Global warming in the palliative care research environment: adapting to change

Symptom Control Trials in Patients With Advanced Cancer: A Qualitative Study

CONTEXT

Symptom control research in patients with advanced cancer is not common. This may be the result of a belief that this research is unethical, not practical, or that patients are not interested. However, the experiences of cancer patients who have actually taken part in symptom control research near the end of life have never been detailed.

OBJECTIVES

The objective was to explore the experiences of patients with advanced cancer who had taken part in symptom control trials.

METHODS

A prospective two-center study was undertaken using grounded theory methodology. Theoretical sampling was used to recruit patients from one of two double-blind, randomized, placebo-controlled trials studying novel analgesic agents for cancer-related pain. Participants completed one semistructured interview. Recruitment and interviewing continued until data saturation was achieved.

RESULTS

Twenty-one participants were recruited. Fifteen (71%) were male, with a mean age of 62 years. Key themes identified included reasons for trial participation, participants' interactions with the trial staff, and participants' responses to the effect the trial had on their pain. In general, participants regarded taking part in a clinical trial as a positive experience, and potentially improving overall well-being. Crucially, this was not related to whether there had been an improvement in symptoms.

CONCLUSION

The findings provide grounds for optimism that patients with advanced cancer may benefit from taking part in symptom control trials, supporting the paradigm that participation in symptom control research should be encouraged in this population.

Establishment and preliminary outcomes of a palliative care research network

Objective:

The difficulties in conducting palliative care research have been widely acknowledged. In order to generate the evidence needed to underpin palliative care provision, collaborative research is considered essential. Prior to formalizing the development of a research network for the state of Victoria, Australia, a preliminary study was undertaken to ascertain interest and recommendations for the design of such a collaboration.

Method:

Three data-collection strategies were used: a cross-sectional questionnaire, interviews, and workshops. The questionnaire was completed by multidisciplinary palliative care specialists from across the state (n = 61); interviews were conducted with senior clinicians and academics (n = 21) followed by two stakeholder workshops (n = 29). The questionnaire was constructed specifically for this study, measuring involvement of and perceptions of palliative care research.

Results:

Both the interview and the questionnaire data demonstrated strong support for a palliative care research network and aided in establishing a research agenda. The stakeholder workshops assisted with strategies for the formation of the Palliative Care Research Network Victoria (PCRNV) and guided the development of the mission and strategic plan.

Significance of results:

The research and efforts to date to establish the PCRNV are encouraging and provide optimism for the evolution of palliative care research in Australia. The international implications are highlighted.

Palliative care research on the island of Ireland over the last decade: a systematic review and thematic analysis of peer reviewed publications

Background

As palliative care research continues to expand across Europe, and the world, questions exist about the nature and type of research undertaken in addition to the research priorities for the future. This systematic review, which is the first stage of a larger scale study to identify the research priorities for palliative care on the island of Ireland, examined palliative care research conducted on the island over the last decade.

Methods

A comprehensive search strategy was implemented and strict eligibility criteria were applied in order to identify relevant peer-reviewed journal articles. Inclusion criteria were all of the palliative care studies undertaken on the island of Ireland and published between January 2002 and May 2012. These were assessed in relation to year, setting, sample size, research methodology, and relevant findings.

Results

412 publications were identified for screening and their abstracts obtained. After eliminating articles that did not meet the inclusion criteria, 151 remained for further analysis. A thematic analysis of 128 studies published between 2006 and 2012 revealed eight core themes: (1) specific groups/populations; (2) services and settings; (3) management of symptoms (physical, psychological, social); (4) bereavement; (5) communication and education; (6) death and dying; (7) spirituality; and (8) complementary and alternative medicine/intervention (CAM). There was an upward trend in the number of publications in palliative care research over the last ten years with over 72% of studies being published within the previous four years. A slightly higher number of studies were quantitative in nature (surveys, questionnaires, standardised assessments) followed by qualitative (individual and focus group interviews, case studies, documentary analysis and retrospective case note reviews), mixed methods, and systematic reviews.

Conclusions

Whilst there has been a welcome growth in palliative care research across Ireland, this has largely been needs-based and small scale studies. In contrast, international researchers and decision makers recommend the need for more outcomes focused multidisciplinary research. An examination of palliative care research is an essential first step in seeking to develop future priority areas for further research, highlighting opportunities for future collaboration both nationally and internationally.

