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Chen PJ, Ho CH, Lin YJ, Chang MH, Liao KM. Characteristics of "do not resuscitate" orders among elderly patients receiving mechanical ventilation in the intensive care unit in Taiwan. Front Med (Lausanne) 2024; 11:1373726. [PMID: 38846140 PMCID: PMC11153661 DOI: 10.3389/fmed.2024.1373726] [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: 01/20/2024] [Accepted: 04/30/2024] [Indexed: 06/09/2024] Open
Abstract
Objective As patient life expectancy has increased and people are living longer than before, the rate of mechanical ventilation among elderly patients in the intensive care unit has increased. Older patients who receive mechanical ventilation and have multiple comorbidities are more likely to have a do not resuscitate order than are younger patients with fewer comorbidities. The aim of our study was to describe the patient characteristics and predictive factors of do not resuscitate orders during hospitalization among elderly patients who received ventilation in the intensive care unit. Methods This was a retrospective review of the electronic medical records of patients in the intensive care unit of a teaching hospital in southern Taiwan. We enrolled patients admitted to the general intensive care unit from January 1, 2018, to September 31, 2020, and patients older than 80 years who experienced respiratory failure, were intubated and received mechanical ventilation. We analyzed patient demographics, disease severity during hospitalization and comorbidities. If a patient had multiple admissions to the intensive care unit, only the first admission was recorded. Results Of the 305 patients over 80 years of age with respiratory failure who were intubated and placed on a ventilator, 66 were excluded because of incomplete data, and 13 were excluded because they had already signed a do not resuscitate order prior to admission to the hospital. Ultimately, 226 patients were included in this study. A higher acute physiology and chronic health evaluation II score (>30) was also associated with an increased likelihood of a do not resuscitate order (odds ratio (OR) = 3.85, 95% CI = 1.09-13.62, p = 0.0362). Patients who had acute kidney injury or cerebrovascular accident were more likely to have a do not resuscitate order (OR = 2.74, 95% CI = 1.03-7.28, p = 0.0428 and OR = 7.32, 95% CI = 2.02-26.49, p = 0.0024, respectively). Conclusion Our study showed that older age, greater disease severity, and certain critical interventions were associated with a greater propensity for do not resuscitate orders, which is crucial for understanding patient preferences and guiding end-of-life care discussions. These findings highlight the importance of clinical severity and specific health events in predicting end-of-life care preferences in older patient groups.
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Affiliation(s)
- Pei-Jun Chen
- Department of Nursing, Nantou Hospital, Ministry of Health and Welfare, Nantou, Taiwan
| | - Chung-Han Ho
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
- Department of Information Management, Southern Taiwan University of Science and Technology, Tainan, Taiwan
- Cancer Center, Taipei Municipal Wanfang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ying-Jia Lin
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Ming-Hung Chang
- Department of Internal Medicine, Chi Mei Medical Center, Chiali, Tainan, Taiwan
| | - Kuang-Ming Liao
- Department of Internal Medicine, Chi Mei Medical Center, Chiali, Tainan, Taiwan
- Department of Nursing, Min-Hwei Junior College of Health Care Management, Tainan, Taiwan
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2
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Kruiswijk AA, van de Sande MAJ, Verhoef C, Schrage YM, Haas RL, Bemelmans MHA, van Ginkel RJ, Bonenkamp JJ, Witkamp AJ, van den Akker-van Marle ME, Marang-van de Mheen PJ, van Bodegom-Vos L. Changes in Health-Related Quality of Life following Surgery in Patients with High-Grade Extremity Soft-Tissue Sarcoma: A Prospective Longitudinal Study. Cancers (Basel) 2024; 16:547. [PMID: 38339298 PMCID: PMC10854952 DOI: 10.3390/cancers16030547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/16/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
INTRODUCTION Changes in health-related quality of life (HRQoL) during the diagnostic and treatment trajectory of high-grade extremity soft-tissue sarcoma (eSTS) has rarely been investigated for adults (18-65 y) and the elderly (aged ≥65 y), despite a potential variation in challenges from diverse levels of physical, social, or work-related activities. This study assesses HRQoL from time of diagnosis to one year thereafter among adults and the elderly with eSTS. METHODS HRQoL of participants from the VALUE-PERSARC trial (n = 97) was assessed at diagnosis and 3, 6 and 12 months thereafter, utilizing the PROMIS Global Health (GH), PROMIS Physical Function (PF) and EQ-5D-5L. RESULTS Over time, similar patterns were observed in all HRQoL measures, i.e., lower HRQoL scores than the Dutch population at baseline (PROMIS-PF:46.8, PROMIS GH-Mental:47.3, GH-Physical:46.2, EQ-5D-5L:0.76, EQ-VAS:72.6), a decrease at 3 months, followed by an upward trend to reach similar scores as the general population at 12 months (PROMIS-PF:49.9, PROMIS GH-Physical:50.1, EQ-5D-5L:0.84, EQ-VAS:81.5), except for the PROMIS GH-Mental (47.5), where scores remained lower than the general population mean (T = 50). Except for the PROMIS-PF, no age-related differences were observed. CONCLUSIONS On average, eSTS patients recover well physically from surgery, yet the mental component demonstrates no progression, irrespective of age. These results underscore the importance of comprehensive care addressing both physical and mental health.
