individuals facing the mishaps of a terminal illness fosters the path to a comfortable death. For health professionals, it is an opportunity to provide structured and humanized care with an ethical attitude, in defence of human dignity.
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Affiliation(s)
- Eleandro Prado
- Postgraduate Program in Nursing, Nursing Department, State University of Maringá, Maringá 87020-900, Brazil
| | - Sonia Marcon
- Postgraduate Program in Nursing, Nursing Department, State University of Maringá, Maringá 87020-900, Brazil
| | - Luciana Kalinke
- Nursing Department, Federal University of Paraná, Curitiba 80210-170, Brazil
| | - Marcelle da Silva
- Anna Nery Nursing School, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Mayckel Barreto
- Postgraduate Program in Nursing, Nursing Department, State University of Maringá, Maringá 87020-900, Brazil
| | - Angelica Takemoto
- Nursing Department, Guairacá University Center, Guarapuava 85010-000, Brazil
| | - Marcela Birolim
- Nursing Department, Guairacá University Center, Guarapuava 85010-000, Brazil
| | - Carlos Laranjeira
- School of Health Sciences of Polytechnic of Leiria, Campus 2, Morro do Lena, Alto do Vieiro, Apartado 4137, 2411-901 Leiria, Portugal
- Centre for Innovative Care and Health Technology, Rua de Santo André 66-68, Campus 5, Polytechnic of Leiria, 2410-541 Leiria, Portugal
- Research in Education and Community Intervention, Piaget Institute, 3515-776 Viseu, Portugal
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12
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Marx G, Mallon T, Pohontsch NJ, Schade F, Dams J, Zimansky M, Asendorf T, Böttcher S, Mueller CA, Freitag M, Hummers E, van den Bussche H, Schäfer I, König HH, Stiel S, Schneider N, Nauck F, Friede T, Scherer M. Effectiveness of a specialist palliative home care nurse-patient consultation followed by an interprofessional telephone case conference compared with usual care among patients with non-oncological palliative care needs: protocol for the multicentre KOPAL cluster-randomised controlled trial. BMJ Open 2022; 12:e059440. [PMID: 35879008 PMCID: PMC9330329 DOI: 10.1136/bmjopen-2021-059440] [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: 11/24/2022] Open
Abstract
INTRODUCTION Progressive chronic, non-malignant diseases (CNMD) like congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are of growing relevance in primary care. Most of these patients suffer from severe symptoms, reduced quality of life and increased numbers of hospitalisations. Outpatient palliative care can help to reduce hospitalisation rate by up to 50%. Due to the complex medical conditions and prognostic uncertainty of the course of CNMD, early interprofessional care planning among general practitioners who provide general palliative care and specialist palliative home care (SPHC) teams seems mandatory. The KOPAL study (a concept for strenghtening interprofessional collaboration for patients with palliative care needs) will test the effectiveness of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference. METHODS AND ANALYSIS Multicentre two-arm cluster randomised controlled trial KOPAL with usual care as control arm. The study is located in Northern Germany and aims to recruit 616 patients in 56 GP practices (because of pandemic reasons reduced to 191 participants). Randomisation will take place on GP practice level immediately after inclusion (intervention group/control group). Allocation concealment is carried out on confirmation of participation. Patients diagnosed with CHF (New York Heart Association (NYHA) classification 3-4), COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage classification 3-4, group D) or dementia GDS stage 4 or above). Primary outcome is a reduced hospital admission within 48 weeks after baseline, secondary outcomes include symptom burden, quality of life and health costs. The primary analysis will follow the intention-to-treat principle. Intervention will be evaluated after the observation period using qualitative methods. ETHICS AND DISSEMINATION The responsible ethics committees of the cooperating centres approved the study. All steps of data collection, quality assurance and data analysis will continuously be monitored. The concept of KOPAL could serve as a blueprint for other regions and meet the challenges of geographical equity in end-of-life care. TRIAL REGISTRATION NUMBER DRKS00017795; German Clinical Trials Register.
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Affiliation(s)
- Gabriella Marx
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tina Mallon
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nadine Janis Pohontsch
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Franziska Schade
- Department of Palliative Medicine, University Medical Center Göttingen, Gottingen, Germany
| | - Judith Dams
- Department of Health Economics and Health Care Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Manuel Zimansky
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - Thomas Asendorf
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Silke Böttcher
- Division of General Practice, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Christiane A Mueller
- Department of General Practice, University Medical Center Goettingen, Goettingen, Germany
| | - Michael Freitag
- Division of General Practice, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Eva Hummers
- Department of General Practice, University Medical Center Goettingen, Goettingen, Germany
| | - Hendrik van den Bussche
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ingmar Schäfer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Care Research, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stephanie Stiel
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice and Palliative Care, Hannover Medical School, Hannover, Germany
| | - Friedemann Nauck
- Department of Palliative Medicine, University Medical Center Göttingen, Gottingen, Germany
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Goettingen, Goettingen, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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13
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Schüttengruber G, Halfens RJ, Lohrmann C. 'End of life': a concept analysis. Int J Palliat Nurs 2022; 28:314-321. [PMID: 35861440 DOI: 10.12968/ijpn.2022.28.7.314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND The concept of end of life (EOL), as in the term end-of-life care, is used synonymously in both palliative and terminal care. Practitioners and researchers both require a clearer specification of the end-of-life concept to be able to provide appropriate care in this phase of life and to conduct robust research on a well-described theoretical basis. AIMS The aim of this study was to critically analyse the end-of-life concept and its associated terminology. METHOD A concept analysis was performed by applying Rodgers' evolutionary concept analysis method. FINDINGS Time remaining, clinical status/physical symptoms, psychosocial symptoms and dignity were identified as the main attributes of the concept. Transition into the end-of-life phase and its recognition were identified as antecedents. This study demonstrates that end-of-life care emerged following the application of the 'end-of-life concept' to clinical practice. CONCLUSION The early recognition of the end-of-life phase seems to be crucial to ensuring an individual has well-managed symptoms and a dignified death.
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Affiliation(s)
| | - Ruud J Halfens
- Associate Professor, Health Service Research, Maastricht University, The Netherlands
| | - Christa Lohrmann
- Professor, Institute of Nursing Science, Medical University of Graz, Austria
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14
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Fors Brandebo M, Börjesson M, Hilmarsson H. Longitudinal studies on cohesion in a military context – A systematic review. MILITARY PSYCHOLOGY 2022. [DOI: 10.1080/08995605.2022.2041995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Maria Fors Brandebo
- Department of Security, Strategy and Leadership, Swedish Defence University, Karlstad, Sweden
| | - Marcus Börjesson
- Department of Security, Strategy and Leadership, Swedish Defence University, Karlstad, Sweden
| | - Hilmar Hilmarsson
- Department of Security, Strategy and Leadership, Swedish Defence University, Karlstad, Sweden
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15
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Sallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, Doble B, Dullie L, Durie R, Finkelstein EA, Guglani S, Hodson M, Husebø BS, Kellehear A, Kitzinger C, Knaul FM, Murray SA, Neuberger J, O'Mahony S, Rajagopal MR, Russell S, Sase E, Sleeman KE, Solomon S, Taylor R, Tutu van Furth M, Wyatt K. Report of the Lancet Commission on the Value of Death: bringing death back into life. Lancet 2022; 399:837-884. [PMID: 35114146 PMCID: PMC8803389 DOI: 10.1016/s0140-6736(21)02314-x] [Citation(s) in RCA: 170] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Afsan Bhadelia
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Yali Cong
- Peking University Health Science Center, Beijing, China
| | | | | | | | | | | | | | | | | | | | | | | | - Julia Neuberger
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Sarah Russell
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eriko Sase
- Georgetown University, Washington, DC, USA
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16
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Bereaved Parent Perspectives on End-of-Life Conversations in Pediatric Oncology. CHILDREN 2022; 9:children9020274. [PMID: 35204993 PMCID: PMC8870516 DOI: 10.3390/children9020274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 02/03/2022] [Accepted: 02/14/2022] [Indexed: 11/17/2022]
Abstract
Background: Professional education pertaining to end-of-life care with pediatric oncology patients is limited. Pediatric trainees learn about end-of-life conversations largely from the provider’s perspective. Bereaved parents can inform the education of oncologists and the interdisciplinary team by sharing their perceptions and preferences through personal narratives. Methods: The aim of this project was to enhance the healthcare teams’ understanding of bereaved parents’ end-of-life care preferences through narratives. Bereaved parents were recruited from our institution’s Pediatric Supportive Care Committee membership. Parents were tasked with identifying elements of care that were of the greatest importance to them, based upon their personal experiences during their child’s end-of-life care. Narratives were analyzed using standard qualitative methods. Results: Parents of five patients participated, including four mothers and three fathers. Ten themes summarizing essential elements of end-of-life care were identified, including early ongoing and stepwise prognostic disclosure, honoring the child’s voice, support of hope and realism, anticipatory guidance on dying, and continued contact with the bereaved. Conclusion: Bereaved parents emphasize the need for providers to have ongoing honest conversations that support realism and hope that can help them to best prepare for their child’s end of life and to remain in contact with them after death.