Past, present, and future of palliative care in Japan

Palliative care in Japan has developed through a number of transition stages. The first of these was the recognition of costs for care received at a palliative care unit as eligible for reimbursement under the medical insurance system. The second stage was the recognition of costs for care received from a hospital-based palliative care team as eligible for reimbursement under the medical insurance system. The third stage was government policy relating to palliative care, including establishment of the Cancer Control Act formulation of the Basic Plan to Promote Cancer Control Programs and implementation of the Promotion Plan for the Platform of Human Resource Development for Cancer. A total of 350 000 cancer patients died during fiscal 2011, of which 9% made use of a palliative care unit. The use of palliative care is steadily growing with a trend away from palliative care units toward palliative care teams and care in the home. Whereas it was once seen as the limited treatment of terminal care, palliative care is increasingly becoming integrated into mainstream treatment. Basic palliative care education programs for physicians not specializing in palliative care and other medical practitioners are bringing about the spread of basic palliative care in Japan, thus putting in place broad foundations for the practice of palliative care. Improving the quality of palliative care and providing specialized palliative care are essential in Japan. Future challenges are (i) the construction of a community palliative care network, (ii) fostering specialists in palliative care and (iii) the provision of high-quality palliative care and end-of-life care to patients with life-threatening illnesses that are not limited to cancer.

A pan-European survey of research in end-of-life cancer care

Background

To date, there is no coordinated strategy for end-of-life (EOL) cancer care research in Europe. The PRISMA (Reflecting the Positive Diversities of European Priorities for Research and Measurement in End-of-life Care) project is aiming to develop a programme integrating research and measurement in EOL care. This survey aimed to map and describe present EOL cancer care research in Europe and to identify priorities and barriers.

Material and methods

A questionnaire of 62 questions was developed and 201 researchers in 41 European countries were invited to complete it online in May 2009. An open invitation to participate was posted on the internet.

Results

Invited contacts in 36 countries sent 127 replies; eight additional responses came through websites. A total of 127 responses were eligible for analysis. Respondents were 69 male and 58 female, mean age 49 (28–74) years; 85% of the scientific team leaders were physicians. Seventy-one of 127 research groups were located in a teaching hospital or cancer centre. Forty-five percent of the groups had only one to five members and 28% six to ten members. Sixty-three of 92 groups reported specific funding for EOL care research. Seventy-five percent of the groups had published papers in journals with impact factor ≤5 in the last 3 years; 8% had published in journals with impact factor >10. Forty-four out of 90 groups reported at least one completed Ph.D. in the last 3 years. The most frequently reported active research areas were pain, assessment and measurement tools, and last days of life and quality of death. Very similar areas—last days of life and quality of death, pain, fatigue and cachexia, and assessment and measurement tools—were ranked as the most important research priorities. The most important research barriers were lack of funding, lack of time, and insufficient knowledge/expertise.

Conclusions

Most research groups in EOL care are small. The few large groups (14%) had almost half of the reported publications, and more than half of the current Ph.D. students. There is a lack of a common strategy and coordination in EOL cancer care research and a great need for international collaboration.

Electronic supplementary material

The online version of this article (doi:10.1007/s00520-010-1048-x) contains supplementary material, which is available to authorized users.

The place of supportive, palliative and end-of-life care research in the United Kingdom Research Assessment Exercise, 2001 and 2008

We report on a study of the place of research on supportive, palliative and end-of-life care within the United Kingdom Research Assessment Exercise of 2001 and 2008. Sixty-seven Higher Education Institutions in 2001 and 66 in 2008 contributed work to the Research Assessment Exercise relevant to supportive, palliative and end-of-life care. This comprised 16 subject areas in 2001 and 25 in 2008, and was generated by 178 authors in 2001 and 176 authors in 2008. Seven 'high-intensity groups' of concentrated research activity were identified in 2001, and eight such groups in 2008. Between the years little growth occurred in contributions to the Research Assessment Exercise relating to supportive, palliative and end-of-life care, and the 'high-intensity groups' remain relatively fragile. With one exception, there is no concentration of effort in clinical studies relating to the medical aspects of supportive, palliative and end-of-life care. By 2008 there were still less than 40 university academics in the UK with major commitments to research in supportive, palliative and end-of-life care, as measured by their Research Assessment Exercise participation.

Resource utilisation and costs of palliative cancer care in an interdisciplinary health care model

This paper presents a detailed description of health care resource utilisation and costs of a pilot interdisciplinary health care model of palliative home care in Ontario, Canada. The descriptive evaluation entailed examining the use of services and costs of the pilot program: patient demographics, length of stay broken down by disposition (discharged, alive, death), access to services/resources, use of family physician and specialist services, and drug use. There were 434 patients included in the pilot program. Total costs were approximately CAN$2.4 million, and the cost per person amounted to approximately CAN$5586.33 with average length of stay equal to over 2 months (64.22 days). One may assume that length of stay would be influenced by the amount of service and support available. Future research might investigate whether in-home palliative home care is the most cost effective and suitable care setting for those patients requiring home care services for expected periods of time.

End-of-life issues in the acute and critically ill patient

The challenges of end-of-life care require emergency physicians to utilize a multifaceted and dynamic skill set. Such skills include medical therapies to relieve pain and other symptoms near the end-of-life. Physicians must also demonstrate aptitude in comfort care, communication, cultural competency, and ethical principles. It is imperative that emergency physicians demonstrate a fundamental understanding of end-of-life issues in order to employ the versatile, multidisciplinary approach required to provide the highest quality end-of-life care for patients and their families.