Specialist palliative care improves the quality of life in advanced neurodegenerative disorders: NE-PAL, a pilot randomised controlled study

Living Will and Advance Care Planning in Patients With Amyotrophic Lateral Sclerosis Admitted to Specialistic Home Palliative Care

Objectives: In Italy a recent law was approved for providing patients' wishes regarding end of life issues, commonly referred internationally to as "living wills", (Dichiarazione anticipata di trattamento, DAT). Regardless of this official document, advance care planning (ACP) is often used in a palliative care setting to share the treatments to start, to continue, to withdraw, thus preventing the stress on an acute decision. The aim of this study was to assess DAT and ACP in patients with amyotropic lateral sclerosis admitted to home palliative care. Methods: Patients consecutively admitted to speciliazed home palliative care were prospectively assessed. The presence of DAT or ACP was recorded. Results: Sixty-eight patients were enrolled in the period taken into consideration. No patient had drown up DAT, and only one patient provided his ACP prior to home palliative care admission. Along the course of home palliative care care assistance, 30.9% of patients provided their ACP. Discussion: In Italy DAT resulted scarcely widespread, despite an existing law, as no patient officially provided their indication on end of life issues. In addition, ACP was given only after starting specialized home palliative care in less than 1/3 of patients. Home palliative care seems to be a fundamental resource for improving communication and soliciting expression of patients' wishes regarding end of life issues.

Outcomes and Issues Addressed by Palliative Care in the Neurology Clinic

Patients with neurological illnesses have many palliative care needs that need to be addressed in the outpatient clinical setting. This review discusses existing models of care delivery, including services delivered by neurology teams, palliative care specialists, telehealth, and home-based programs. We review the existing literature that supports these services and ongoing limitations that continue to create barriers to necessary clinical care for this vulnerable patient population.

Palliative care needs and utilisation of specialist services for people diagnosed with motor neuron disease: a national population-based study

INTRODUCTION

There is a growing emphasis on the importance of the availability of specialist palliative care for people with motor neuron disease (MND). However, the palliative care needs of this population and the utilisation of different specialist services remain poorly defined.

OBJECTIVES

To (1) describe clinical characteristics, symptom burden and functional levels of patients dying with MND on their admission to palliative care services; (2) determine factors associated with receiving inpatient or community palliative care services.

DESIGN

An observational study based on point-of-care assessment data from the Australian Palliative Care Outcomes Collaboration.

PARTICIPANTS

A total of 1308 patients who received palliative care principally because of MND between 1 January 2013 and 31 December 2020.

MEASURES

Five validated clinical instruments were used to assess each individual's function, distress from symptoms, symptom severity and urgency and acuity of their condition.

RESULTS

Most patients with MND had no or mild symptom distress, but experienced a high degree of functional impairment. Patients who required 'two assistants for full care' relative to those who were 'independent' (OR=11.53, 95% CI: 4.87 to 27.26) and those in 'unstable' relative to 'stable' palliative care phases (OR=16.74, 95% CI: 7.73 to 36.24) were more likely to use inpatient versus community-based palliative care. Associations between the use of different palliative care services and levels of symptom distress were not observed in this study.

CONCLUSIONS

Patients with MND were more likely to need assistance for decreased function and activities of daily living, rather than symptom management. This population could have potentially been cared for in the palliative phase in a community setting if greater access to supportive services were available in this context.

Characteristics of Patients With Amyotrophic Lateral Sclerosis Followed by a Home Palliative Care Team

BACKGROUND

Information about patients with amyothrophic lateral sclerosis (ALS) followed at home is limited.

OBJECTIVES

To assess patients's characteristics at admission to a home palliative care program based on a multidisciplinary team, and the temporal course along the trajectory of ALS disease.

DESIGN

Retrospective. Setting/subjects: Charts of a consecutive number of ALS patients who were referred to a specialistic home palliative care were reviewed.

MEASUREMENT

General data, referral, start of home palliative care, use of ventilator support and nutritional support, were recorded. The existence of advance directives and shared care planning was also collected.

RESULTS

82 patients were examined; 31 patients died before the term of the study and 51 patients were still living. No patient anticipately expressed their will regarding their treatments. However, a certain number of patients shared a care planning with ALS team, generally after starting home care. Most patients did not have ventilatory support at the beginning of home care assistance, but progressively received ventilatory support by NIV or MV, particularly those who were still living. NIV at start of home care was negatively correlated to frontotemporal dementia. (P = 0.015), and directly correlated to referral from hospital and GP (P = 0.031) and awareness of disease (P = 0.034). Gastrostomy at start of home care was positively correlated to referral from hospital (P = 0.046). Gastrostomy during home care was correlated to bulbar SLA (P = 0.017). The use of NIV during home care was positively correlated to shared care planning (P = 0.001).

CONCLUSION

The continuous presence of a multi-specialist team may provide timely intervention, guarantee and trust on the part of the patient and family members.

Patients' and caregivers' perception of multidimensional and palliative care in amyotrophic lateral sclerosis - protocol of a German multicentre study

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) is an inevitably fatal condition that leads to a progressive loss of physical functioning, which results in a high psychosocial burden and organizational challenges related to medical care. Multidimensional and multiprofessional care is advised to meet the complex needs of patients and their families. Many healthcare systems, including Germany, may not be able to meet these needs because non-medical services such as psychological support or social counselling are not regularly included in the care of patients with ALS (pwALS). Specialised neuropalliative care is not routinely implemented nor widely available. Caregivers of pwALS are also highly burdened, but there is still a lack of support services for them.

METHODS

This project aims to assess the perceptions and satisfaction with ALS care in Germany in pwALS and their caregivers. This will be achieved by means of a cross-sectional, multicentre survey. The examination will assess, to which extend the patients' needs in the six domains of physical, psychological, social, spiritual, practical and informational are being met by current care structures. This assessment will be linked to mental well-being, subjective quality of life, attitudes toward life-sustaining measures and physician-assisted suicide, and caregiver burden. The study aims to recruit 500 participants from nationwide ALS centres in order to draw comprehensive conclusions for Germany. A total of 29 centres, mostly acquired via the clinical and scientific German Network for Motor Neuron Diseases (MND-NET), will take part in the project, 25 of which have already started recruitment.

PERSPECTIVE

It is intended to provide data-based starting points on how current practice of care in Germany is perceived pwALS and their caregivers and how it can be improved according to their needs. Planning and initiation of the study has been completed.

TRIAL REGISTRATION

The study is registered at ClinicalTrails.gov; NCT06418646.

Palliative Care Interventions for Persons With Neurodegenerative Disease: A Scoping Review of Clinical Trial Study Design Features

Background: Within palliative care research, best practice guidelines to conduct scientifically rigorous clinical trials for neurodegenerative diseases are underexplored. This patient population experiences unique challenges, including fluctuations in cognitive capacity, care partner (CP) and proxy involvement, and high adverse events (AEs), that necessitate special consideration when designing clinical trials. Objective: The objective of this study was to describe and identify clinical trial design features that have been documented in studies involving a neuropalliative intervention for persons with neurodegenerative diseases, highlighting features that have been adapted for this unique patient population. Design: We conducted a scoping review of clinical trials with a neuropalliative intervention for persons with neurodegenerative disease. We searched Cochrane, Web of Science, EMBASE, Scopus, and PubMed (MEDLINE) databases for articles published in English between 1950 and 2023. Two reviewers screened, extracted, and synthesized data from the included articles. A third reviewer adjudicated instances of conflict. The data were analyzed using a thematic framework approach. Results: Of 1025 texts, 44 articles were included. Seven study design features were analyzed: (1) consent, (2) proxies and CPs, (3) recruitment strategies, (4) retention strategies, (5) choice of comparator, (6) AEs, and (7) internal validity. This scoping review found disparities in study design features around structured consent, proxies and CPs, comparators, and AEs. Conclusions: To date, neuropalliative care clinical trials have had varied study designs and the majority of research has focused on dementia. Research guideline development for high-quality neuropalliative care clinical trials is greatly needed across the range of neurodegenerative diseases. To increase the scientific rigor of clinical trials and neuropalliative care, we recommend a standardized capacity assessment for consent, defining conditions for the CP, proxy, and AEs, systematizing appropriate comparators, and outlining preemptive recruitment and retention strategies to address the broader unpredictable challenges of palliative care research.