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van Baal K, Schrader S, Schneider N, Wiese B, Stiel S, Afshar K. [End-of-life care in a rural small-town region in Lower Saxony: a retrospective cross-sectional analysis based on routinely collected general practice data]. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 168:48-56. [PMID: 34998676 DOI: 10.1016/j.zefq.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 09/29/2021] [Accepted: 10/07/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Up to 90% of people at the end of life are in need of palliative care. The majority can be cared for within general outpatient palliative care (AAPV) by general practitioners. Previous studies have described outpatient palliative care to fall short behind the estimated needs and to be initiated rather late in the health care process. Yet, little is known about the development of outpatient palliative care in recent years and about the parameters influencing its utilisation. Therefore, this study aimed to investigate the number and time of initiation for AAPV and specialised outpatient palliative care (SAPV) in a rural and small-town region in Lower Saxony on the basis of routinely collected general practice data. Furthermore, this study sought to estimate the influence of various parameters related to patients, practices and physicians on the provision of AAPV and SAPV. METHODS All general practitioners (n=190) in two counties in Lower Saxony were invited to take part in the project "Optimal care at the end of life - OPAL" (Innovation Fund, 01VSF17028) between autumn 2018 and spring 2019. In the participating practices, clinical data pertaining to patients with statutory health insurance, who had died in the second or third quarter of 2018, were collected in pseudonymised form and analysed using selected indicators for end-of-life care. The number of hospital stays and the provision of AAPV and SAPV were the subject of the descriptive analyses. In order to take the cluster effect of the practices into account, mixed-model analyses were carried out. RESULTS The data of 279 deceased patients (48% female; median age 82 years) from 31 general practices were analysed. In the last year of life, AAPV was provided for 78 deceased patients (28.0%) with a median onset of 20 days before death. 52 deceased patients (18.6%) received SAPV with a median onset of 28 days before death, respectively. In the last six months of life, 207 deceased patients (74.2%) were hospitalised at least once. The mixed-model analyses showed a greater probability of receiving AAPV (odds ratio (OR)=3.3) or SAPV (OR=3.2) in the last year of life for patients with oncological diseases. It was also shown that GPs with a higher value on the subscale practice organisation billed more AAPV (OR=1.4). DISCUSSION The number of patients with SAPV is at least equivalent to the estimated needs known from the literature in both selected regions. In contrast, AAPV seems to be provided relatively rarely and rather late in the health care process. Relevant reasons for this may be the lack of concrete criteria for AAPV (e. g., ambiguities and competing codes for billing) as well as prognostic uncertainties of health care providers especially for patients with non-oncological diseases. CONCLUSION Strategies to further develop end-of-life care should especially strengthen the AAPV provided by general practitioners and focus on patients with non-oncological diseases.
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Affiliation(s)
- Katharina van Baal
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover.
| | - Sophie Schrader
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover
| | - Nils Schneider
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover
| | - Birgitt Wiese
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover
| | - Stephanie Stiel
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover
| | - Kambiz Afshar
- Institut für Allgemeinmedizin und Palliativmedizin, Medizinische Hochschule Hannover
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Heyman ET, Ashfaq A, Khoshnood A, Ohlsson M, Ekelund U, Holmqvist LD, Lingman M. Improving Machine Learning 30-Day Mortality Prediction by Discounting Surprising Deaths. J Emerg Med 2021; 61:763-773. [PMID: 34716042 DOI: 10.1016/j.jemermed.2021.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 08/13/2021] [Accepted: 09/11/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Machine learning (ML) is an emerging tool for predicting need of end-of-life discussion and palliative care, by using mortality as a proxy. But deaths, unforeseen by emergency physicians at time of the emergency department (ED) visit, might have a weaker association with the ED visit. OBJECTIVES To develop an ML algorithm that predicts unsurprising deaths within 30 days after ED discharge. METHODS In this retrospective registry study, we included all ED attendances within the Swedish region of Halland in 2015 and 2016. All registered deaths within 30 days after ED discharge were classified as either "surprising" or "unsurprising" by an adjudicating committee with three senior specialists in emergency medicine. ML algorithms were developed for the death subclasses by using Logistic Regression (LR), Random Forest (RF), and Support Vector Machine (SVM). RESULTS Of all 30-day deaths (n = 148), 76% (n = 113) were not surprising to the adjudicating committee. The most common diseases were advanced stage cancer, multidisease/frailty, and dementia. By using LR, RF, and SVM, mean area under the receiver operating characteristic curve (ROC-AUC) of unsurprising deaths in the test set were 0.950 (SD 0.008), 0.944 (SD 0.007), and 0.949 (SD 0.007), respectively. For all mortality, the ROC-AUCs for LR, RF, and SVM were 0.924 (SD 0.012), 0.922 (SD 0.009), and 0.931 (SD 0.008). The difference in prediction performance between all and unsurprising death was statistically significant (P < .001) for all three models. CONCLUSION In patients discharged to home from the ED, three-quarters of all 30-day deaths did not surprise an adjudicating committee with emergency medicine specialists. When only unsurprising deaths were included, ML mortality prediction improved significantly.
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Affiliation(s)
- Ellen Tolestam Heyman
- Department of Emergency Medicine, Halland Hospital, Region Halland, Sweden; Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden
| | - Awais Ashfaq
- Center for Applied Intelligent Systems Research (CAISR), Halmstad University, Halmstad, Sweden; Halland Hospital, Region Halland, Sweden
| | - Ardavan Khoshnood
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden; Skåne University Hospital Lund, Lund, Sweden
| | - Mattias Ohlsson
- Center for Applied Intelligent Systems Research (CAISR), Halmstad University, Halmstad, Sweden; Department of Astronomy and Theoretical Physics, Division of Computational Biology and Biological Physics, Lund University, Lund, Sweden
| | - Ulf Ekelund
- Department of Clinical Sciences Lund, Faculty of Medicine, Lund University, Lund, Sweden; Skåne University Hospital Lund, Lund, Sweden
| | - Lina Dahlén Holmqvist
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Sahlgrenska University Hospitals, Gothenburg, Sweden
| | - Markus Lingman
- Halland Hospital, Region Halland, Sweden; Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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19
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The conscious state of the dying patient: An integrative review. Palliat Support Care 2021; 20:731-743. [PMID: 34615571 DOI: 10.1017/s1478951521001541] [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: 11/06/2022]
Abstract
OBJECTIVES The cognitive state of the dying in the last days of life may deteriorate, resulting in a reduced ability to communicate their care needs. Distressing symptoms, physical and existential, may go unrecognized and untreated. The objectives of this integrative review were to systematically interrogate the literature to determine the changing conscious state of dying adults and to identify changes in their care needs. METHODS An integrative review protocol was registered with PROSPERO (CRD42020160475). The World Health Organization definition of palliative care informed the review. CINAHL, MEDLINE (OVID), Scopus, PsycINFO, Cochrane Library, and PubMed were searched from inception to October 2019 using search strategies for each database. Inclusion and exclusion criteria were applied. Methodological quality was appraised using the Joanna Briggs Institute Checklist for the Case Series appraisal tool. Extracted data were synthesized using a narrative approach. RESULTS Of 5,136 papers identified, 11 quantitative case series studies were included. Six themes were identified: conscious state and change over time, awareness, pain, absence of holistic care, the voiceless patient, and signs and symptoms of dying. SIGNIFICANCE OF RESULTS In the last days of life, the physical and conscious state of the dying patient declines, resulting in an inability to express their care needs. Dignity in dying and freedom from pain and suffering are both an imperative and a human right; and unvoiced care needs can result in unnecessary suffering and distress. This review revealed that little is known about how healthcare professionals assess holistic care needs at this vulnerable time. Although much has been written about palliative and end-of-life care, the assessment of care needs when patients are no longer able to voice their own needs has largely been ignored, with little attention from clinical, educational, or research perspectives. This gap in evidence has important implications for the dying and their families.
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Fien S, Plunkett E, Fien C, Greenaway S, Heyland DK, Clark J, Cardona M. Challenges and facilitators in delivering optimal care at the End of Life for older patients: a scoping review on the clinicians' perspective. Aging Clin Exp Res 2021; 33:2643-2656. [PMID: 33713331 DOI: 10.1007/s40520-021-01816-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 02/13/2021] [Indexed: 01/28/2023]
Abstract
The concepts and elements determining quality of care at the End of Life may vary across professional groups but there is consensus that high-quality care at the End of Life is beneficial for the patient, families, health systems and society at large. This scoping review aimed to elucidate gaps in the delivery of this specific type of care in older people from the clinicians' perspective, and to identify potential solutions to both improve this care and promote work satisfaction by the involved clinicians. Twelve studies published since 2010 with data from 18 countries identified four major gaps: (1) Core clinical competencies; (2) Shared decision-making; (3) Health care system, environmental context, and resources; and (4) Organisational leadership, culture and legislation. Multiple suggestions for staff communications training, multidisciplinary mentoring, and advance care planning alignment with patient wishes were identified. However, a clear picture arose of consistently unmet needs that have been previously highlighted in research for more than a decade. This indicates poor uptake of previous recommendations and highlights the difficulties in changing the service culture to ensure provision of optimal services at the End of Life. Future investigations on the reasons for poor uptake and identification of effective approaches to execute the agreed recommendations are warranted.
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21
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Nnate DA. Treatment withdrawal of the patient on end of life: An analysis of values, ethics and guidelines in palliative care. Nurs Open 2021; 8:1023-1029. [PMID: 33569923 PMCID: PMC8046138 DOI: 10.1002/nop2.777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 01/07/2021] [Accepted: 01/21/2021] [Indexed: 11/07/2022] Open
Abstract
AIM Family surrogate decision-making during the later stage of a patient's life may sometimes result in conflict and emotional distress among the parties involved. The present article aims to promote ethical end-of-life decision-making among healthcare professionals in a view to eliminating any misunderstanding that may arise while meeting the care needs of the patient. DESIGN A case study involving a request for treatment withdrawal by the family of a patient on end of life. METHODS This paper draws upon a scenario encountered during practice to analyse the moral commitments in delivering high-quality end-of-life care with much emphasis on pre-existing palliative care guidelines for adults. RESULTS Healthcare professionals are bound by the principle of beneficence, non-maleficence, autonomy and justice. Although the use of guidelines may be tenable, decisions often take into consideration the patient's choice and then weighed against the moral values of healthcare specialists and those required in the profession.