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Affiliation(s)
- Anouk A. Kruiswijk
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (L.v.B.-V.)
- Orthopedic Surgery, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | | | - Cornelis Verhoef
- Department of Surgical Oncology and Gastrointestinal Surgery, Erasmus MC Cancer Institute, Erasmus Medical Center, 3000 CA Rotterdam, The Netherlands;
| | - Yvonne M. Schrage
- Department of Surgical Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
| | - Rick L. Haas
- Department of Radiotherapy, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands;
- Department of Radiotherapy, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Marc H. A. Bemelmans
- Department of Surgical Oncology, Maastricht University Medical Center, 6229 ER Maastricht, The Netherlands
| | - Robert J. van Ginkel
- Department of Surgical Oncology, University Medical Center Groningen, 9713 GZ Groningen, The Netherlands
| | - Johannes J. Bonenkamp
- Department of Surgery, Radboud University Medical Center, 6525 EP Nijmegen, The Netherlands;
| | - Arjen J. Witkamp
- Department of Surgical Oncology, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - M. Elske van den Akker-van Marle
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (L.v.B.-V.)
| | - Perla J. Marang-van de Mheen
- Safety & Security Science and Centre for Safety in Healthcare, Delft University of Technology, 2826 CN Delft, The Netherlands;
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands (L.v.B.-V.)
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3
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Henriques A, Ruano L, Fraga S, Soares S, Barros H, Talih M. Life-course socio-economic status and its impact on functional health of Portuguese older adults. J Biosoc Sci 2024; 56:36-49. [PMID: 37309019 DOI: 10.1017/s0021932023000093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Functional health is arguably one of the most important health indicators for older adults, because it assesses physical, cognitive and social functions in combination. However, life-course circumstances may impact this multidimensional construct. The aim of the present study was to assess the relationship between life-course socio-economic status (SES) and different dimensions of functional health in older adults. Data on 821 Portuguese adults aged 50 years and over in 2013-2015 were analysed. Life-course SES was computed using participants' paternal occupation (non-manual (nm); manual (m)) and own occupation (nm; m), resulting in four patterns: stable high (nm + nm), upward (m + nm), downward (nm + m) and stable low (m + m). Functional health included physical and mental functioning, cognitive function, handgrip strength, and walking speed. Linear (beta coefficients) and logistic regressions (odds ratios) were used to estimate the association between life-course SES and functional health.Overall, those who accumulated social disadvantage during life-course presented worse functional health than those with stable high SES (stable low - SF-36 physical functioning: β = -9.75; 95% CI: -14.34; -5.15; SF-36 mental health: β = -7.33; 95% CI: -11.55; -3.11; handgrip strength: β = -1.60; 95% CI: -2.86; -0.35; walking time, highest tertile: OR = 5.28; 95% CI: 3.07; 9.09). Those with an upward SES were not statistically different from those in the stable high SES for most of the health outcomes; however, those with an upward SES trajectory tended to have higher odds of cognitive impairment (OR = 1.75; 95% CI: 0.96; 3.19). A downward SES trajectory increased the odds of slower walking speed (OR = 4.62; 95% CI: 1.78; 11.95). A disadvantaged life-course SES impacts older adults' physical and mental functioning. For some outcomes, this was attenuated by a favourable adulthood SES but those with a stable low SES consistently presented worse functional health.