Palliative Care Aspects in Multiple Sclerosis

CONTEXT

Multiple sclerosis (MS) is an inflammatory, chronic, demyelinating, and neurodegenerative disorder of central nervous system, determined by an auto-immune dysfunction. Severe disability generally occurs in patients with progressive forms of MS that typically develop either after an earlier relapsing phase or less commonly from disease onset. Despite advances in research to slow the progression of MS, this condition remains a life-limiting disease with symptoms impacting negatively the lives of patients and caregivers.

OBJECTIVES

To analyze the difefrent aspects of palliative cae in patients with MS.

METHODS

To analyse selected literature assessing several palliative care aspects in patients with MS.

RESULTS

People with MS have complex symptoms and different needs. These demands include how to deal with the burden of physical disability, how to organise daily life, restructuring social roles in the family and at work, keeping self-sufficiency in personal care, and preserving personal identity and community roles.

CONCLUSION

An early palliative care approach aims to improve the palliative care skills and competencies of health professionals caring for the patients since the early stage of disease, including those who are actively undergoing disease-targeted therapies, rather than merely providing end-of-life care.

Optimizing breathlessness management in amyotrophic lateral sclerosis: insights from a comprehensive systematic review

BACKGROUND

Breathlessness is a prevalent symptom affecting the quality of life (QOL) of Amyotrophic Lateral Sclerosis (ALS) patients. This systematic review explored the interventions for controlling breathlessness in ALS patients, emphasizing palliative care (PALC), non-invasive ventilation (NIV), opioids, and non-pharmacological strategies.

METHODS

A comprehensive search of PubMed, Cochrane Library, and Web of Science databases was conducted. Eligibility criteria encompassed adults with ALS or motor neuron disease experiencing breathlessness. Outcomes included QOL and symptom control. Study designs comprised qualitative studies, cohort studies, and randomized controlled trials.

RESULTS

Eight studies were included, most exhibiting low bias risk, comprising one randomized controlled trial, three cohort studies, two comparative retrospective studies, and two qualitative studies (interviews). Most studies originated from Europe, with one from the United States of America. The participants totaled 3423, with ALS patients constituting 95.6%. PALC consultations significantly improved symptom assessment, advance care planning, and discussions about goals of care. NIV demonstrated efficacy in managing breathlessness, with considerations for device limitations. Opioids were effective, though predominantly studied in non-ALS patients. Non-pharmacological strategies varied in efficacy among patients.

CONCLUSION

The findings underscore the need for individualized approaches in managing breathlessness in ALS. PALC, NIV, opioids, and non-pharmacological strategies each play a role, with unique considerations. Further research, especially ALS-specific self-management studies, is warranted.

An introduction to neuropalliative care: A growing need

Palliative care (PC) defined as 'an approach improving the quality of life of patients and their families facing problems associated with life-limiting illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual' aims to enhance the improve the remaining time that patients have, emphasising choice for patients and families.1 Patients with neurological disease such as Parkinson's (PD) and motor neurone disease (MND) benefit from PC earlier in disease with increasing emphasis over time. Understanding and communicating uncertain trajectories, honest prognostic communication when patients are ready and careful symptom control has been shown to enhance quality of life in patients and caregivers, giving greater autonomy to these patients when supported in decision-making by a palliative approach. Although obstacles to palliative care are frequent, there are strategies which can help overcome them.

Caregiver Burden in Parkinson Disease: A Scoping Review of the Literature from 2017-2022

Caregiver burden is a term that refers to the adverse effect of caregiving on the physical, emotional, social, spiritual, and financial well-being of the caregiver. Caregiver burden is associated with providing care to an individual with a chronic illness or disability, and the unique symptoms of Parkinson disease (PD) can amplify a patient's needs and reliance on others, leading to adverse outcomes for patients and their caregivers. In this scoping review of the literature from January 2017 through April 2022 that included 114 studies, we provide an updated, evidence-based summary of patient and caregiver-related factors that contribute to caregiver burden in PD. We also describe the impact of caregiver stress and burden on caregivers based on qualitative research studies and review recent interventions to mitigate burden. By providing clinical updates for practitioners, this review is designed to improve recognition of caregiver burden in the post-pandemic era and foster the development of targeted interventions to reduce caregiver burden in PD.

Patient and Family Outcomes of Community Neurologist Palliative Education and Telehealth Support in Parkinson Disease

Importance

Parkinson disease and related disorders (PDRD) are the fastest growing neurodegenerative illness in terms of prevalence and mortality. As evidence builds to support palliative care (PC) for PDRD, studies are needed to guide implementation.

Objective

To determine whether PC training for neurologists and remote access to a PC team improves outcomes in patients with PDRD in community settings.

Design, Setting, and Participants

This pragmatic, stepped-wedge comparative effectiveness trial enrolled and observed participants from 19 community neurology practices supported by PC teams at 2 academic centers from March 8, 2017, to December 31, 2020. Participants were eligible if they had PDRD and moderate to high PC needs. A total of 612 persons with PDRD were referred; 253 were excluded. Patients were excluded if they had another diagnosis meriting PC, were receiving PC, or were unable or unwilling to follow study procedures. Patients received usual care or the intervention based on when their community neurologist was randomized to start the intervention. Data were analyzed from January 2021 to September 2023.

Intervention

The intervention included (1) PC education for community neurologists and (2) team-based PC support via telehealth.

Main Outcomes and Measures

The primary outcomes were differences at 6 months in patient quality of life (QOL; measured by the Quality of Life in Alzheimer Disease Scale [QOL-AD]) and caregiver burden (Zarit Burden Interview) between the intervention and usual care.

Results

A total of 359 patients with PDRD (233 men [64.9%]; mean [SD] age, 74.0 [8.8] years) and 300 caregivers were enrolled. At 6 months, compared with usual care, participants receiving the intervention had better QOL (QOL-AD score, 0.09 [95% CI, -0.63 to 0.82] vs -0.88 [95% CI, -1.62 to -0.13]; treatment effect estimate, 0.97; 95% CI, 0.07-1.86; P = .03). No significant difference was observed in caregiver burden (Zarit Burden Interview score, 1.19 [95% CI, 0.16 to 2.23] vs 0.55 [95%, -0.44 to 1.54]; treatment effect estimate, 0.64; 95% CI, -0.62 to 1.90; P = .32). Advance directive completion was higher under the intervention (19 of 38 [50%] vs 6 of 31 [19%] among those without directives at the beginning of the study; P = .008). There were no differences in other outcomes.

Conclusions and Relevance

PC education for community neurologists and provision of team-based PC via telehealth is feasible and may improve QOL and advance care planning. Overall treatment effects were small and suggest opportunities to improve both the intervention and implementation.