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Affiliation(s)
- Daniel A. Nnate
- Nursing and Community HealthSchool of Health and Life SciencesGlasgow Caledonian UniversityGlasgowUK
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22
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De Giorgi A, Fabbian F, Cappadona R, Tiseo R, Molino C, Misurati E, Gambuti E, Savriè C, Boari B, Raparelli V, Manfredini R. Do Sex-Related Differences of Comorbidity Burden and/or In-Hospital Mortality Exist in Cancer Patients? A Retrospective Study in an Internal Medicine Setting. Life (Basel) 2021; 11:261. [PMID: 33810124 PMCID: PMC8004908 DOI: 10.3390/life11030261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 03/18/2021] [Accepted: 03/19/2021] [Indexed: 11/26/2022] Open
Abstract
Cancer represents important comorbidity, and data on outcomes are usually derived from selected oncologic units. Our aim was to evaluate possible sex-related differences and factors associated with in-hospital mortality (IHM) in a consecutive cohort of elderly patients with cancer admitted to internal medicine. We included all patients admitted to our department with a diagnosis of cancer during 2018. Based on the International Classification of Diseases, 9th Revision, Clinical Modification, demography, comorbidity burden, and diagnostic procedures were evaluated, with IHM as our outcome. We evaluated 955 subjects with cancer (23.9% of total hospital admissions), 42.9% were males, and the mean age was 76.4 ± 11.4 years. Metastatic cancer was diagnosed in 18.2%. The deceased group had a higher modified Elixhauser Index (17.6 ± 7.7 vs. 14 ± 7.3, p < 0.001), prevalence of cachexia (17.9% vs. 7.2%, p < 0.001), and presence of metastasis (27.8% vs. 16.3%, p = 0.001) than survivors. Females had a higher age (77.4 ± 11.4 vs. 75.5 ± 11.4, p = 0.013), and lower comorbidity (10.2 ± 5.9 vs. 12.0 ± 5.6, p < 0.001) than males. IHM was not significantly different among sex groups, but it was independently associated with cachexia and metastasis only in women. Comorbidities are highly prevalent in patients with cancer admitted to the internal medicine setting and are associated with an increased risk of all-cause mortality, especially in female elderly patients with advanced disease.
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Affiliation(s)
- Alfredo De Giorgi
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
| | - Fabio Fabbian
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Rosaria Cappadona
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Ruana Tiseo
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
| | - Christian Molino
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
| | - Elisa Misurati
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
| | - Edoardo Gambuti
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
| | - Caterina Savriè
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
| | - Benedetta Boari
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
| | - Valeria Raparelli
- Department of Translational Medicine, University of Ferrara, 44121 Ferrara, Italy;
| | - Roberto Manfredini
- Clinica Medica Unit, Azienda Ospedaliero-University of Ferrara, 44121 Ferrara, Italy; (A.D.G.); (R.T.); (C.M.); (E.M.); (E.G.); (C.S.); (B.B.)
- Department of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
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van Baal K, Schrader S, Wiese B, Geyer S, Stiel S, Schneider N, Müller-Mundt G, Afshar K. GPs' perspective on End-of-Life Care - an evaluation based on the German version of the General Practice End of Life Care Index. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc10. [PMID: 33299388 PMCID: PMC7705118 DOI: 10.3205/000286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 07/16/2020] [Indexed: 11/30/2022]
Abstract
Objective: General practitioners (GPs) play a key role in the provision of general outpatient palliative care (AAPV) for the majority of patients at the end of life. The aim of this study was to evaluate the quality of End-of-Life Care (EoLC) from a GPs’ perspective using the German version of the General Practice End of Life Care Index (GP-EoLC-I). Methods: Between autumn 2018 and spring 2019, all registered and eligible GPs in two counties in Lower Saxony (n=190) were asked to participate in a survey on EoLC using the German version of the self-assessment questionnaire GP-EoLC-I. The index comprises two subscales: clinical care (13 items) and practice organisation (12 items). The summated index of both subscales measures the quality of EoLC by GPs (25 items; range 14–40). The questionnaire was supplemented by questions on sociodemographic data, indicators for good palliative care (PC) and requirements to improve PC. Quantitative data were analysed by descriptive statistics and free text answers by conventional content analysis according to Hsieh and Shannon. Results: 52 GPs (females: n=16) of 34 practices (single practices: n=26) participated in the study. The mean GP-EoLC-I was 27.5 (SD 4.5). The items revealed potential for improvement: systematic identification of patients with potential PC needs, multidisciplinary case conferences to discuss PC patients, application of care protocols and symptom assessment tools, documentation of patients’ wishes and beliefs as well as inclusion of family and carers. Regarding the indicators for good PC, the most relevant indicators from the GPs’ perspective were collaboration and coordination, integration of relatives, advance care planning and documentation. As requirements to improve PC, GPs highlighted further training and the use of standardised tools such as instruments to support the systematic identification of PC patients. Conclusions: To our knowledge for the first time in Germany, an internationally tested self-assessment questionnaire measuring the quality of EoLC by GPs was applied. The GP-EoLC-I in this study was slightly lower than the index of GPs in the United Kingdom. Including relatives and family carers, implementing tools to support early identification of PC patients and strengthening cooperation between GPs and other stakeholders in PC may be promising approaches to improve general PC and EoLC in Germany.
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Affiliation(s)
- Katharina van Baal
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Sophie Schrader
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Siegfried Geyer
- Medical Sociology Unit, Hannover Medical School, Hannover, Germany
| | - Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | | | - Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Hannover, Germany
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24
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van Baal K, Schrader S, Schneider N, Wiese B, Stahmeyer JT, Eberhard S, Geyer S, Stiel S, Afshar K. Quality indicators for the evaluation of end-of-life care in Germany - a retrospective cross-sectional analysis of statutory health insurance data. BMC Palliat Care 2020; 19:187. [PMID: 33292204 PMCID: PMC7724721 DOI: 10.1186/s12904-020-00679-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 10/29/2020] [Indexed: 11/10/2022] Open
Abstract
Background The provision and quality of end-of-life care (EoLC) in Germany is inconsistent. Therefore, an evaluation of current EoLC based on quality indicators is needed. This study aims to evaluate EoLC in Germany on the basis of quality indicators pertaining to curative overtreatment, palliative undertreatment and delayed palliative care (PC). Results were compared with previous findings. Methods Data from a statutory health insurance provider (AOK Lower Saxony) pertaining to deceased members in the years 2016 and 2017 were used to evaluate EoLC. The main indicators were: chemotherapy for cancer patients in the last month of life, first-time percutaneous endoscopic gastrostomy (PEG) for patients with dementia in the last 3 months of life, number of hospitalisations and days spent in inpatient treatment in the last 6 months of life, and provision of generalist and specialist outpatient PC in the last year of life. Data were analysed descriptively. Results Data for 64,275 deceased members (54.3% female; 35.1% cancer patients) were analysed. With respect to curative overtreatment, 10.4% of the deceased with cancer underwent chemotherapy in the last month and 0.9% with dementia had a new PEG insertion in the last 3 months of life. The mean number of hospitalisations and inpatient treatment days per deceased member was 1.6 and 16.5, respectively, in the last 6 months of life. Concerning palliative undertreatment, generalist outpatient PC was provided for 28.0% and specialist outpatient PC was provided for 9.0% of the deceased. Regarding indicators for delayed PC, the median onset of generalist and specialist outpatient PC was 47.0 and 24.0 days before death, respectively. Conclusion Compared to data from 2010 to 2014, the data analysed in the present study suggest an ongoing curative overtreatment in terms of chemotherapy and hospitalisation, a reduction in new PEG insertions and an increase in specialist PC. The number of patients receiving generalist PC remained low, with delayed onset. Greater awareness of generalist PC and the early integration of PC are recommended. Trial registration The study was registered in the German Clinical Trials Register (DRKS00015108; 22 January 2019). Supplementary Information The online version contains supplementary material available at 10.1186/s12904-020-00679-x.
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Affiliation(s)
- Katharina van Baal
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Sophie Schrader
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Jona Theodor Stahmeyer
- AOK Lower Saxony, Department for Health Services Research, Hildesheimer Str. 273, 30519, Hannover, Germany
| | - Sveja Eberhard
- AOK Lower Saxony, Department for Health Services Research, Hildesheimer Str. 273, 30519, Hannover, Germany
| | - Siegfried Geyer
- Medical Sociology Unit, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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25
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Zambrano SC, Haugen DF, van der Heide A, Tripodoro VA, Ellershaw J, Fürst CJ, Voltz R, Mason S, Daud ML, De Simone G, Kremeike K, Halfdanardottir SI, Sigurdardottir V, Johnson J, Allan S, Hafeez H, Simões C, Sigurdardottir KR, Rasmussen BH, Williamson P, Eychmüller S. Development of an international Core Outcome Set (COS) for best care for the dying person: study protocol. BMC Palliat Care 2020; 19:184. [PMID: 33256786 PMCID: PMC7706044 DOI: 10.1186/s12904-020-00654-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 09/15/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND In contrast to typical measures employed to assess outcomes in healthcare such as mortality or recovery rates, it is difficult to define which specific outcomes of care are the most important in caring for dying individuals. Despite a variety of tools employed to assess different dimensions of palliative care, there is no consensus on a set of core outcomes to be measured in the last days of life. In order to optimise decision making in clinical practice and comparability of interventional studies, we aim to identify and propose a set of core outcomes for the care of the dying person. METHODS Following the COMET initiative approach, the proposed study will proceed through four stages to develop a set of core outcomes: In stage 1, a systematic review of the literature will identify outcomes measured in existing peer reviewed literature, as well as outcomes derived through qualitative studies. Grey literature, will also be included. Stage 2 will allow for the identification and determination of patient and proxy defined outcomes of care at the end of life via quantitative and qualitative methods at an international level. In stage 3, from a list of salient outcomes identified through stages 1 and 2, international experts, family members, patients, and patient advocates will be asked to score the importance of the preselected outcomes through a Delphi process. Stage 4 consists of a face-to-face consensus meeting of international experts and patient/family representatives in order to define, endorse, and propose the final Core Outcomes Set. DISCUSSION Core Outcome Sets aim at promoting uniform assessment of care outcomes in clinical practice as well as research. If consistently employed, a robust set of core outcomes for the end of life, and specifically for the dying phase, defined by relevant stakeholders, can ultimately be translated into best care for the dying person. Patient care will be improved by allowing clinicians to choose effective and meaningful treatments, and research impact will be improved by employing internationally agreed clinically relevant endpoints and enabling accurate comparison between studies in systematic reviews and/or in meta-analyses.