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Affiliation(s)
- A Henriques
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - L Ruano
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
- Serviço de Neurologia, Centro Hospitalar de Entre Douro e Vouga, Santa Maria da Feira, Portugal
| | - S Fraga
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - S Soares
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
| | - H Barros
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
- Departamento de Ciências da Saúde Pública e Forenses e Educação Médica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - M Talih
- EPIUnit - Instituto de Saúde Pública, Universidade do Porto, Porto, Portugal
- Laboratório para a Investigação Integrativa e Translacional em Saúde Populacional (ITR), Porto, Portugal
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Tan MZ. 1948 healthcare: still appropriate today? J R Soc Med 2023; 116:433-436. [PMID: 38054400 PMCID: PMC10850870 DOI: 10.1177/01410768231214336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Affiliation(s)
- Mark Zy Tan
- Health Education England Northwest, Department of Anaesthesia, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
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5
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Mikaelsson Midlöv E, Lindberg T, Sterner T, Skär L. Support given by health professionals before and after a patient's death to relatives involved in general palliative care at home in Sweden: Findings from the Swedish Register of Palliative Care. Palliat Support Care 2023:1-8. [PMID: 37746762 DOI: 10.1017/s1478951523001323] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
OBJECTIVES General palliative care (PC) is provided more at home, leading to increased involvement of relatives. Although support for relatives is a fundamental component of PC, there are deficiencies in the support provided to relatives when general PC is provided at home. This study aimed to describe the support provided by health professionals before and after a patient's death to relatives involved in general PC at home. METHODS A cross-sectional register study was implemented, with data from the Swedish Register of Palliative care. The sample consisted of 160 completed surveys from relatives who had been involved in general PC at home, with 160 related surveys answered by health professionals. Only the questions about support to relatives were used from the surveys. RESULTS The findings showed that although many relatives appear to receive support in general PC at home, not all relatives receive optimal support before or after a patient's death. The findings also indicated differences in whether relatives received some support before and after a patient's death depending on the type of relative. There were also differences in responses between health professionals and relatives regarding if relatives received counseling from a doctor about whether the patient was dying. SIGNIFICANCE OF RESULTS There is potential for improvements regarding support for relatives, especially after a patient's death, which has been confirmed in previous studies. The differences in whether relatives received support before and after a patient's death depending on the type of relative highlight the need for future research on how to support different types of relatives before and after a patient's death when general PC is provided at home.
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Affiliation(s)
- Elina Mikaelsson Midlöv
- Faculty of Engineering, Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden
- Faculty of Health and Society, Department of Care Science, Malmö University, Malmö, Sweden
| | - Terese Lindberg
- Faculty of Engineering, Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden
| | - Therese Sterner
- Faculty of Health and Society, Department of Care Science, Malmö University, Malmö, Sweden
| | - Lisa Skär
- Faculty of Engineering, Department of Health, Blekinge Institute of Technology, Karlskrona, Sweden
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Hodges JS, Stoyanova LV, Galizzi MM. End-of-Life Preferences: A Randomized Trial of Framing Comfort Care as Refusal of Treatment in the Context of COVID-19. Med Decis Making 2023; 43:631-641. [PMID: 37199414 PMCID: PMC10196681 DOI: 10.1177/0272989x231171139] [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: 06/09/2022] [Accepted: 03/23/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Rates of advance directive (AD) completion in the United Kingdom are lower than in the United States and other western European countries, which is especially concerning in light of the COVID-19 pandemic. UK residents typically complete an advance decision to refuse care (ADRT), whereas US versions of ADs present a more neutral choice between comfort-oriented or life-prolonging care. The purpose of this study is to test whether this framing affects decision making for end-of-life care and if this is affected by exposure to information about the COVID-19 pandemic. METHODS In an online experiment, 801 UK-based respondents were randomly allocated to document their preferences for end-of-life care in a 2 (US AD or UK ADRT) by 2 (presence or absence of COVID-19 prime) between-subjects factorial design. RESULTS Most (74.8%) of participants across all conditions chose comfort-oriented care. However, framing comfort care as a refusal of treatment made respondents significantly less likely to choose it (65.4% v. 84.1%, P < 0.001). This effect was exacerbated by priming participants to think about COVID-19: those completing an ADRT were significantly more likely to choose life-prolonging care when exposed to the COVID-19 prime (39.8% v. 29.6%, P = 0.032). Subgroup analyses revealed these effects differed by age, with older participants' choices influenced more by COVID-19 while younger participants were more affected by the AD framing. CONCLUSIONS The UK ADRT significantly reduced the proportion of participants choosing comfort-oriented care, an effect that was heightened in the presence of information about COVID-19. This suggests the current way end-of-life care wishes are documented in the United Kingdom could affect people's choices in a way that does not align with their preferences, especially in the context of the COVID-19 pandemic. HIGHLIGHTS Participants completing an AD framed as an advance decision to refuse treatment were significantly less likely to choose comfort-oriented care than participants completing an AD with a neutral choice between comfort-oriented and life-prolonging care.Exposure to a COVID-19 prime had an interactive effect on documented preferences in the refusal of treatment condition, with these participants even less likely to choose comfort-oriented care.Policy makers and organizations that design templates for advance care planning, particularly in the time of the COVID-19 pandemic, should be aware how the framing of these forms can influence decisions.