Trial Registration

ClinicalTrials.gov Identifier: NCT03076671.

Reach of Palliative Care for Parkinson Disease: Results From a Large National Survey of Patients and Care Partners

Background and Objectives

People with Parkinson disease (PWP) and their care partners have high palliative care needs resulting from disabling motor and nonmotor symptoms. There is growing support for palliative care (PC) approaches to Parkinson disease. However, little is known regarding the extent to which the palliative needs of PWP and care partners are currently being met. This study's primary objective is to describe PWP's and care partners' perceptions of the extent to which their PC needs are being met. Secondary objectives are to describe their perceptions of the quality of clinical communication and their knowledge of PC.

Methods

PWPs and care partners (n = 12,995) who had consented to receiving surveys from the Parkinson's Foundation were emailed an electronic survey. PC was operationalized as comprising 5 key components: systematic assessment and management of (1) nonmotor symptoms, (2) PWPs' emotional and spiritual needs, (3) care partners' needs, (4) the completion of annual advance care planning, and (5) timely referrals to specialist palliative care and hospice when appropriate.

Results

A total 1,882 individuals (1,266 PWP and 616 care partners) responded to the survey (response rate 14.5%). Few PWP (22%) reported that their neurologists never asked regarding bothersome nonmotor symptoms or did so or only if they brought it up. Fifty percent of PWP reported that pain as a specific nonmotor symptom was never managed or managed only if they brought it up. Similarly, PWPs' emotional and spiritual needs (55%), care partners' well-being (57%), and completion of advance care planning documentation (79%) were never addressed or only addressed if PWP brought it up. The quality of clinical communication was generally rated as open and honest (64% PWP). Fewer PWP (30%) reported that doctors helped them deal with the uncertainties of Parkinson disease. Most PWP (85%) reported being knowledgeable regarding PC, and 68% reported that the goal of PC was to help friends and family cope with the illness.

Discussion

Although some elements of PC are currently being addressed in routine care for PWP, there are many gaps and opportunities for improvement. These data may facilitate focused attention and development of resources to improve the quality and availability of PC for Parkinson disease.

Withdrawal of mechanical ventilation in amyotrophic lateral sclerosis patients: a multicenter Italian survey

BACKGROUND

Law 219/2017 was approved in Italy in December 2017, after a years-long debate on the autonomy of healthcare choices. This Law, for the first time in Italian legislation, guarantees the patient's right to request for withdrawal of life-sustaining treatments, including mechanical ventilation (MV).

OBJECTIVE

To investigate the current status of MV withdrawal in amyotrophic lateral sclerosis (ALS) patients in Italy and to assess the impact of Law 219/2017 on this practice.

METHODS

We conducted a Web-based survey, addressed to Italian neurologists with expertise in ALS care, and members of the Motor Neuron Disease Study Group of the Italian Society of Neurology.

RESULTS

Out of 40 ALS Italian centers, 34 (85.0%) responded to the survey. Law 219/2017 was followed by an increasing trend in MV withdrawals, and a significant increase of neurologists involved in this procedure (p 0.004). However, variations across Italian ALS centers were observed, regarding the inconsistent involvement of community health services and palliative care (PC) services, and the intervention and composition of the multidisciplinary team.

CONCLUSIONS

Law 219/2017 has had a positive impact on the practice of MV withdrawal in ALS patients in Italy. The recent growing public attention on end-of-life care choices, along with the cultural and social changes in Italy, requires further regulatory frameworks that strengthen tools for self-determination, increased investment of resources in community and PC health services, and practical recommendations and guidelines for health workers involved.

Palliative Care in Neuro-oncology: an Update

PURPOSE OF REVIEW

While the benefits of palliative care for patients with cancer are well established, palliative care in neuro-oncology is still in its early stages. However, in recent years, there has been increasing attention drawn to the need for better palliative care for patients with brain tumors.

RECENT FINDINGS

There is a growing body of literature demonstrating the high symptom burden and significant supportive care and information needs of these patients and their caregivers. In the area of caregiver needs, the last 3 years has seen a more rapid growth in recognizing and characterizing these needs. However, there remains a knowledge gap regarding the optimal means of addressing these needs. In this article, we outline important recent advances in the literature on palliative care for patients with brain tumors and highlight areas in need of greater attention and investigation.

Motor neurone disease: A point-prevalence study of patient reported symptom prevalence, severity and palliative care needs

BACKGROUND

Motor neurone disease is a rare but debilitating illness with incomplete evidence regarding patients' symptom burden. Palliative care and generalist clinicians are often in-experienced in caring for these patients and assessing their needs.

AIM

To identify the symptom prevalence and severity experienced by patients with motor neurone disease. Secondary objectives were to examine differences in symptom burden and clusters according to phenotype, functional status, palliative care provision and those in their last months of life.

DESIGN

A point prevalence study assessing patient-reported symptoms using a modified IPOS-Neuro assessment tool, incorporating 41 symptom items.

SETTING/PARTICIPANTS

Patients with motor neurone disease attending the State-wide Progressive Neurological Disease Service or inpatient unit at Calvary Health Care Bethlehem, Melbourne Australia, from March to December 2021.

RESULTS

A total of 102 patients participated, the majority diagnosed with lumber-onset (30.4%), bulbar-onset (28.4%) and cervical-onset (25.5%) phenotypes. Patients experienced a median of 17 symptoms (range 2-32) with a median of 3 symptoms rated as severe/overwhelming (range 0-13). Motor and functional symptoms predominated, with differences in symptom clusters present according to phenotype. Patients had a higher number of severe/overwhelming symptoms if they were accessing palliative care services (p = 0.005), in their last 6 months of life (p = 0.003) and experiencing moderate or severe functional impairment (p < 0.001).

CONCLUSIONS

Patients with motor neurone disease report high symptom burden. A validated motor neurone disease-specific symptom assessment tool is needed to accurately assess patients, including important variations in symptom clusters according to phenotype. Further research must focus on evidence-based treatment guidelines for symptoms experienced commonly and severely.

Palliative Care in Amyotrophic Lateral Sclerosis

Amyotrophic lateral sclerosis (ALS) is an incurable neurodegenerative disease of the motor neurons. Given the evolutive characteristics of this disease, palliative care principles should be a foundation of ALS care. A multidisciplinary medical intervention is of paramount importance in the different phases of disease. The involvement of the palliative care team improves quality of life and symptoms, and prognosis. Early initiation is of paramount importance to ensuring patient-centered care, when the patient has still the capability to communicate effectively and participate in his medical care. Advance care planning supports patients and family members in understanding and sharing their preferences according to their personal values and life goals regarding future medical treatment. The principal problems which require intensive supportive care include cognitive disturbances, psychological distress, pain, sialorrhrea, nutrition, and ventilatory support. Communication skills of health-care professionals are mandatory to manage the inevitability of death. Palliative sedation has peculiar aspects in this population, particularly with the decision of withdrawing ventilatory support.

Individualized Implementation of Youth Quality of Life Instrument-Research Version (YQOL-R) Among Chinese Adolescents with Different Weight Status

Purpose

This study implemented the individualized Youth Quality of Life Instrument-Research Version (YQOL-R) to estimate the quality of life (QoL) among Chinese adolescents with three different Body Mass Index (BMI) levels. The study aims to explore and provide a reference for developing individualized QoL (IQoL) measurements in China.