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Affiliation(s)
- Sofia C Zambrano
- University Center for Palliative Care, Department of Oncology, Inselspital, Bern University Hospital, Bern, Switzerland.
| | | | | | | | | | | | - Raymond Voltz
- Department of Palliative Care, Universitätsklinikum Köln (AöR), Köln, Germany
| | | | | | | | - Kerstin Kremeike
- Department of Palliative Care, Universitätsklinikum Köln (AöR), Köln, Germany
| | | | | | | | - Simon Allan
- Arohanui Hospice, Palmerston North, New Zealand
| | - Haroon Hafeez
- Shaukat Khanum Memorial Cancer Hospital & Research Centre, Peshawar, Pakistan
| | - Catarina Simões
- Palliative Care Team H. Luz Arrábida, Vila Nova de Gaia, Portugal
| | | | | | | | - Steffen Eychmüller
- University Center for Palliative Care, Department of Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
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26
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Sizoo EM, Monnier AA, Bloemen M, Hertogh CMPM, Smalbrugge M. Dilemmas With Restrictive Visiting Policies in Dutch Nursing Homes During the COVID-19 Pandemic: A Qualitative Analysis of an Open-Ended Questionnaire With Elderly Care Physicians. J Am Med Dir Assoc 2020; 21:1774-1781.e2. [PMID: 33197412 PMCID: PMC7584414 DOI: 10.1016/j.jamda.2020.10.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 09/03/2020] [Accepted: 10/18/2020] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To mitigate the spread of COVID-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (NHs) was established in the Netherlands. The aim of this study was an exploration of dilemmas experienced by elderly care physicians (ECPs) as a result of the COVID-19 driven restrictive visiting policy. SETTING AND PARTICIPANTS ECPs working in Dutch NHs. METHODS A qualitative exploratory study was performed using an open-ended questionnaire. A thematic analysis was applied. Data were collected between April 17 and May 10, 2020. RESULTS Seventy-six ECPs answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. Thematic analysis revealed 4 major themes: (1) The need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) The challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) The profound emotional impact on ECPs; (4) Many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. Many alternatives for visits highlight the wish to compensate for the absence of face-to-face opportunities but given the diversity of NH residents, alternatives were often only suitable for some of them. CONCLUSIONS AND IMPLICATIONS ECPs reported that the restrictive visitor policy deeply impacts NHs residents, their loved ones, and care professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified an overview of aspects to consider when drafting future visiting policies for NHs during the COVID-19 pandemic.
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Affiliation(s)
- Eefje M Sizoo
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands.
| | - Annelie A Monnier
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Maryam Bloemen
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Cees M P M Hertogh
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
| | - Martin Smalbrugge
- Department of Medicine for Older People, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, Location VUmc, Amsterdam, the Netherlands
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García-Gollarte JF, García-Andrade MM, Santaeugenia-González SJ, Solá Hermida JC, Baixauli-Alacreu S, Santabalbina FJT. Risk Factors for Mortality in Nursing Home Residents: An Observational Study. Geriatrics (Basel) 2020; 5:geriatrics5040071. [PMID: 33050016 PMCID: PMC7709674 DOI: 10.3390/geriatrics5040071] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 09/29/2020] [Accepted: 10/03/2020] [Indexed: 01/04/2023] Open
Abstract
Purpose: Identifying mortality risk factors in people living in nursing homes could help healthcare professionals to individualize or develop specific plans for predicting future care demands and plan end-of-life care in this population. This study aims to identify mortality risk factors in elderly nursing home (NH) residents, based on variables adapted to this environment, routinely collected and easily accessible to their healthcare professionals. Methods: A prospective, longitudinal, observational study of NH residents aged 65 years and older was carried out collecting sociodemographic, functional and cognitive status, nutritional variables, comorbidities, and other health variables. These variables were analyzed as mortality risk factors by Cox proportional hazard models. Results: A total of 531 residents (75.3% female; average age 86.7 years (SD: 6.6)) were included: 25.6% had total dependence, 53.4% had moderate to severe cognitive impairment, 84.5% were malnourished or at risk of malnutrition, and 79.9% were polymedicated. Risk of mortality (hazard ratio, HR) increased in totally dependent residents (HR = 1.52; p = 0.02) and in those with moderate or severe cognitive impairment ((HR = 1.59; p = 0.031) and (HR = 1.93; p = 0.002), respectively). Male gender (HR = 1.88; p < 0.001), age ≥80 years (HR = 1.73; p = 0.034), hypertension (HR = 1.53; p = 0.012), atrial fibrillation/arrhythmia (HR = 1.43; p = 0.048), and previous record of pneumonia (HR = 1.65; p = 0.029) were also found to be mortality drivers. Conclusion: Age and male gender (due to the higher prevalence of associated comorbidity in these two variables), certain comorbidities (hypertension, atrial fibrillation/arrhythmia, and pneumonia), higher functional and cognitive impairment, and frequency of medical emergency service care increased the risk of mortality in our study. Given their importance and their easy identification by healthcare professionals in nursing homes, these clinical variables should be used for planning care in institutionalized older adults.
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Affiliation(s)
- José Fermín García-Gollarte
- Medical Department Grupo Ballesol, Universidad Católica de Valencia, La Eliana, 46183 Valencia, Spain;
- Correspondence:
| | | | - Sebastiá J. Santaeugenia-González
- Chronic Care Program, Ministry of Health, Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care, 08500 Barcelona, Spain;
| | - José Carlos Solá Hermida
- Medical Department Grupo Ballesol, Universidad Católica de Valencia, La Eliana, 46183 Valencia, Spain;
| | - Susana Baixauli-Alacreu
- Department of Nursing, Universidad Católica de Valencia San Vicente Mártir, 46001 Valencia, Spain;
| | - Francisco José Tarazona Santabalbina
- Geriatric Service, Hospital Universitario de la Ribera, 46600 Alzira, Spain;
- Division of Geriatric Medicine, 7GPR+3M Doha, Qatar
- CIBERFES, Centro de Investigación Biomédica en Red Fragilidad y Envejecimiento Saludable, 0 28029 Madrid, Spain
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28
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Ducharlet K, Philip J, Kiburg K, Gock H. Renal supportive care, palliative care and end-of-life care: Perceptions of similarities, differences and challenges across Australia and New Zealand. Nephrology (Carlton) 2020; 26:15-22. [PMID: 32989844 DOI: 10.1111/nep.13787] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 07/15/2020] [Accepted: 09/16/2020] [Indexed: 12/21/2022]
Abstract
Renal supportive care (RSC) is an approach integrating nephrology and palliative care to improve quality of life for people with chronic kidney disease (CKD). RSC practice varies across services; therefore, understanding clinicians' perspectives is important to the evolution and definition of RSC. AIM To understand renal clinicians' views and experiences of RSC, palliative care and end-of-life care. METHOD A cross-sectional online survey was undertaken across Australia and New Zealand between February and May 2018. Participants were asked about end-of-life care, RSC, palliative care and an ideal model of RSC. RESULTS Estimated response rate 13% included 382 clinicians; doctors (32%), nurses (68%); of whom 84% access specialist palliative care and 59% RSC. A lack of agreed treatment goals (86%) and late or rushed treatment decision making (85%) was associated with challenging end-of-life experiences. Variable concepts of RSC were described, with RSC being considered the same as: usual care for all CKD patients (40%), conservative (30%) or palliative care (22%). The term RSC was generally distinct from (77%) and more acceptable than palliative care (80%) with preferential RSC referral for symptoms (86% vs 69%, P < .01) and complex treatment decision making (82% vs 58%, P < .01). Aspirations for RSC included improving symptoms and quality of life (89%), with an ideal model comprising: symptom management (98%), improved nephrology and community service integration (96%) and clinician education (94%). CONCLUSION This study revealed challenges for renal clinicians in providing end-of-life care and variation of views and experiences of RSC. It represents opportunities to develop RSC aligned with clinician priorities to improve patient care.
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Affiliation(s)
- Kathryn Ducharlet
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia.,Department of Nephrology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Palliative Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Jennifer Philip
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia.,Department of Palliative Medicine, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Katerina Kiburg
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia
| | - Hilton Gock
- Department of Medicine, Melbourne University, Melbourne, Victoria, Australia.,Department of Nephrology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
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Todd S, Bernal J, Shearn J, Worth R, Jones E, Lowe K, Madden P, Barr O, Forrester Jones R, Jarvis P, Kroll T, McCarron M, Read S, Hunt K. Last months of life of people with intellectual disabilities: A UK population‐based study of death and dying in intellectual disability community services. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2020; 33:1245-1258. [DOI: 10.1111/jar.12744] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 03/09/2020] [Accepted: 03/29/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Stuart Todd
- Care Sciences University of South Wales Pontypridd UK
| | - Jane Bernal
- Care Sciences University of South Wales Pontypridd UK
| | - Julia Shearn
- Care Sciences University of South Wales Pontypridd UK
| | - Rhian Worth
- Care Sciences University of South Wales Pontypridd UK
| | - Edwin Jones
- Care Sciences University of South Wales Pontypridd UK
| | - Kathy Lowe
- Care Sciences University of South Wales Pontypridd UK
| | | | - Owen Barr
- School of Nursing Ulster University Derry UK
| | | | - Paul Jarvis
- Care Sciences University of South Wales Pontypridd UK
| | - Thilo Kroll
- School of Nursing Midwifery and Health Systems University College Dublin Dublin UK
| | - Mary McCarron
- School of Nursing & Midwifery Trinity College Dublin Dublin UK
| | - Sue Read
- School of Nursing & Midwifery University of Keele Newcastle under Lyme UK
| | - Katherine Hunt
- Faculty of Health Sciences Southampton University Southampton UK
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30
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Gómez-Batiste X, Turrillas P, Tebé C, Calsina-Berna A, Amblàs-Novellas J. NECPAL tool prognostication in advanced chronic illness: a rapid review and expert consensus. BMJ Support Palliat Care 2020; 12:e10-e20. [PMID: 32241958 DOI: 10.1136/bmjspcare-2019-002126] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/24/2020] [Accepted: 03/11/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To develop a proposal for a 2-year mortality prognostic approach for patients with advanced chronic conditions based on the palliative care need (PCN) items of the NECesidades PALiativas (NECPAL) CCOMS-ICO V.3.1 2017 tool. METHODS A phase 1 study using three components based on the NECPAL items: (1) a rapid review of systematic reviews (SRs) on prognostic factors of mortality in patients with advanced chronic diseases and PCNs; (2) a clinician and statistician experts' consensus based on the Delphi technique on the selection of mortality prognostic factors; and (3) a panel meeting to discuss the findings of components (1) and (2). RESULTS Twenty SRs were included in a rapid review, and 50% were considered of moderate quality. Despite methodological issues, nutritional and functional decline, severe and refractory dyspnoea, multimorbidity, use of resources and specific disease indicators were found to be potentially prognostic variables for mortality across four clinical groups and end-of-life (EoL) trajectories: cancer, dementia and neurologic diseases, chronic organ failure and frailty. Experts' consensus added 'needs' identified by health professionals. However, clinicians were less able to discriminate which NECPAL items were more reliable for a 'general' model. A retrospective cohort study was designed to evaluate this proposal in phase 2. CONCLUSIONS We identified several parameters with prognostic value and linked them to the tool's utility to timely identify PCNs of patients with advanced chronic conditions in all settings of care. Initial results show this is a clinical and feasible tool, that will help with clinical pragmatic decision-making and to define services.