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Affiliation(s)
- Juliet S Hodges
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Lilia V Stoyanova
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
| | - Matteo M Galizzi
- Department of Psychological and Behavioural Science, London School of Economics, London, UK
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7
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Leniz J, Davies JM, Bone AE, Hocaoglu M, Verne J, Barclay S, Murtagh FEM, Fraser LK, Higginson IJ, Sleeman KE. Deaths at home, area-based deprivation and the effect of the Covid-19 pandemic: An analysis of mortality data across four nations. Palliat Med 2023; 37:1034-1039. [PMID: 37088955 PMCID: PMC10125882 DOI: 10.1177/02692163231167212] [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] [Indexed: 04/25/2023]
Abstract
BACKGROUND The number and proportion of home deaths in the UK increased during the Covid-19 pandemic. It is not known whether these changes were experienced disproportionately by people from different socioeconomic groups. AIM To examine the association between home death and socioeconomic position during the Covid-19 pandemic, and how this changed between 2019 and 2020. DESIGN Retrospective cohort study using population-based individual-level mortality data. SETTING/PARTICIPANTS All registered deaths in England, Wales, Scotland and Northern Ireland. The proportion of home deaths between 28th March and 31st December 2020 was compared with the same period in 2019. We used Poisson regression models to evaluate the association between decedent's area-based level of deprivation and risk of home death, as well as the interaction between deprivation and year of death, for each nation separately. RESULTS Between the 28th March and 31st December 2020, 409,718 deaths were recorded in England, 46,372 in Scotland, 26,410 in Wales and 13,404 in Northern Ireland. All four nations showed an increase in the adjusted proportion of home deaths between 2019 and 2020, ranging from 21 to 28%. This increase was lowest for people living in the most deprived areas in all nations, with evidence of a deprivation gradient in England. CONCLUSIONS The Covid-19 pandemic exacerbated a previously described socioeconomic inequality in place of death in the UK. Further research to understand the reasons for this change and if this inequality has been sustained is needed.