Methods

The sample consisted of 822 aged 11-18 from nine schools. The data collection included all participants' primary characters (age, sex, annual household income, parental education, and recruitment community) and their self-report QoL. Precisely, based on the generic measurement of YQOL-R, we developed IQoL measurements by asking adolescents' perceived five most important things to them (IQOLimportance) and the aspects they most want to change (IQOLchange) from 19 facets, respectively. The one-way analysis of variance (ANOVA) was applied to compare total and subscale scores of IQOLimportance, IQOLchange, and YQOL-R among adolescents with three different weight status. Also, the data analysis used multivariable linear regression modeling to test the effects on scores of IQOLimportance and IQOLchange.

Results

Overall, the obese adolescents identified "Having good physical health" as the most important (54.03%) and most like-to-change (42.65%); in contrast, the normal-weight group ranked "Being myself" as the top facet of IQOLimportance (52.42%) and "Having good friends" as the top facet of IQOLchange (43.12%). The obese adolescents' reported IQOLimportance scores are significantly lower than those of the normal-weight group (P=0.039). However, there is no significant difference in IQOLchange score among the three weight-status groups. The multivariable linear regression models indicated that adolescents who are girls (P=0.035), have higher educated fathers (P=0.049), and are overweight/obese (P=0.041) self-reported worse IQOLimportance score; yet, the girls (P=0.023) and older adolescents (P=0.004) answered lower IQOLchange scores. In addition, adolescents who had higher educated mothers (P=0.047; 0.023) and responded with higher total YQOL-R scores (P<0.001; <0.001) reported higher IQOLimportance and IQOLchange scores.

Conclusion

In the current study, although the self-reported YQOL-R scores from different weight status did not present a significant difference, the obese group reported a statistical trend towards lower IQOLimportance scores than the normal-weight and overweight adolescents. These findings emphasize that IQOLimportance and IQOLchange could capture adolescents' perspectives with different weight statuses about their lives, which are unique as complementary health outcomes accompanying YQOL-R in health surveys and interventions among Chinese adolescents.

A roadmap for early psychosocial support in palliative care for people impacted by ALS-reducing suffering, building resiliency, and setting the stage for delivering timely transdiagnostic psychosocial care

This commentary describes the current state of psychosocial care for people with amyotrophic lateral sclerosis and their caregivers. We provide recommendations for developing a roadmap for future research based on existing literature and our group's clinical and research experience to inform next steps to expand evidence-based psychosocial care for people with amyotrophic lateral sclerosis and their caregivers, with potential implications for a range of advanced illnesses.

Healthcare Costs at the End of Life for Patients with Non-cancer Diseases and Cancer in Denmark

OBJECTIVES

To examine costs of care from a healthcare sector perspective within 1 year before death in patients with non-cancer diseases and patients with cancer.

METHODS

This nationwide registry-based study identified all Danish citizens dying from major non-cancer diseases or cancer in 2010-2016. Applying the cost-of-illness method, we included costs of somatic hospitals, including hospital-based specialist palliative care, primary care, prescription medicine and hospice expressed in 2022 euros. Costs of patients with non-cancer diseases and cancer were compared using regression analyses adjusting for sex, age, comorbidity, residential region, marital/cohabitation status and income level.

RESULTS

Within 1 year before death, mean total healthcare costs were €27,185 [95% confidence interval (CI) €26,970-27,401] per patient with non-cancer disease (n = 109,723) and €51,348 (95% CI €51,098-51,597) per patient with cancer (n = 108,889). The adjusted relative total healthcare costs, i.e. the ratio of the mean costs, of patients with non-cancer diseases was 0.64 (95% CI 0.63-0.66) at 12 months before death and 0.91 (95% CI 0.90-0.92) within 30 days before death compared with patients with cancer. Mean costs of hospital-based specialist palliative care and hospice in the year leading up to death were €17 (95% CI €13-20) and €90 (95% CI €77-102) per patient with non-cancer disease but €1552 (95% CI €1506-1598) and €3411 (95% CI €3342-3480) per patient with cancer.

CONCLUSIONS

Within 1 year before death, total healthcare costs, mainly driven by hospital costs, were substantially lower for patients with non-cancer diseases compared with patients with cancer. Moreover, the costs of hospital-based specialist palliative care and hospice were minimal for patients with non-cancer diseases.

Palliative care to support the needs of adults with neurological disease

Neurological diseases cause physical, psychosocial, and spiritual or existential suffering from the time of their diagnosis. Palliative care focuses on improving quality of life for people with serious illness and their families by addressing this multidimensional suffering. Evidence from clinical trials supports the ability of palliative care to improve patient and caregiver outcomes by the use of outpatient or home-based palliative care interventions for people with motor neuron disease, multiple sclerosis, or Parkinson's disease; inpatient palliative care consultations for people with advanced dementia; telephone-based case management for people with dementia in the community; and nurse-led discussions with decision aids for people with advanced dementia in long-term care. Unfortunately, most people with neurological diseases do not get the support that they need for their palliative care under current standards of healthcare. Improving this situation requires the deployment of routine screening to identify individual palliative care needs, the integration of palliative care approaches into routine neurological care, and collaboration between neurologists and palliative care specialists. Research, education, and advocacy are also needed to raise standards of care.

Neuropalliative care for progressive neurological diseases: A scoping review on models of care and priorities for future research

BACKGROUND

Neuropalliative care is a newly-defined subspeciality bringing specific aspects of fields of neurology and palliative care together to better meet the complex care needs of people with progressive neurological diseases. Examining these needs would help provide guidance about developing relevant models of care and identify gaps in research knowledge.

AIM

To identify current models and approaches to neuropalliative care for people with progressive neurological diseases and the priorities for future research work.

DESIGN

A scoping literature review following the methods described by the Joanna Briggs Institute.

DATA SOURCES

An electronic search of the literature was undertaken from six sources including MEDLINE (Ovid), EMCARE, PsycINFO and CINAHL covering the years January 2011 to September 2021.

RESULTS

Twenty-eight studies were found examining neuropalliative care from the perspectives of 4795 PND patients, 774 informal carers and 138 health professionals. All studies held themes of integrative care, with most studies employing outpatient models of multidisciplinary care. Topics discussed included: overcoming local system-issues, providing education for professionals, patients and carers, early referral and capturing outcome measures for quality-assurance and future research work.

CONCLUSIONS

Most models of neuropalliative care described in the international literature are predominantly outpatient, multidisciplinary and integrative. Clinicians typically utilise existing neurology and palliative care infrastructure to provide care. More high-quality research and outcome tools are needed to guide the design of evidence-based palliative care for people with progressive neurological diseases.

Adopting a palliative care mindset is an unmet need in Parkinson's disease

Introduction

Parkinson's disease (PD) affects multiple facets of patients' lives, many of which may not be recognized or addressed by their healthcare team. A growing body of evidence has shown that palliative care improves patients' quality of life with PD; however, little is currently known about how patients with PD perceive palliative care.

Methods

An 8-question multiple choice survey was created and given to patients with established care for PD at a movement disorders clinic in a quaternary care center. Patients with less than two years of follow-up or that had atypical features of PD were excluded from the survey.

Results

There were 106 respondents to the survey. A third of patients reported having never heard of palliative care and an additional 25% had heard of it but did not know what it was. Eighty-eight percent reported being familiar with or very knowledgeable about hospice, though 50% of respondents did not know the difference between hospice and palliative care. 93% had never been offered either service. 37.7% thought their neurologist should discuss advance care planning early in the course of their disease.

Conclusion

Even among established patients with Parkinson's disease in a quaternary center, over half were not familiar with palliative care, and the majority had never been offered palliative or hospice services despite growing evidence that it could improve their quality of life. Additionally, patients would like to be introduced to advanced care planning early in the course of their disease.