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Affiliation(s)
- Xavier Gómez-Batiste
- The 'Qualy' Observatory/WHO Collaborating Centre for Public Health Palliative Care Programmes, Institut Catala d' Oncologia, Barcelona, Spain .,Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain
| | - Pamela Turrillas
- The 'Qualy' Observatory/WHO Collaborating Centre for Public Health Palliative Care Programmes, Institut Catala d' Oncologia, Barcelona, Spain.,Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain
| | - Cristian Tebé
- Department of Statistics, Biomedical Research Institute of Bellvitge (IDIBELL), Barcelona, Spain
| | - Agnès Calsina-Berna
- The 'Qualy' Observatory/WHO Collaborating Centre for Public Health Palliative Care Programmes, Institut Catala d' Oncologia, Barcelona, Spain.,Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain
| | - Jordi Amblàs-Novellas
- Chair of Palliative Care, Faculty of Medicine, University of Vic ‒ Central University of Catalonia, Vic, Barcelona, Spain.,Central Catalonia Chronicity Research Group (C3RG), Centre for Health and Social Care Research (CESS), University of Vic - Central University of Catalonia, Vic, Barcelona, Spain
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31
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Affiliation(s)
- Helen Merlane
- Senior Lecturer, Adult Nursing, Northumbria University
| | - Laura Cauwood
- Nurse Specialist, Palliative Care, Community Palliative Care Team, Newcastle upon Tyne Hospitals NHS Foundation Trust
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32
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Afshar K, Wiese B, Schneider N, Müller-Mundt G. Systematic identification of critically ill and dying patients in primary care using the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE). GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2020; 18:Doc02. [PMID: 32047417 PMCID: PMC6997946 DOI: 10.3205/000278] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 08/01/2019] [Indexed: 11/30/2022]
Abstract
Objective: The systematic identification of patients who are at risk of deteriorating and dying is the prerequisite for the provision of palliative care (PC). This study aimed to investigate the feasibility and practicability of the German version of the Supportive and Palliative Care Indicators Tool (SPICT-DE) for the systematic identification of these patients in general practice. Methods: In the beginning of 2017, twelve general practitioners (GPs; female n=6) were invited to take part in the study. GPs were asked to apply the SPICT-DE in everyday practice over a period of two months in patients with chronic progressive diseases. Six months after initial assessment, a follow-up survey revealed how the clinical situation of the initially identified patients had changed and which PC actions had been initiated by GPs. In addition, GPs gave feedback on the practicability of SPICT-DE in daily routine. Results: 10 of the 12 GPs (female n=5, median age 46 years, range 38–68) participated in both the two-month assessment period and the follow-up survey. A total of 79 patients (female n=40, median age 79 years, range 44–94) was assessed with the SPICT-DE. Main diagnoses were predominately of cardio-vascular (n=28) or oncological (n=26) origin. Follow-up after six months showed that 38 patients (48%) went through at least one crisis during the course of disease and almost one third (n=26) had died. The majority of GPs (n=7) considered the SPICT-DE to be practical in daily routine and helpful in identifying patients who might benefit from PC. Seven GPs indicated that they would use the SPICT-DE as part of everyday practice. Conclusions: The SPICT-DE seems to be a practical tool supporting the systematic identification of critically ill and dying patients in general practice.
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Affiliation(s)
- Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Hannover, Germany
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Olsson C, Kling E, Grundel Persson K, Larsson M. Impact of the Liverpool Care Pathway on quality end-of- care in residential care homes and home care-Nurses' perceptions. Nurs Open 2019; 6:1589-1599. [PMID: 31660187 PMCID: PMC6805710 DOI: 10.1002/nop2.364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/28/2019] [Accepted: 08/05/2019] [Indexed: 12/02/2022] Open
Abstract
AIM Aim was to describe how Registered Nurses (RNs) and assistant nurses (ANs) working in residential care homes and home care perceived quality end-of-life care after implementation of the Liverpool Care Pathway (LCP) in terms of subjective importance of care aspects and actual care given. DESIGN Descriptive cross-sectional. METHODS Registered Nurses (N = 22; 100% response rate) and ANs (N = 120; 59% response rate) working in a Swedish municipality. Data collection with a study-specific questionnaire (50 items) about perceived reality (PR) and subjective importance (SI). Non-parametric statistics. RESULTS Implementation of the LCP ensured systematic assessment and alleviation of patients' symptoms and needs. The ANs, more than the RNs, perceived that the patients received the best possible nursing and medical care (p = .01). Both groups considered that communication with patients and families as well as the information exchange between the team members was facilitated. Areas for improvement were identified about psychological and existential support and patients and families' participation in care.
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Affiliation(s)
- Cecilia Olsson
- Department of Health SciencesKarlstad UniversityKarlstadSweden
| | - Elisabeth Kling
- Department of Health SciencesKarlstad UniversityKarlstadSweden
| | | | - Maria Larsson
- Department of Health SciencesKarlstad UniversityKarlstadSweden
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Sobanski PZ, Alt-Epping B, Currow DC, Goodlin SJ, Grodzicki T, Hogg K, Janssen DJA, Johnson MJ, Krajnik M, Leget C, Martínez-Sellés M, Moroni M, Mueller PS, Ryder M, Simon ST, Stowe E, Larkin PJ. Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement. Cardiovasc Res 2019; 116:12-27. [DOI: 10.1093/cvr/cvz200] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 04/19/2019] [Accepted: 08/02/2019] [Indexed: 01/12/2023] Open
Abstract
Abstract
Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.
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Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Centre, Department of Internal Medicine, Spital Schwyz, Waldeggstrasse 10, 6430 Schwyz, Switzerland
| | - Bernd Alt-Epping
- Department of Palliative Medicine, University Medical Center Göttingen Georg August University, Robertkochstrasse 40, 37075 Göttingen, Germany
| | - David C Currow
- University of Technology Sydney, Broadway, Ultimo, Sydney, 2007 New South Wales, Australia
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), Faculty of Health, University of Technology Sydney, Ultimo, Sydney, New South Wales, Australia
| | - Sarah J Goodlin
- Department of Medicine-Geriatrics, Portland Veterans Affairs Medical Center and Patient-cantered Education and Research, 3710 SW US Veterans Rd, Portland, 97239 OR, USA
| | - Tomasz Grodzicki
- Department of Internal Medicine and Gerontology, Jagiellonian University Medical College, 31-531 Kraków, Śniadeckich 10, Poland
| | | | - Daisy J A Janssen
- Department of Research and Education, CIRO, Hornerheide 1, 6085 NM Horn, The Netherlands
- Department of Health Services Research, CAPHRI School for Public Health and Primary Care, Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, 6229 GT, Maastricht, The Netherlands
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Allam Medical Building University of Hull, Cottingham Road, Hull, HU6 7RX, UK
| | - Małgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Skłodowskiej-Curie 9, 85-094 Bydgoszcz, Poland
| | - Carlo Leget
- University of Humanistic Studies, Chair Care Ethics, Kromme Nieuwegracht 29, Utrecht, The Netherlands
| | - Manuel Martínez-Sellés
- Department of Cardiology, Hospital Universitario Gregorio Marañón, CIBERCV, Universidad Europea, Universidad Complutense, C/ Dr. Esquerdo, 46, 28007 Madrid, Spain
| | - Matteo Moroni
- S.S.D. Cure Palliative, sede di Ravenna, AUSL Romagna, Via De Gasperi 8, 48121 Ravenna, Italy
| | - Paul S Mueller
- Mayo Clinic Health System, Mayo Clinic Collage of Medicine and Science, 700 West Avennue South, La Crosse, 54601 Wisconsin, USA
| | - Mary Ryder
- School of Nursing, Midwifery & Health Systems, University College Dublin, Ireland St. Vincent’s University Hospital Dublin,Belfield, Dublin 4, Ireland
| | - Steffen T Simon
- Department of Palliative Medicine, Medical Faculty of the Universityof Cologne, Köln, Germany
- Centre for Integrated Oncology Cologne/Bonn (CIO), Medical Faculty ofthe University of Cologne, Kerpener Strasse 62, 50924 Köln, Germany
| | | | - Philip J Larkin
- Service des soins palliatifs Lausanne University Hospital, CHUV, Centre hospitalier univeritaire vaudois, Lausanne Switzerland
- Institut universitaire de formation et de recherche en soins – IUFRS, Faculté de viologie et de medicine – FBM, Lausanne, Switzerland
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The association between PaTz and improved palliative care in the primary care setting: a cross-sectional survey. BMC FAMILY PRACTICE 2019; 20:112. [PMID: 31376833 PMCID: PMC6679548 DOI: 10.1186/s12875-019-1002-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 07/24/2019] [Indexed: 12/04/2022]
Abstract
Background The PaTz-method (acronym for Palliatieve Thuiszorg, palliative care at home) is perceived to improve coordination, continuity and communication in palliative care in the Netherlands. Although important for further implementation, research showing a clear effect of PaTz on patient-related outcomes is scarce. This study aimed to examine perceived barriers and added value of PaTz and its association with improved care outcomes. Methods Ninety-eight Dutch general practitioners and 229 Dutch district nurses filled out an online questionnaire with structured questions on added value and barrier perception of PaTz-participation, and palliative care provided to their most recently deceased patient, distributed online by Dutch medical and nurses’ associations. Data from PaTz-participants and non-participants was compared using Chi-square tests, independent t-tests and logistic regression analyses. Results While both PaTz-participants and non-participants perceived PaTz to be beneficial for knowledge collaboration, coordination and continuity of care, time (or lack thereof) is considered the most important barrier for participation. PaTz-participation is associated with discussing five or more end-of-life topics with patients (OR = 3.16) and with another healthcare provider (OR = 2.55). PaTz-participation is also associated with discussing palliative sedation (OR = 3.85) and euthanasia (OR = 2.97) with another healthcare provider. Significant associations with other care outcomes were not found. Conclusions General practitioners and district nurses feel that participating in a PaTz-group has benefits, but perceive various barriers for participation. While participating in a PaTz-group is associated with improved communication between healthcare providers and with patients, the effect on patient outcomes remains unclear. To stimulate further implementation, future research should focus on the effect of PaTz on tangible care characteristics and how to facilitate participation and remove barriers.