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Affiliation(s)
- Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Pontificia Universidad Católica de Chile, Escuela de Medicina, Departamento de Salud Pública, Santiago, Chile
| | - Joanna M Davies
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Anna E Bone
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Mevhibe Hocaoglu
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Harvard Medical School, Blavatnik Institute, Global Health and Social Medicine, Boston, MA, USA
| | - Julia Verne
- Office for Health Improvement and Disparities, Department of Health and Social Care, London, UK
| | - Stephen Barclay
- Martin House Research Centre, Department of Health Sciences, University of York, Heslington, York, UK
| | - Fliss E M Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Lorna K Fraser
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Kruiswijk AA, Dorleijn DMJ, Marang-van de Mheen PJ, van de Sande MAJ, van Bodegom-Vos L. Health-Related Quality of Life of Bone and Soft-Tissue Tumor Patients around the Time of Diagnosis. Cancers (Basel) 2023; 15:2804. [PMID: 37345139 DOI: 10.3390/cancers15102804] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/28/2023] [Accepted: 05/16/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Bone and soft-tissue tumor patients experience long-lasting physical and psychological challenges. It is unknown to what extent Health-Related Quality of Life (HRQoL) is already affected during the diagnostic process. This study assesses the HRQoL of bone and soft-tissue tumor patients around time of diagnosis and explores which patient or tumor characteristics are associated with a reduced HRQoL. METHODS All patients with a suspected benign/malignant bone tumor (BT), benign soft-tissue tumor (STT), or malignant soft-tissue sarcoma (STS) visiting the Leiden University Medical Center between 2016 and 2020 were invited to complete the Patient-Reported Outcomes Measurement Information System (PROMIS) 29-item profile questionnaire. Mean scores of all included patients and per diagnosis group were compared to mean scores of the general population using one-sample t-tests. RESULTS Overall, patients (n = 637) reported statistically significantly worse HRQoL-scores on anxiety (51.3 ± 9.6), pain (55.3 ± 10.1), physical functioning (46.0 ± 9.7), and social functioning (48.1 ± 10.8) with the difference in pain and physical functioning being clinically relevant (based on a 3-point difference on t-metric). HRQoL-scores differed between diagnosis subgroups, i.e., patients with malignant tumors had higher anxiety levels and experienced more pain, where patients with bone tumors had worse physical functioning. CONCLUSION The HRQoL of patients with suspected bone and soft-tissue tumors is already affected during the diagnostic process.
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Affiliation(s)
- Anouk A Kruiswijk
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
- Department of Orthopedic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Desiree M J Dorleijn
- Orthopedic Surgery, Ghent University Hospital, Corneel Heymanslaan 10, 9000 Gent, Belgium
| | - Perla J Marang-van de Mheen
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Michiel A J van de Sande
- Department of Orthopedic Surgery, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
| | - Leti van Bodegom-Vos
- Department of Biomedical Data Sciences, Medical Decision Making, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Baim-Lance A, Ferreira KB, Cohen HJ, Ellenberg SS, Kuchel GA, Ritchie C, Sachs GA, Kitzman D, Morrison RS, Siu A. Improving the Approach to Defining, Classifying, Reporting and Monitoring Adverse Events in Seriously Ill Older Adults: Recommendations from a Multi-stakeholder Convening. J Gen Intern Med 2023; 38:399-405. [PMID: 35581446 PMCID: PMC9905384 DOI: 10.1007/s11606-022-07646-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 04/27/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Clinical trials are needed to study topics relevant to older adults with serious illness. Investigators conducting clinical trials with this population are challenged by how to appropriately define, classify, report, and monitor serious and non-serious adverse events (SAEs/AEs), given that some traditionally reported AEs (pressure ulcers, delirium) and SAEs (death, hospitalization) are common in persons with serious illness, and may be consistent with their goals of care. OBJECTIVES A multi-stakeholder group convened to establish greater clarity on and new approaches to address this critical issue. PARTICIPANTS Thirty-two study investigators, members of regulatory and sponsor agencies, and patient stakeholders took part. APPROACH The group met virtually four times and, using a collaborative approach, conducted a survey, select interviews, and reviewed regulatory guidance to collectively define the problem and identify a new approach. RESULTS SAE/AE challenges fell into two areas: (1) definitions and classifications, including (a) implausible relationships, (b) misalignment with patient-centered care goals, and (c) well-known associations, and (2) reporting and monitoring, including (a) limited guidance, (b) inconsistent standards across regulators, and (c) Data Safety Monitoring Board (DSMB) member knowledge gaps. Problems largely reflected practice norms rather than regulatory requirements that already support context-specific and aggregate reporting. Approaches can be improved by adopting principles that better align strategies for addressing adverse events with the type of intervention being tested, favoring routine and aggregate over expedited reporting, and prioritizing how SAE/AEs relate to patient-centered care goals. Reporting plans and decisions should follow an algorithm underpinned by these principles. CONCLUSIONS Adoption of the proposed approach-and supporting it with education and better alignment with regulatory guidance and procedures-could improve the quality and efficiency of clinical trials' safety involving older adults with serious illness and other vulnerable populations.
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Affiliation(s)
- Abigail Baim-Lance
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA.