Clinical milestones as triggers for palliative care intervention in progressive Supranuclear palsy and multiple system atrophy

not required for reviews.

Neurological update: the palliative care landscape for atypical parkinsonian syndromes

Atypical parkinsonian syndromes are neurodegenerative conditions, characterised by rapid disease progression and shorter life expectancy compared to idiopathic Parkinson's disease. These conditions inflict substantial physical and psychosocial burden on patients and their families; hence, there is a clear rationale for a palliative care approach from diagnosis. An interdisciplinary care model has been shown to improve symptom burden, quality of life and engagement with advance care planning, in a heterogeneous group of neurodegenerative conditions. In this update, we summarise how the landscape for treating these patients has changed and the questions that still need to be resolved.

Effects of Palliative Care for Progressive Neurologic Diseases: A Systematic Review and Meta-Analysis

OBJECTIVES

To determine the association of palliative care for progressive neurologic diseases with patient- and caregiver-centered outcomes.

DESIGN

Systematic review and meta-analysis of randomized controlled trials and quasi-experimental studies, including pilot studies.

SETTING AND PARTICIPANTS

Adults with progressive neurologic diseases (dementia, multiple sclerosis, Parkinson's disease, motor neuron disease, multiple system atrophy, and progressive supranuclear palsy) and their caregivers.

METHODS

MEDLINE, EMBASE, CINAHL PLUS, Cochrane CENTRAL, and PubMed were searched from inception to September 2021. Two reviewers independently screened studies, extracted data, and assessed risk of bias using the Cochrane risk of bias tools. Narrative synthesis was conducted. Patient quality of life (QoL), symptom burden, caregiver burden, and satisfaction with care were meta-analyzed using a random-effects model.

RESULTS

Fifteen trials provided data on 3431 patients (mean age, 73.9 years). Compared with usual care, palliative care was statistically significantly associated with lower symptom burden [standardized mean difference (SMD), -0.34 (95% Cl, -0.59 to -0.09)] and higher caregiver satisfaction [SMD, 0.41 (95% Cl, 0.12 to 0.71)] and patient satisfaction [SMD, 0.43 (95% Cl, -0.01 to 0.87)]. However, the associations were not significant after excluding studies with high risk of bias. Insignificant associations of palliative care with caregiver burden [SMD, -0.09 (95% Cl, -0.21 to 0.03)] and patient QoL [SMD, 0.19 (95% Cl, -0.07 to 0.44)] were observed.

CONCLUSIONS AND IMPLICATIONS

Palliative care is likely to improve symptom burden and satisfaction with care among patients with progressive neurologic diseases and their caregivers, while its effects on QoL and caregiver burden remains inconclusive. Specific intervention components including interdisciplinary team, palliative care physicians, home visits, and spiritual care appeared to be associated with increased effects on improving palliative outcomes. More rigorous designed studies are warranted to examine the effects of neuropalliative care, effective intervention components, optimal timing, and symptom triggers of palliative care referrals.

Referral criteria to palliative care for patients with Parkinson's disease: a systematic review

OBJECTIVE

This systematic review aimed to identify the referral criteria for palliative care in patients with Parkinson's disease.

METHODS

We conducted an electronic search for publications on referral criteria for palliative care in patients with Parkinson's disease in six electronic databases. The articles were thoroughly reviewed by two independent reviewers for inclusion using a predefined data extraction list. The referral criteria were thematically classified using a coding methodology.

RESULTS

This systematic review included 36 publications. We identified 14 referral criteria themes. The most common referral indicators were functional decline (n = 11 [31%]), needs assessment tools (n = 11 [31%]), physical or emotional symptoms (n = 10[28%]), need for palliative care (n = 10 [28%]), decision support (n = 9 [25%]), advanced Parkinson's disease (n = 7[19%]), and diagnosis of Parkinson's disease (n = 7 [19%]). However, there was a lack of consensus on symptom assessment tools. In addition, there were no agreed cut-offs or defined time for palliative care referral for patients with Parkinson's disease.

CONCLUSIONS

The 14 themes identified in this systematic review were categorized into disease- and needs-based criteria. These themes show the wide range of referral timing and procedures. Further studies should be conducted to reveal standardized referral criteria.

Outpatient neuropalliative care

Palliative care is an approach to patient care that focuses on enhancing quality of life through relief of physical, emotional, and spiritual sources of distress and patient-tailored discussions about goals of care. The palliative care approach can be delivered by any provider, and can occur alongside disease-modifying therapies. For patients with a serious neurologic illness or a neurodegenerative disease, neuropalliative care is a growing field focused on providing high-quality palliative care to neurology patients. There are three models of neuropalliative care delivery in the outpatient setting: a consultative model with a palliative care specialist, an integrated model with an embedded palliative care provider, and a primary palliative care model with the patient's neurology provider. The main components of an outpatient palliative care visit include symptom assessment and treatment, communication about serious illness, advance care planning, and assessment of caregiver needs. For patients with advanced illness, palliative care can help facilitate timely referral to hospice. Through a palliative care approach, outpatient care for patients with serious neurologic disease or neurodegenerative disease can focus on the issues most important to the patient, promote improved illness understanding and planning, and can improve the overall quality of care.

Community-based neuropalliative care

Community-based palliative care is defined as palliative care delivered outside of the hospital and outpatient clinics. These settings include the home, nursing homes, day programs, volunteer organizations, and support groups. There is strong evidence outside of the neuropalliative context that community-based palliative care can reduce hospital costs and admissions at the end of life. Research that focuses on specialized community-based palliative care for neurologic disease have similar findings, although with significant variability across conditions and geographic locations. Several of these studies have investigated home-based care for neurologic conditions including dementia, Parkinson's disease, multiple sclerosis, brain tumors, and motor neuron disease. Other work has focused on incorporating palliative care models into the treatment of patients with neurologic diseases within nursing home settings. Similar to nonneurologic community-based palliative care, little has been published on patient and caregiver quality-of-life outcomes in such models of care, although the emerging data are generally positive. Future studies should explore how best to provide comprehensive, cost-effective, scalable, and replicable models of community-based neuropalliative care, patient and caregiver outcomes in such models, and how care can be adapted between and within specific patient populations and healthcare systems.

Palliative care in multiple sclerosis

Main target in palliative care (PC) is burden care of patients and their families, with the aim to reduce suffering through the management of symptoms, rehabilitation, psychosocial issues, and spiritual well-being, using a multidisciplinary approach. Multiple sclerosis (MS) is a chronic disease which induces physical and psychosocial symptoms, with a significant impact on the quality of life. As a consequence, despite advances in research in disease-modifying drugs, MS remains a life-limiting disease with symptoms negatively impacting the lives of MS patients and their families. PC has been developed for end-of-life treatment in oncology, being little used in MS. Specific issues in MS, like pain due to spasticity, requires a different approach respect to cancer pain management. Moreover, it is difficult to anticipate life expectancy in people with severe MS, who often need palliative care for a long extended period. PC teams are trained to keep open full and competent lines of communication about symptoms and disease progression, advanced care planning, and end-of-life issues and wishes. Many studies investigated the effects of home-based PC in advanced MS, showing weak evidences about the efficacy of PC versus usual care in MS. However, current evidence does not support or refute the routine use of PC interventions for people with MS.