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Dobson J. Providing high-quality care at the end of life: the role of education and guidance. ACTA ACUST UNITED AC 2019; 26:1116-1120. [PMID: 29125338 DOI: 10.12968/bjon.2017.26.20.1116] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Palliative care in the UK has been ranked as the best in the world. So where did palliative care go so wrong that a 168-page document is required to inform staff how to care for dying patients if it has been going so well for so long? Those nearing the end of their life deserve to be given optimum care, attention, compassion and consideration, but this is not always the case. The Liverpool Care Pathway was a tool originally devised to help health professionals provide high-quality end-of-life care to people in the final phase of life. This tool, when used in the correct way, could provide the 'gold standard' of end-of-life care for patients. However, a national review found that rather than a tick-box exercise, care of the dying should be centred around individualised care planning for the dying patient, as highlighted in the publication of the guidance: One Chance to Get It Right. Care of the dying is a complex skill that requires nurses to provide some of the most challenging care, and for which many nurses have received little or no training. The implementation of this guidance into practice will require thoughtful change management, abandoning an old way of working in order to ensure excellence and high-quality care for patients nearing the end of life.
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Affiliation(s)
- Jill Dobson
- Senior Lecturer, Acute, Critical and Emergency Nursing, University of Central Lancashire, Preston
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Afshar K, Müller-Mundt G, van Baal K, Schrader S, Wiese B, Bleidorn J, Stiel S, Schneider N. Optimal care at the end of life (OPAL): study protocol of a prospective interventional mixed-methods study with pretest-posttest-design in a primary health care setting considering the view of general practitioners, relatives of deceased patients and health care stakeholders. BMC Health Serv Res 2019; 19:486. [PMID: 31307457 PMCID: PMC6631539 DOI: 10.1186/s12913-019-4321-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/03/2019] [Indexed: 11/10/2022] Open
Abstract
Background At the end of life, about 85–90% of patients can be treated within primary palliative care (PC) provided by general practitioners (GPs). In Germany, there is no structured approach for the provision of PC by GPs including a systematic as well as timely identification of patients who might benefit from PC, yet. The project “Optimal care at the end of life” (OPAL) focusses on an improvement of primary PC for patients with both oncological and non-oncological chronic progressive diseases in their last phase of life provided by GPs and health care services. Methods OPAL will take place in Hameln-Pyrmont, a rural region in Lower Saxony, Germany. Target groups are (a) GPs, (b) relatives of deceased patients and (c) health care providers. The study follows a three-phase approach in a mixed-methods and pre-post design. In phase I (baseline, t0) we explore the usual practice of providing PC for patients with chronic progressive diseases by GPs and the collaboration with other health care providers. In phase II (intervention) the Supportive and Palliative Care Indicators Tool (SPICT) for the timely identification of patients who might benefit from PC will be implemented and tested in general practices. Furthermore, a public campaign will be started to inform stakeholders, to connect health care providers and to train change agents. In phase III (follow-up, t1) we investigate the potential effect of the intervention to evaluate differences in the provision of PC by GPs and to convey factors for the implementation of SPICT in general practices. Discussion The project OPAL is the first study to implement the SPICT-DE regionwide in general practices in Germany. The project OPAL may contribute to an overall optimisation of primary PC for patients in Germany by reducing GPs’ uncertainty in initiating PC, by consolidating their skills and competencies in identifying patients who might benefit from PC, and by improving the cooperation between GPs and different health care stakeholders. Trial registration The study was retrospectively registered at the German Clinical Trials Register (Deutsches Register Klinischer Studien; trial registration number: DRKS00015108; date of registration: 22th of January 2019).
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Affiliation(s)
- Kambiz Afshar
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Gabriele Müller-Mundt
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.
| | - Katharina van Baal
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Sophie Schrader
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Birgitt Wiese
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Jutta Bleidorn
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany.,Institute of General Practice and Family Medicine, Jena University Hospital, Bachstraße 18, 07743, Jena, Germany
| | - Stephanie Stiel
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Nils Schneider
- Institute for General Practice, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
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White N, Reid F, Harries P, Harris AJL, Minton O, McGowan C, Lodge P, Tookman A, Stone P. The (un)availability of prognostic information in the last days of life: a prospective observational study. BMJ Open 2019; 9:e030736. [PMID: 31292186 PMCID: PMC6624101 DOI: 10.1136/bmjopen-2019-030736] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES The aims of this study were (1) to document the clinical condition of patients considered to be in the last 2 weeks of life and (2) to compare patients who did or did not survive for 72 hours. DESIGN A prospective observational study. SETTING Two sites in London, UK (a hospice and a hospital palliative care team). PARTICIPANTS Any inpatient, over 18 years old, English speaking, who was identified by the palliative care team as at risk of dying within the next 2 weeks was eligible. OUTCOME MEASURES Prognostic signs and symptoms were documented at a one off assessment and patients were followed up 7 days later to determine whether or not they had died. RESULTS Fifty participants were recruited and 24/50 (48%) died within 72 hours of assessment. The most prevalent prognostic features observed were a decrease in oral food intake (60%) and a rapid decline of the participant's global health status (56%). Participants who died within 72 hours had a lower level of consciousness and had more care needs than those who lived longer. A large portion of data was unavailable, particularly that relating to the psychological and spiritual well-being of the patient, due to the decreased consciousness of the patient. CONCLUSIONS The prevalence of prognostic signs and symptoms in the final days of life has been documented between those predicted to die and those who did not. How doctors make decisions with missing information is an area for future research, in addition to understanding the best way to use the available information to make more accurate predictions.
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Affiliation(s)
- Nicola White
- Marie Curie Palliative Care Research Department, University College London, London, London, UK
| | - Fiona Reid
- Department of Primary Care & Public Health Sciences, King’s College London, London, London, UK
| | - Priscilla Harries
- Centre for Applied Health and Social Care Research (CAHSCR), Kingston University & St George’s, University of London, London, UK
- Department of Clinical Sciences, Brunel University London, London, UK
| | - Adam J L Harris
- Experimental Psychology, University College London, London, London, UK
| | - Ollie Minton
- Palliative Medicine, Brighton and Sussex University Hospitals NHS Trust, Brighton, Brighton and Hove, UK
| | - Catherine McGowan
- Palliative Medicine, St. Georges University Hospitals NHS Foundation Trust, London, UK
| | - Philip Lodge
- Palliative Medicine, Royal Free London NHS Foundation Trust, London, London, UK
- Marie Curie Hospice Hampstead, London, UK
| | - Adrian Tookman
- Palliative Medicine, Royal Free London NHS Foundation Trust, London, London, UK
- Marie Curie Hospice Hampstead, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, London, UK
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Abstract
This review proposes that the end of life is a uniquely contemporary life course stage. Epidemiologic, technological, and cultural shifts over the past two centuries have created a context in which dying has shifted from a sudden and unexpected event to a protracted, anticipated transition following an incurable chronic illness. The emergence of an end-of-life stage lasting for months or even years has heightened public interest in enhancing patient well-being, autonomy, and the receipt of medical care that accords with patient and family members' wishes. We describe key components of end-of-life well-being and highlight socioeconomic and race disparities therein, drawing on fundamental cause theory. We describe two practices that are critical to end-of-life well-being (advance care planning and hospice) and identify limitations that may undermine their effectiveness. We conclude with recommendations for future sociological research that could inform practices to enhance patient and family well-being at the end of life.