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA.
| | - Katelyn B Ferreira
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
| | - Harvey Jay Cohen
- Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC, USA
| | - Susan S Ellenberg
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - George A Kuchel
- UConn Center on Aging, University of Connecticut, Farmington, CT, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine and the Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Greg A Sachs
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Dalane Kitzman
- Department of Internal Medicine: Sections on Cardiovascular Medicine and Geriatrics, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - R Sean Morrison
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA
| | - Albert Siu
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1070, New York, NY, 10029, USA
- Geriatric Research Education and Clinical Center (GRECC), James J Peters VA Medical Center, Bronx, NY, USA
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10
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Strang P. Palliative oncology and palliative care. Mol Oncol 2022; 16:3399-3409. [PMID: 35762045 PMCID: PMC9533690 DOI: 10.1002/1878-0261.13278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/23/2022] [Accepted: 06/25/2022] [Indexed: 12/02/2022] Open
Abstract
New therapeutic approaches can produce promising results even in severely ill cancer patients. But they also pose new challenges with respect to prognostication, as patients who were once not eligible for treatment, due to age or comorbidities, now are. Palliative oncology constitutes a major part of oncological care, with life prolongation and quality of life as its main goals. Palliative care specialists are experts in symptom control and psychosocial and existential support, and the integration of their expertise early on in patient care can prolong survival. In this article, I discuss the need to integrate specialist palliative care into early cancer treatment plans to achieve quality of life for patients. I also discuss the ways in which palliative care specialists balance the benefits of novel treatments against their adverse effects for patients, particularly for the elderly, the frail and those in advance stages of disease. I highlight the need to ensure equal access to palliative care to improve cancer patients' quality of life but also why futile, burdensome treatments should be avoided especially in the frail, elderly patients. Further, I discuss benefits and problems related to nutritional support in patients with cachexia and exemplify why translational research is needed to link basic research with clinical oncology and effective symptom control.
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Affiliation(s)
- Peter Strang
- Department of Oncology‐Pathology, Karolinska Institutet, Regional Cancer Centre in Stockholm – Gotland, and R & D DepartmentStockholm's Sjukhem FoundationSweden
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11
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Kim IJ. Exploring societal perspectives on priorities at the end of life in South Korea using Q-methodology. Jpn J Nurs Sci 2022; 19:e12495. [PMID: 35678103 DOI: 10.1111/jjns.12495] [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: 02/03/2022] [Revised: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 11/29/2022]
Abstract
AIM To explore societal perspectives on priorities at the end of life in South Korea, an Asian country with high characteristics of Confucian culture. Based on this understanding, this study proposes strategies for establishing well-dying Confucian heritage cultures. METHODS Q-methodology, suitable for analyzing human subjectivity, was used in this study. Thirty-four Q-statements were extracted from the 170 Q population, which were gathered from literature reviews and online resources. Participants were 33 people expected to present diverse views of priorities at the end of their lives. The data were analyzed with principal component analysis and varimax rotations using the PQMethod software. RESULTS Four distinct perspectives on priorities at the end of life in South Korea were identified: "Emphasizing the right to self-determination," "Avoiding burdening the family," "Putting life first," and "Connotations with a complex perspective." CONCLUSIONS This study provides strategies for preparing various nursing interventions or policies for the establishment of a well-dying culture based on the four identified perspectives on priorities at the end of life, especially in countries with Confucian heritage cultures.
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Affiliation(s)
- Ick-Jee Kim
- Department of Nursing, Youngsan University, Yangsan, Gyeongsangnam-do, Republic of Korea
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12
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Hov R, Bjørsland B, Kjøs BØ, Wilde-Larsson B. Pasienters opplevelse av trygghet med palliativ omsorg i hjemmet. TIDSSKRIFT FOR OMSORGSFORSKNING 2022. [DOI: 10.18261/issn.2387-5984-2021-01-05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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13
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Neto IG. Palliative care and its own identity, through an autoethnography: do you recognize these patterns? Palliat Care Soc Pract 2022; 16:26323524221122346. [PMID: 36118620 PMCID: PMC9478704 DOI: 10.1177/26323524221122346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 07/28/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction: After more than 25 years working in palliative care (PC) observing thousands
of patients and family behaviors, I use my long experience and notes as a
source of data for a qualitative research study. The aim is to identify
frequent families’ behavior patterns in PC and better describe the culture
in PC. Methods: This article is part of a larger project, using autoethnography as
methodology, with the aim of helping doctors and interested health
professionals better understand the culture and reality of PC. The focus is
not the author but patients and families’ patterns of
social behavior – the social context – within the
end-of-life period and how to deal with these professionally.