Palliative care in Parkinson disease and related disorders

Although neuropalliative care is a relatively new field, there is increasing evidence for its use among the degenerative parkinsonian syndromes, including idiopathic Parkinson disease, progressive supranuclear palsy, multiple system atrophy, dementia with Lewy bodies, and corticobasal syndrome. This chapter outlines the current state of evidence for palliative care among individuals with the degenerative parkinsonian syndromes with discussion surrounding: (1) disease burden and needs across the conditions; (2) utility, timing, and methods for advance care planning; (3) novel care models for the provision of palliative care; and 4) end-of-life care issues. We also discuss currently unmet needs and unanswered questions in the field, proposing priorities for research and the assessment of implemented care models.

Neurological consultations via telemedicine for specialized outpatient palliative care (SOPC) at home and in hospice (TANNE project): study protocol for a randomized controlled trial

BACKGROUND

Neurological diseases cause numerous challenges in palliative care. Telemedicine may improve the access to specialized expertise in neurology for patients, their relatives, and palliative care physicians. The TANNE study offers teleconsultations by a hospital-based neuropalliative center for specialized outpatient palliative care (SOPC) and hospices. A prospective, partially randomized, controlled trial aims at generating evidence for clinical improvements, quality of life, and cost efficiency.

METHODS

SOPC and hospice teams in Bavaria, Germany, are partially randomized to one of two study arms, namely a treatment group with teleconsultations by specialists for neurology and palliative medicine or to a control group with interventions after a 12-months delay. Individual and population-based measures are assessed with a mixed-methods design in order to evaluate the medical effects, the potential for implementation in standard care, and health economic aspects. The primary outcome consists of the mean change difference between groups in the Integrated Palliative Care Outcome Scale (IPOS), which physicians assess before and after treatment of a neurological event. Besides, several secondary outcomes are investigated, including quality of life, which is measured with the revised McGill Quality of Life Questionnaire (McGill QOL-R) as well as items regarding general and health-related quality of life. Further secondary outcomes include the concrete progress of the neurological signs and symptoms; the subjective change in well-being since the start of the treatment of the neurological diseases from the perspectives of patients, their relatives, as well as medical and nursing professionals; as well as patient, professional, and caregiver satisfaction with the teleconsultations. Moreover, a health economic evaluation compares group differences regarding hospital visits and emergency calls with utilization measurements.

DISCUSSION

The TANNE trial provides a comprehensive and complex evaluation design for teleconsultations in neuropalliative care. Ethical considerations need to take the patients' vulnerability into account. The project promises to substantially broaden the width of health care services and to improve the quality of life for deserving patients.

TRIAL REGISTRATION

German Clinical Trials Register ( www.germanctr.de [July 17, 2022], DRKS ID: DRKS00027436. Registered February 10th, 2022, retrospectively registered. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00027436 [July 17, 2022].

The involvement of palliative care with neurology – a comparison of UK, Switzerland and Italy

OBJECTIVES

To ascertain the involvement of palliative care with neurology services in the care of people with amyotrophic lateral sclerosis (ALS) in the United Kingdom, Italy and Switzerland, in particular the collaboration with and referral from neurology, the involvement in multidisciplinary team care and in the respiratory support of ALS patients.

METHODS

In 2019, two online surveys were undertaken of palliative care specialists, using specialist groups of the European Academy of Neurology, European Association of Palliative Care and the Association of Palliative Medicine for Great Britain and Ireland.

RESULTS

The respondents were specialist palliative care professionals, predominantly senior doctors, involved in the care of people with ALS. As the numbers of respondents from many countries were in single figures the analysis was restricted to the United Kingdom, Italy and Switzerland. The time of involvement varied, with early involvement commonest in the UK. Barriers to referral included neurologists not referring and financial issues, particularly in Switzerland. The reluctance of patients and families to see palliative care services was reported as less than 20% in all countries. Respondents were often involved in the care of people receiving noninvasive ventilation (NIV), in all countries. and with tracheostomy ventilation (TV), particularly in Italy.

CONCLUSIONS

Palliative care services are often involved in the care of people with ALS, but the extent and timing of involvement varies. The use of clinical guidelines and education on palliative care for neurology services may encourage collaboration, for the benefit of people with ALS and their families.

What's in the Sauce? The Specific Benefits of Palliative Care for Parkinson's Disease

CONTEXT

Increasing evidence demonstrates the benefits of palliative care among individuals with Parkinson's disease and related disorders (PDRD), but the critical components that contribute to therapeutic effects are not well understood.

OBJECTIVES

To determine the specific items most responsive to a palliative care intervention in PDRD and identify key correlates of improvement in patient and care partner outcomes.

METHODS

The main trial was a pragmatic comparative effectiveness trial of outpatient integrated palliative care compared to standard care among participants with PDRD (NCT02533921), showing significantly higher patient QOL at six months and lower care partner burden at 12 months. We used longitudinal regression models to analyze changes in subdomains of patient QOL and care partner burden and Spearman correlations to evaluate key correlates of change scores in patient and care partner outcomes. We performed a secondary analysis of data from 210 patients and 175 care partners.

RESULTS

Compared to controls, patients in the intervention reported greater improvement in perceptions of the "self as a whole" at six months (coeff = 0.22, P < 0.05) and care partners reported greater reduction in stress, anger, and loss of control at 12 months (coeff = -.40, -0.25, -0.31, P < 0.05). Positive change in numerous patient non-motor symptoms and grief correlated with improved patient QOL, reduced patient anxiety, and increased care partner spirituality. Alleviation of care partner anxiety and depression correlated with reduced care partner burden.

CONCLUSION

Specific benefits of an integrated palliative approach in PDRD include improvement in patient holistic self-impressions, care partner self-efficacy, and non-motor symptoms.

The Impact of a Neurocritical Care and Neuropalliative Collaboration on Intensive Care Unit Outcomes

BACKGROUND

Neurocritical care (NCC) and neuropalliative care (NPC) clinicians provide care in specialized intensive care units (ICU). There is a paucity of data regarding the impact of NCC and NPC collaboration in smaller, community-focused settings.

OBJECTIVE

To determine the clinical impact of introducing a NCC/NPC collaborative model in a mixed ICU community-based teaching hospital.

DESIGN

Retrospective pre/post cohort study.

SUBJECTS

Patients ≥18 years of age admitted to the ICU who received neurology and palliative care consultations between September 1, 2015 and August 31, 2017 at a 300 bed community-focused hospital were included.

INTERVENTION

The addition of a NCC/NPC collaborative model took place in September of 2016. The time periods before (9/1/2015 to 8/31/2016) and after (9/1/2016 to 8/31/2017) the addition were compared.

RESULTS

A total of 274 admissions (pre: 130, post: 144) were included. There were significantly more NCC consultations provided in the post-period (44.6% vs 57.6%; P = .03). NPC consultation increased (55.4% vs 66.7%; P = .056) Median LOS was significantly shorter after implementation of the collaborative model (11 vs 8 days; P = .01). Median ICU LOS was also shorter by 1 ICU-day in the post-period, though this was not statistically significant (P = .23). Mortality rates were similar (P = .95).

CONCLUSIONS

Our findings suggest NCC/NPC collaboration in a community-focused teaching hospital was associated with more NCC consultations, as well as shorter LOS without increasing mortality. These data highlight the importance of supporting collaborative models of care in community settings. Further research is warranted.

Triggers for Referral to Specialized Palliative Care in Advanced Neurologic and Neurosurgical Conditions: A Systematic Review

Background and Objectives

To systematically review the literature for the most suitable trigger criteria for referral to specialist palliative care services in life-limiting and life-threatening neurologic and neurosurgical conditions.