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Affiliation(s)
- Deborah Carr
- Department of Sociology, Boston University, Boston, Massachusetts 02215, USA
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Cardona M, O'Sullivan M, Lewis ET, Turner RM, Garden F, Alkhouri H, Asha S, Mackenzie J, Perkins M, Suri S, Holdgate A, Winoto L, Chang DW, Gallego‐Luxan B, McCarthy S, Hillman K, Breen D. Prospective Validation of a Checklist to Predict Short-term Death in Older Patients After Emergency Department Admission in Australia and Ireland. Acad Emerg Med 2019; 26:610-620. [PMID: 30428145 PMCID: PMC6619350 DOI: 10.1111/acem.13664] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 11/03/2018] [Accepted: 11/07/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Emergency departments (EDs) are pressured environment where patients with supportive and palliative care needs may not be identified. We aimed to test the predictive ability of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist to flag patients at risk of death within 3 months who may benefit from timely end-of-life discussions. METHODS Prospective cohorts of >65-year-old patients admitted for at least one night via EDs in five Australian hospitals and one Irish hospital. Purpose-trained nurses and medical students screened for frailty using two instruments concurrently and completed the other risk factors on the CriSTAL tool at admission. Postdischarge telephone follow-up was used to determine survival status. Logistic regression and bootstrapping techniques were used to test the predictive accuracy of CriSTAL for death within 90 days of admission as primary outcome. Predictability of in-hospital death was the secondary outcome. RESULTS A total of 1,182 patients, with median age 76 to 80 years (IRE-AUS), were included. The deceased had significantly higher mean CriSTAL with Australian mean of 8.1 (95% confidence interval [CI] = 7.7-8.6) versus 5.7 (95% CI = 5.1-6.2) and Irish mean of 7.7 (95% CI = 6.9-8.5) versus 5.7 (95% CI = 5.1-6.2). The model with Fried frailty score was optimal for the derivation (Australian) cohort but prediction with the Clinical Frailty Scale (CFS) was also good (areas under the receiver-operating characteristic [AUROC] = 0.825 and 0.81, respectively). Values for the validation (Irish) cohort were AUROC = 0.70 with Fried and 0.77 using CFS. A minimum of five of 29 variables were sufficient for accurate prediction, and a cut point of 7+ or 6+ depending on the cohort was strongly indicative of risk of death. The most significant independent predictor of short-term death in both cohorts was frailty, carrying a twofold risk of death. CriSTAL's accuracy for in-hospital death prediction was also good (AUROC = 0.795 and 0.81 in Australia and Ireland, respectively), with high specificity and negative predictive values. CONCLUSIONS The modified CriSTAL tool (with CFS instead of Fried's frailty instrument) had good discriminant power to improve certainty of short-term mortality prediction in both health systems. The predictive ability of models is anticipated to help clinicians gain confidence in initiating earlier end-of-life discussions. The practicalities of embedding screening for risk of death in routine practice warrant further investigation.
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Affiliation(s)
- Magnolia Cardona
- Centre for Research in Evidence‐Based PracticeFaculty of Health Sciences and MedicineBond UniversityRobinaQLDAustralia
- School of Public Health and Community MedicineThe University of New South WalesSydneyNSWAustralia
| | | | - Ebony T. Lewis
- School of Public Health and Community MedicineThe University of New South WalesSydneyNSWAustralia
| | - Robin M. Turner
- Dean's OfficeDunedin School of MedicineUniversity of OtagoDunedinNew Zealand
| | - Frances Garden
- Ingham Institute for Applied Medical ResearchLiverpoolNSWAustralia
| | - Hatem Alkhouri
- Emergency Care InstituteAgency for Clinical InnovationChatswoodNSWAustralia
| | - Stephen Asha
- Emergency DepartmentSt George HospitalKogarahNSWAustralia
| | - John Mackenzie
- Emergency DepartmentPrince of Wales Hospital RandwickNSWAustralia
| | - Margaret Perkins
- Emergency DepartmentCampbelltown HospitalCampbelltownNSWAustralia
| | - Sam Suri
- Intensive Care UnitCampbelltown HospitalCampbelltownNSWAustralia
| | - Anna Holdgate
- Emergency DepartmentLiverpool HospitalLiverpoolNSWAustralia
| | - Luis Winoto
- Emergency DepartmentSutherland Hospital SutherlandNSWAustralia
| | - David C. W. Chang
- Graduate School of Biomedical EngineeringThe University of New South WalesSydneyNSWAustralia
| | - Blanca Gallego‐Luxan
- Centre for Health InformaticsAustralian Institute of Health InnovationMacquarie UniversitySydneyNSWAustralia
| | - Sally McCarthy
- Emergency DepartmentPrince of Wales Hospital RandwickNSWAustralia
| | - Ken Hillman
- South Western Sydney Clinical SchoolThe University of New South WalesSydneyNSWAustralia
- Intensive Care UnitLiverpool HospitalLiverpoolNSWAustralia
| | - Dorothy Breen
- Intensive Care UnitCork University HospitalCorkIreland
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Gunasekaran B, Scott C, Ducharlet K, Marco D, Mitchell I, Weil J. Recognising and managing dying patients in the acute hospital setting: can we do better? Intern Med J 2019; 49:119-122. [DOI: 10.1111/imj.14177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 06/03/2018] [Accepted: 06/13/2018] [Indexed: 11/27/2022]
Affiliation(s)
| | | | - Kathryn Ducharlet
- Department of Nephrology; St Vincent’s Hospital; Victoria Australia
- Department of Medicine; St Vincent’s Hospital; Victoria Australia
| | - David Marco
- Centre for Palliative Care; Victoria Australia
- Melbourne School of Psychological Sciences; The University of Melbourne; Melbourne Victoria Australia
| | - Imogen Mitchell
- Intensive Care Unit; The Canberra Hospital; Canberra Australian Capital Territory Australia
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Alt-Epping B. Palliative Care. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_116-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Palliative Care. Radiat Oncol 2019. [DOI: 10.1007/978-3-319-52619-5_116-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Taylor P, Johnson MJ, Dowding DW. Clinical decision-making at the end of life: a mixed-methods study. BMJ Support Palliat Care 2018; 10:e26. [PMID: 30337327 DOI: 10.1136/bmjspcare-2018-001535] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 08/10/2018] [Accepted: 09/05/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To improve the ability of clinical staff to recognise end of life in hospital inpatients dying as a result of cancer and heart failure, and to generate new hypotheses for further research. METHODS This mixed-methods study used decision theory as a theoretical basis. It involved a parallel databases-convergent design, incorporating findings from previously published research, with equal priority to study groups and synthesis by triangulation. The individual arms were (1) a retrospective cohort study of 102 patients with cancer and 81 patients with heart failure in an acute trust in the North of England, and(2) a semistructured interview study of 19 healthcare professionals caring for the same patient groups. RESULTS The synthesis of findings demonstrated areas of agreement, partial agreement, silence and dissonance when comparing the cohort findings with the interview findings. Trajectories of change are identified as associated with poor prognosis in both approaches, but based on different parameters. Management of patients has a significant impact on decision-making. The decision process requires repeated, iterative assessments and may benefit from a multidisciplinary approach. Uncertainty is a defining characteristic of the overall process, and objective parameters only have a limited role in predicting end of life. CONCLUSIONS The role of uncertainty is important as a trigger for discussions and a defined stage in a patient's illness journey. This is consistent with current approaches to recognising irreversible deterioration in those with serious illness. This study contributes ongoing evidence that these concepts are vital for decision-making.
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Affiliation(s)
- Paul Taylor
- St Luke's Hospice, Sheffield, UK .,School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
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Couples affected by dementia and their experiences of advance care planning: a grounded theory study. AGEING & SOCIETY 2018. [DOI: 10.1017/s0144686x1800106x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractGlobal policy places emphasis on the implementation and usage of advance care planning (ACP) to inform decision making at the end of life. For people with dementia, where its use is encouraged at the point of diagnosis, utilisation of ACP is relatively poor, particularly in parts of Europe. Using a constructivist grounded theory methodology, this study explores the ways in which co-residing couples considered ACP. Specifically, it seeks to understand the ways in which people with dementia and their long-term co-residing partners consider and plan, or do not plan, for future medical and social care. Sixteen participants were interviewed. They identified the importance of relationships in the process of planning alongside an absence of formal service support and as a result few engaged in ACP. The study recognises the fundamental challenges for couples in being obliged to consider end-of-life issues whilst making efforts to ‘live well’. Importantly, the paper identifies features of the ACP experience of a relational and biographical nature. The paper challenges the relevance of current global policy and practice, concluding that what is evident is a process of ‘emergent planning’ through which couples build upon their knowledge of dementia, their networks and relationships, and a number of ‘tipping points’ leading them to ACP. The relational and collective nature of future planning is also emphasised.
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Teggi D. Unexpected death in ill old age: An analysis of disadvantaged dying in the English old population. Soc Sci Med 2018; 217:112-120. [PMID: 30300761 DOI: 10.1016/j.socscimed.2018.09.048] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 09/19/2018] [Accepted: 09/24/2018] [Indexed: 11/30/2022]
Abstract
The literature on death expectation in ill old age is mostly medical. A social science standpoint (especially quantitative) is practically absent. However, whether families, social and healthcare services can anticipate, support and prepare for the deaths of ill old adults is not reducible to the biomedical paradigm. Yet it is critical for end of life care (EOLC) policy. This study's aim is to investigate relatives' perception of death as unexpected in relation to both disease-related and care-related factors. Using the English Longitudinal Study of Ageing End-of-life Interviews Wave 6 this paper draws on probit regression analysis of unexpected (vs. expected) death in ill adults aged 50+. Findings are interpreted considering the containment of sudden death and the trajectories of dying in ill old age. The latter display overall visible decline preceding death. On this basis, EOLC literature and policy evidence death's uncertain timing as much as death's certain emergence in the horizon of expectation. Therefore, unexpected death in ill old age was interpreted as a failure to acknowledge dying, rather than the impossibility of discerning its approach. Very old age, dementia diagnoses and supported care environments were found to shape unexpected death.
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Affiliation(s)
- Diana Teggi
- Department of Social & Policy Sciences, Centre for Death & Society, University of Bath, Claverton Down, Bath, BA2 7AY, United Kingdom.
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Who Benefits from Aggressive Rapid Response System Treatments Near the End of Life? A Retrospective Cohort Study. Jt Comm J Qual Patient Saf 2018; 44:505-513. [PMID: 30166034 DOI: 10.1016/j.jcjq.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 04/02/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Many patients near the end of life are subject to rapid response system (RRS) calls. A study was conducted in a large Sydney teaching hospital to identify a cutoff point that defines nonbeneficial treatment for older hospital patients receiving an RRS call, describe interventions administered, and measure the cost of hospitalization. METHODS This was a retrospective cohort of 733 adult inpatients with data for the period three months before and after their last placed RRS call. Subgroup analysis of patients aged ≥ 80 years was conducted. Log-rank, chi-square, and t-tests were used to compare survival, and logistic regression was used to examine predictors of death. RESULTS Overall, 65 (8.9%) patients had a preexisting not-for-resuscitation (NFR) or not-for-RRS order; none of those patients survived to three months. By contrast, patients without an NFR or not-for-RRS order had three-month survival probability of 71% (log-rank χ2 145.63; p < 0.001). Compared with survivors, RRS recipients who died were more likely to be older, to be admitted to a medical ward, and to have a larger mean number of admissions before the RRS. The average cost of hospitalization for the very old transferred to the ICU was higher than for those not requiring treatment in the ICU (US$33,990 vs. US$14,774; p = 0.045). CONCLUSION Identifiable risk factors clearly associated with poor clinical outcomes and death can be used as a guide to administer less aggressive treatments, including reconsideration of ICU transfers, adherence to NFR orders, and transition to end-of-life management instead of calls to the RRS team.