Methods

Literature searches were conducted in Ovid MEDLINE and EMBASE (1990-December 2020). To be included, studies must have trigger/referral criteria clearly outlined, a ≥75% nononcology neurosciences population, and consensus or guidelines documents regarding palliative neurosciences or trigger/referral criteria. We excluded studies that had an oncologic or non-neurosciences population as the main focus of study, trigger and referral criteria not clearly outlined, and no primary or duplicative data. The protocol was registered with PROSPERO (CRD4202013579), and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. The American Academy of Neurology Clinical Practice Guidelines Process Manual was used to assess for risk of bias.

Results

Our search identified 1,748 publications, of which 22 articles met the eligibility criteria. Studies were considered in 2 main groups: (A) studies designed specifically to identify trigger criteria for referral to specialized neuropalliative care services (n = 9) and (B) studies that retrospectively reported the reason for referral to specialized palliative care or reflected a consensus statement among people with advanced neurologic illness (n = 13). Overall, the results suggest that several published referral triggers for specialized neuropalliative care are based on expert consensus. However, there is a growing body of literature providing evidence-based condition-specific triggers for multiple sclerosis, parkinsonism, amyotrophic lateral sclerosis, and dementia.

Discussion

There is a growing body of research that outlines evidence-based referral triggers for neuropalliative care. The ambiguity of nomenclature surrounding referral triggers in the current literature and field of neuropalliative care was a limitation to this study. We suggest that condition-specific triggers are likely to be the most effective for identifying the appropriate patients and timing for referral to specialist palliative care. (PROSPERO registration number: CRD42020135791, crd.york.ac.uk/prospero).

The Systematic Workplace-Improvement Needs Generation (SWING): Verifying a Worker-Centred Tool for Identifying Necessary Workplace Improvements in a Nursing Home in Japan

This study developed and tested a new measurement instrument, the Systematic Workplace-Improvement Needs Generation (SWING), to identify workplace-improvement needs. The participants were 53 workers in a Japanese nursing home for the elderly. The respondents used the SWING questionnaire to self-generate five ‘cues’ they considered important to improve the workplace. The workers determined each cue’s sufficiency level and weight balance (importance), and then we summarised the 265 cues into 21 categories for workplace improvements. The respondents identified the following items as the most important and the least sufficiently provided areas for workplace improvement: ‘interaction with customers’, ‘physical and psychological harassment’, ‘rewarding and challenging work’, and ‘sharing goals and objectives’. Although the workplace-improvement recommendations differed greatly from person to person, SWING prioritised the items by weight (importance) and sufficiency (current status), allowing organisations to address the needed improvements systematically. The SWING tool effectively elicited and prioritised respondents’ recommendations for improving the workplace. Because its items are self-generated by the respondents, SWING can be used for any occupation or workplace. Visualisation with bubble plots to clarify the improvement needs is incorporated into SWING.

Caregivers' View of Socio-Medical Care in the Terminal Phase of Amyotrophic Lateral Sclerosis-How Can We Improve Holistic Care in ALS?

Multidimensional socio-medical care with an early integration of palliative principles is strongly recommended in amyotrophic lateral sclerosis (ALS), but provided inconsistently. We conducted telephone interviews with 49 former caregivers of deceased ALS patients to examine their experience of care in the terminal phase including caregiver burden. Patients who received specialized palliative care (45% of patients) were more likely to die at home (p = 0.004) and without burdening symptoms (p = 0.021). The majority of caregivers (86%) reported deficits in socio-medical care. Most frequently mentioned were problems receiving medical aids (45%) and a lack of caregiver support (35%). A higher level of deficits experienced by caregivers was associated with negative health outcomes on the side of the caregivers (reported by 57% of them; p = 0.002) and stronger caregiver burden (p = 0.004). To provide good quality of dying to patients and reduce the burden on caregivers, multidimensional—including palliative—care in ALS urgently needs to be strengthened in the healthcare structures.

Delivery models of neuropalliative care

Drawing its beginnings from end-of-life care, palliative care has developed into a specialized interdisciplinary effort aiming to alleviate distress in all its form, and spanning the whole serious illness trajectory. With this evolution came the inevitable expansion to different sites and modes of care delivery. This section discusses the various models of bringing palliative care to patients with neurologic illness. It begins by distinguishing primary from specialist palliative care, then examines various models of inpatient and outpatient care. Hospital-based models include consultation service and dedicated inpatient units, while outpatient care mainly consists of palliative care specialists embedded in disease-specific clinics. Home-based palliative care and services provided through telemedicine are discussed. Hospice, a model of care often associated with end-of-life palliative care is detailed, together with suggestions on when to consider transitioning to hospice care. It is worth noting that there is not a single best model of palliative care delivery for persons living with neurologic illness. The models discussed in this chapter are complementary not competing and should be adopted by clinicians to fit the needs of patients and caregivers, the resources available in the healthcare system, and based on where patients are in the spectrum of their illness.

What palliative care physicians wish neurologists knew

This chapter describes several features of palliative care that we believe can assist neurologists in caring for patients with serious illness. These features include the importance of recognizing suffering, the central of total pain (including physical, emotional, spiritual, and existential aspects), structural features of palliative care such as the distinction been palliative care and hospice, and the concept of primary and specialty palliative care. Structural features of palliative care such as interdisciplinary teamwork, approaches to self-care, and a perspective on prognostic uncertainty are also considered. Throughout this chapter, the focus is on ways in which neurologists can integrate these approaches in caring for patients and their families.

Neuropalliative care: Defining an emerging field

Palliative care is increasingly becoming an established part of medical care, providing the holistic assessment and management of the person at the center of care-physical, psychological, social, and spiritual. This had originally been primarily provided for people with terminal cancers but in the last 50 years, this care has extended to caring for people with issues throughout disease progression and for all diagnoses, including neurologic diseases. Palliative care in fact is now included within guidelines and standards for many neurologic diseases. Palliative care may be delivered as an approach provided by all health and social care professionals; by focused care provided within neurology; and through the involvement of specialist palliative care and neuropalliative care for more complex issues. The education of neurologists and palliative care specialists is essential to enable all to be aware of the issues faced by patients and their families and provide adequate support for patients, families, and healthcare professionals. In this way, the quality of life can be maintained as much as possible and patients are able to die with as little distress as possible, with their families and carers supported.

International models of neuropalliative care

Can equitable Neuropalliative care (NpC) be delivered globally? This chapter surveys existing services and ground realities in different parts of the world. In many countries, universal healthcare (UHC) seems to have been a precondition for the establishment of palliative care (PC). PC has been recognized as a basic human right as a part of UHC. Quality of Death and PC surveys provide an overview of the existing situation. Currently, PC is largely focused on the needs of cancer patients and this is a legacy issue for professionals and systems. Communities however recognize suffering and do not distinguish between medical diagnoses. The development of NpC as a subspecialty of neurology allows neurologists everywhere to become primary palliative care providers for their own patients. It is also necessary to integrate neurology with existing palliative care services. There is much that can be done to improve NpC provision even within the limits that bound every jurisdiction and trial evidence is emerging to inform this practice. This chapter is a survey of the challenges and the potential.

Palliative Care Intervention Trials for Adults Living With Progressive Central Nervous System Diseases and Their Caregivers: A Systematic Review

CONTEXT

Interest in implementing palliative care for adults living with progressive central nervous system diseases (PCNSD) and their caregivers is increasing.

OBJECTIVES

To inform evidence-based practice and future research by critically evaluating randomized clinical trials (RCTs) investigating palliative care interventions (PCIs) for adults living with PCNSD and their caregivers using self-reported outcomes and the patient- and caregiver-reported outcome measures employed.

METHODS

A systematic search using PRISMA methods of EMBASE, PubMed, Scopus, Web of Science databases using index and keyword methods for articles published from inception through February 28, 2021 was performed. RCTs investigating PCI as their primary aim using patient- and/or caregiver-reported outcomes to assess PCI effectiveness in adults living with PCNSD and their caregivers were included for qualitative synthesis.

RESULTS

Five RCTs met criteria and used 21 unique outcome measures. Pooled patient diagnoses included multiple sclerosis, motor neuron disease and movement disorders, primarily Parkinson's Disease. All five RCTs assessed PCI effectiveness on patient symptom burden and caregiver burden, and three RCTs used patient QOL as a primary outcome. Overall risk of bias was low. Pooled positive findings were limited to very modest changes in patient QOL, specific physical symptoms and caregiver burden. Most outcome measures lacked clinimetric responsiveness to detect change whether caused by disease or an intervention to the patient or caregiver.

CONCLUSION

Sparse, low-certainty evidence for PCI impact on patient QOL, symptom burden and caregiver burden indicate future research should consider refining study populations, interventions, outcomes assessed and outcome measures to detect any change due to PCI.

The neuropalliative multidisciplinary team-Members and their roles

Neurodegenerative conditions are prominent contributors to both morbidity and mortality worldwide. They pose a significant challenge to health professionals, health systems, and the often unpaid, untrained family members and carers. The many and varied challenges encountered are best managed by a multidisciplinary neuropalliative team, as it is impossible for a single clinician to possess and deliver the wide range of skills and services required to optimally care for these patients. This chapter discusses the assembly, maintenance, and care of such a team, as well as potential difficulties and solutions in domains such as funding, training, geographical remoteness, as well as the potential lack of awareness and acceptance by colleagues. A comprehensive description of the role of all possible team members is discussed. The chapter outlines the concept, content, and potential benefits of a multidisciplinary team in neuropalliative care. Its thesis is twofold: that multidisciplinary care is vital and, second, that the sum of the whole of a team can be greater than the individual parts with respect to organization, planning, experience, and creativity of approach. With all these factors considered, and implemented wherever possible, we may all move closer to optimizing the comfort and care of our shared neuropalliative patients.

Healthcare utilisation trajectories in patients dying from chronic obstructive pulmonary disease, heart failure or cancer: a nationwide register-based cohort study

OBJECTIVES

To investigate illness trajectories as reflected by healthcare utilisation, including hospital and intensive care unit admissions, consultations in general practice and home care provision, before death comparing people dying from chronic obstructive pulmonary disease (COPD), heart failure and cancer.

DESIGN

Nationwide register-based cohort study.

SETTING

Data on all hospital admissions, including intensive care unit admissions, consultations in general practice and home care provision were obtained from nationwide Danish registries.

PARTICIPANTS

All adult decedents in Denmark dying from COPD, heart failure or cancer between 2006 and 2016.

OUTCOME MEASURES

For each day within 5 years before death, we computed a daily prevalence proportion (PP) of being admitted to hospital or consulting a general practitioner. For each day within 6 months before death, we computed PPs of being admitted to intensive care or receiving home care. The PPs were plotted and compared by regression analyses adjusting for age, gender, comorbidity level, marital/cohabitation status, municipality and income level.

RESULTS

Among 1 74 086 patients dying from COPD (n=22 648), heart failure (n=11 498) or cancer (n=139 940), the PPs of being admitted to hospital or consulting a general practitioner showed similar steady progression and steep increase in the last year of life for all patient populations. The PP of being admitted to intensive care showed modest increase during the last 6 months of life, accelerating in the last month, for all patient populations. For patients with COPD and heart failure, the PP of receiving home care remained stable during the last 6 months of life but increased steadily for patients with cancer.

CONCLUSION

We found limited differences in healthcare resource utilisation at the end of life for people with COPD, heart failure or cancer, indicating comparable illness trajectories.This supports the need to reconsider efforts in achieving equal access to palliative care interventions, which is still mainly offered to patients with cancer.

Integration of palliative care in Parkinson's disease management

BACKGROUND

Parkinson's disease is a progressive neurodegenerative disorder that negatively impacts the lives of affected people. The therapeutic benefits of treatment only decrease going forward from the time of diagnosis. Motor and non-motor symptoms alike create a heavy burden for patients and those involved in their care. Palliative care is utilized for patients with serious illnesses and when integrated into patients with Parkinson's disease, improves quality of life by addressing symptoms of discomfort, which ultimately reduces symptom burden to patients and alleviates caregiver stress.

OBJECTIVE

This review aims to assess the efficacy of palliative care in the management of Parkinson's disease by exploring the benefits of palliative care integration throughout multiple relevant themes to demonstrate the optimal care delivery.

METHODS

Comprehensive searches on the role of palliative care in Parkinson's disease patients within MEDLINE, PUBMED, CINAHL, CENTRAL, PsycINFO, Embase, and BioMed Central, considering publications between March 2010 - February 2020 were performed. A grey literature search was also performed for additional information.

RESULTS

Analysis of various existing literature has demonstrated promise in timely palliative care integration for patients with Parkinson's disease, which has shown improvement in the quality of life of Parkinson's disease patients. It also strives to alleviate caregivers' stress and improve their quality of life, although insufficient research exists to support this. Palliative care in Parkinson's disease is a growing area of interest, evidently demonstrating the potential to expand among the current approaches.

CONCLUSION

Understanding the connections between the themes surrounding palliative care is crucial for successful integration in Parkinson's disease management. It is determined that integration of palliative care in patients with Parkinson's disease help to not only improve patients' experiences but also their caregiver's experiences throughout the disease trajectory. Further research should be conducted to address how palliative care will focus on alleviating caregiver burden and establish specific prognostication tools for Parkinson's disease patients.

The Palliative Care Information Needs of Patients with Amyotrophic Lateral Sclerosis and their Informal Caregivers: A Scoping Review

CONTEXT

Amyotrophic Lateral Sclerosis (ALS) is a fatal neurodegenerative disease, associated with impaired quality of life for patients and caregivers. As treatment is largely supportive, early involvement of palliative care (PC) is recommended as standard of care. Despite this, literature surrounding PC information needs is limited.

OBJECTIVES

To explore the PC information needs of patients with ALS and their caregivers and identify gaps in the literature.

METHODS

A scoping review using MEDLINE, EMBASE, CINAHL and PsycINFO databases (2000-2019) was conducted. Articles examining PC information needs as stated by ALS patients and/or current/bereaved caregivers were included. Studies examining other diagnoses and those focused on healthcare workers were excluded. Thematic synthesis was used to summarize and identify prevalent domains and themes in the literature.

RESULTS

581 articles underwent primary screening, with thirty-two ultimately included (26 original articles, six reviews). Fourteen examined information needs of both patients and caregivers, 13 caregivers only, 5 patients only. The most common PC information needs were as follows: for patients, disease course/prognosis (n = 10), general disease information (n = 9), decision-making (n = 7) and symptoms (n = 6); for caregivers, services and resources (n = 15), disease course/prognosis (n = 14), general disease information (n = 13) and skills (n = 10). There was substantial variability in information needs, both between patients and caregivers and among members of the same group.

CONCLUSION

ALS patients and caregivers have unique and varying PC information needs. Future research should better characterize these needs to improve patient and caregiver quality of life. The delivery of information must be tailored to individual patient or caregiver preferences.