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Taylor P, Crouch S, Howell DA, Dowding DW, Johnson MJ. Change in Physiological Variables in the Last Two Weeks of Life: An Observational Study of Hospitalized Adults With Heart Failure. J Pain Symptom Manage 2018; 55:1335-1340. [PMID: 29366912 DOI: 10.1016/j.jpainsymman.2018.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/05/2018] [Accepted: 01/10/2018] [Indexed: 01/17/2023]
Abstract
CONTEXT Recognition of dying is a difficult task in end-stage heart failure, yet it remains an important clinical skill in providing good palliative care to these patients. OBJECTIVES To use routinely collected data to explore evidence for physiological change in the final two weeks of life in end-stage heart failure. METHODS This was a retrospective cohort study of routinely collected data from hospital inpatients dying as a result of heart failure during a one-year period in a U.K. hospital. Data were analyzed using descriptive techniques and multilevel modeling. RESULTS Results were obtained on 81 patients. Respiratory function (evidenced by falling oxygen saturation and rising respiratory rate) deteriorated by a clinically significant amount in the final two weeks of life (P < 0.001). Renal function (evidenced by rising serum urea and creatinine) also demonstrated a clinically significant deterioration over the same period (P < 0.001 and P = 0.005, respectively). Serum albumin fell over a period of months (P < 0.001). Heart rate and blood pressure did not demonstrate clinically significant change over the same period. CONCLUSIONS Deteriorating respiratory and renal function may indicate imminent dying in heart failure. A fall in serum albumin may signify poor prognosis over a timescale of weeks to months. Conversely, hemodynamic parameters may remain relatively stable in the final days of life and should not be reassuring in end-stage heart failure patients.
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Affiliation(s)
- Paul Taylor
- School of Health and Related Research, University of Sheffield, Sheffield, UK; St Luke's Hospice, Sheffield, UK.
| | | | | | - Dawn W Dowding
- Columbia University School of Nursing, New York, New York, USA; Centre for Home Care Policy and Research, Visiting Nurse Service of New York, New York, New York, USA
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Abstract
The hospice philosophy embraces palliative care for the terminally ill, for whom quality of life is the central focus of comfort care management. Often, caregivers hesitate or simply do not elect to extend oral care for patients nearing the end of life, due to difficulties encountered in patient compliance, a sense of futility in doing so, staff time constraints in prioritizing care, underfunding, or a lack of education as to how and why such care should be delivered to the hospice patient. This article aims to show physiological and psychosocial reasons why the hospice patient has a need for properly and regularly implemented oral care and why dental professionals have an ethical responsibility to address the current void that exists in hospice-centered oral care. Varying viewpoints are discussed regarding the need for oral health monitoring and maintenance in both the capable patient with capacity and in the patient who lacks capacity and is totally dependent, yet who exhibits no particular signs of oral distress nor desire for hygiene measures. Consideration is given to family dynamics in such care. Oral care of the elderly patients and terminally ill is sorely lacking, and dental educators are challenged to cultivate in students a sense of professional duty toward caring for the vulnerable elderly patients. Dental professionals should create initiatives in developing, promoting, and implementing an appropriate standard of oral care for the hospice patient.
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Affiliation(s)
- Kristi Soileau
- 1 Private Periodontal Practice in New Orleans, New Orleans, LA, USA
| | - Nanette Elster
- 2 Neiswanger Institute for Bioethics and Health Policy, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA
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Cardona M, Lewis ET, Turner RM, Alkhouri H, Asha S, Mackenzie J, Perkins M, Suri S, Holdgate A, Winoto L, Chang CW, Gallego-Luxan B, McCarthy S, Kristensen MR, O'Sullivan M, Skjøt-Arkil H, Ekmann AA, Nygaard HH, Jensen JJ, Jensen RO, Pedersen JL, Breen D, Petersen JA, Jensen BN, Mogensen CB, Hillman K, Brabrand M. Efficacy of a tool to predict short-term mortality in older people presenting at emergency departments: Protocol for a multi-centre cohort study. Arch Gerontol Geriatr 2018. [PMID: 29524917 DOI: 10.1016/j.archger.2018.02.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Prognostic uncertainty inhibits clinicians from initiating timely end-of-life discussions and advance care planning. This study evaluates the efficacy of the CriSTAL (Criteria for Screening and Triaging to Appropriate aLternative care) checklist in emergency departments. METHODS Prospective cohort study of patients aged ≥65 years with any diagnosis admitted via emergency departments in ten hospitals in Australia, Denmark and Ireland. Electronic and paper clinical records will be used to extract risk factors such as nursing home residency, physiological deterioration warranting a rapid response call, personal history of active chronic disease, history of hospitalisations or intensive care unit admission in the past year, evidence of proteinuria or ECG abnormalities, and evidence of frailty to be concurrently measured with Fried Score and Clinical Frailty Scale. Patients or their informal caregivers will be contacted by telephone around three months after initial assessment to ascertain survival, self-reported health, post-discharge frailty and health service utilisation since discharge. Logistic regression and bootstrapping techniques and AUROC curves will be used to test the predictive accuracy of CriSTAL for death within 90 days of admission and in-hospital death. DISCUSSION The CriSTAL checklist is an objective and practical tool for use in emergency departments among older patients to determine individual probability of death in the short-term. Its validation in this cohort is expected to reduce clinicians' prognostic uncertainty on the time to patients' death and encourage timely end-of-life conversations to support clinical decisions with older frail patients and their families about their imminent or future care choices.
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Affiliation(s)
- Magnolia Cardona
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, PO Box 6087, UNSW, NSW, 1466 Australia.
| | - Ebony T Lewis
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, PO Box 6087, UNSW, NSW, 1466 Australia.
| | - Robin M Turner
- Dean's Office Dunedin School of Medicine, University of Otago, PO Box 56, Dunedin, 9054, New Zealand.
| | - Hatem Alkhouri
- Agency for Clinical Innovation, Emergency Care Institute, PO Box 699, Chatswood, NSW, 2057, Australia.
| | - Stephen Asha
- St George Hospital Emergency Department, Gray St, Kogarah, Sydney, NSW, 2217, Australia.
| | - John Mackenzie
- Prince of Wales Hospital Emergency Department, Barker St, Randwick, Sydney, NSW, 2031, Australia.
| | - Margaret Perkins
- Campbelltown Hospital Emergency Department, Therry Rd, Sydney, Campbelltown, NSW, 2560, Australia.
| | - Sam Suri
- Campbelltown Hospital Intensive Care Unit, Therry Rd, Sydney, Campbelltown, NSW, 2560, Australia.
| | - Anna Holdgate
- Liverpool Hospital Emergency Department, Corner of Elizabeth and Goulburn Streets, Sydney, Liverpool, NSW, 2170, Australia.
| | - Luis Winoto
- Sutherland Hospital Emergency Department, The Kingsway, Sydney, Caringbah, NSW, 2229, Australia.
| | - Chan-Wei Chang
- The University of New South Wales, Graduate School of Biomedical Engineering, Library Rd, Sydney, Kensington, NSW, 2033, Australia.
| | - Blanca Gallego-Luxan
- Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, North Ryde, Sydney, NSW, 2113, Australia.
| | - Sally McCarthy
- Agency for Clinical Innovation, Emergency Care Institute, PO Box 699, Chatswood, NSW, 2057, Australia; Prince of Wales Hospital Emergency Department, Barker St, Randwick, Sydney, NSW, 2031, Australia.
| | - Mette R Kristensen
- Hospital of South West Jutland, Finsensgade, 35, 6700, Esbjerg, Denmark.
| | | | - Helene Skjøt-Arkil
- Hospital of Southern Denmark, Kresten Philipsens Vej 15, 6200, Aabenraa, Denmark.
| | - Anette A Ekmann
- Bispebjerg og Frederiksberg University Hospital, Bispebjerg Bakke 23, Copenhagen 2400 NV, Denmark.
| | - Hanne H Nygaard
- Bispebjerg og Frederiksberg University Hospital, Bispebjerg Bakke 23, Copenhagen 2400 NV, Denmark.
| | - Jonas J Jensen
- Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, Denmark.
| | - Rune O Jensen
- Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, Denmark.
| | - Jonas L Pedersen
- Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, Denmark.
| | | | - John A Petersen
- Bispebjerg og Frederiksberg University Hospital, Bispebjerg Bakke 23, Copenhagen 2400 NV, Denmark.
| | - Birgitte N Jensen
- Bispebjerg og Frederiksberg University Hospital, Bispebjerg Bakke 23, Copenhagen 2400 NV, Denmark.
| | | | - Ken Hillman
- The Simpson Centre for Health Services Research, South Western Sydney Clinical School, The University of New South Wales, PO Box 6087, UNSW, NSW, 1466 Australia; Campbelltown Hospital Intensive Care Unit, Therry Rd, Sydney, Campbelltown, NSW, 2560, Australia; Liverpool Hospital Intensive Care Unit, The Ingham Institute for Applied Medical Research, Corner of Elizabeth and Goulburn Streets, Sydney, Liverpool, NSW, 2170, Australia.
| | - Mikkel Brabrand
- Hospital of South West Jutland, Finsensgade, 35, 6700, Esbjerg, Denmark; Odense University Hospital, J. B. Winsløws Vej 4, 5000, Odense C, Denmark.
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