Confidentiality and privacy of patients’ data were guaranteed. Results: The vast number of treated cases, the regular observation and recording, and
the continuous reflection and analysis over many years have led to these
results. Due to editorial restrictions, in this article I only describe four
of at least eight typical scenarios I have identified. Each is given a short
title and I explore some of their inside-issues, integrating previous
knowledge, research, and explanations, with practical suggestions on how to
deal with them. Significance: As far as we know, these scenarios/patterns have never been described in this
way. This work expands knowledge, innovates, and contributes to better
describing PC culture. The final goal is to create a set of scripts that can
be used to help clinicians quickly identify the clinical situation and how
to deal with it in clinical practice. Reflecting on how patients and
families frequently behave in PC can be very useful and then teach other
professionals to better deal with these challenges.
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Affiliation(s)
- Isabel Galriça Neto
- Palliative Care Unit, Hospital da Luz-Lisboa, Lisbon University Medical School, Catolica University Medical School, Av.Lusíada 100, Lisboa 1500-650, Portugal
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14
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Schaeffner E. Smoothing transition to dialysis to improve early outcomes after dialysis initiation among old and frail adults-a narrative review. Nephrol Dial Transplant 2021; 37:2307-2313. [PMID: 34865111 PMCID: PMC9681923 DOI: 10.1093/ndt/gfab342] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Indexed: 12/31/2022] Open
Abstract
The number of patients ≥65 years of age suffering from advanced chronic kidney disease and transitioning to end-stage kidney disease (ESKD) is increasing. However, elderly patients often have poor outcomes once haemodialysis is initiated, including high mortality within the first year as well as fast cognitive and functional decline and diminished quality of life. The question is how we can smooth this transition to ESKD in older patients who also exhibit much higher proportions of frailty when compared with community-dwelling non-dialysis older adults and who are generally more vulnerable to invasive treatment such as kidney replacement therapy. To avoid early death and poor quality of life, a carefully prepared smooth transition should precede the initiation of treatment. This involves pre-dialysis physical and educational care, as well as mental and psychosocial preparedness of the patient to enable an informed and shared decision about the individual choice of treatment modality. Communication between a healthcare professional and patient plays a pivotal role but can be challenging given the high rate of cognitive impairment in this particular population. In order to practise patient-centred care, adapting treatment tailored to the individual patient should include comprehensive conservative care. However, structured treatment pathways including multidisciplinary teams for such conservative care are still rare and may be difficult to establish outside of large cities. Generally, geriatric nephrology misses data on the comparative effectiveness of different treatment modalities in this population of old and very old age on which to base recommendations and decisions.
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15
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Mularski RA, Mittman B, Haupt E, Wang S, Scholle S, McMullen C, Henry M, Shen E, Nguyen HQ. Performance of Patient-Reported Outcome Measures in a Large Pragmatic Trial of Home-Based Palliative Care (HomePal): Methodological and Practical Considerations for Embedded Patient-Centered Design. J Palliat Med 2021; 25:620-627. [PMID: 34735285 DOI: 10.1089/jpm.2021.0164] [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: 11/12/2022] Open
Abstract
Background: The research enterprise has embraced patient centeredness in embedded efficient pragmatic trials, but limited data exist on using patient-reported outcomes (PROs) collected as part of usual clinical care for research. Objectives: We sought to assess the performance of different assessment methods for obtaining PROs in a pragmatic cluster randomized trial (HomePal study) designed to compare two models of home-based palliative care (HBPC). Design: Descriptive analytics, comparative trends, and psychometric performance of PROs collected in the HomePal study; measures included Edmonton Symptom Assessment System (ESAS), PROMIS-10, and others administered at baseline, 1, and 6 months. Setting/Subjects: HomePal was conducted in the Southern California and Northwest Kaiser Permanente regions in the United States; subjects were patients receiving HBPC and their caregivers. Measurements: We specifically compared ESAS obtained by research staff with those obtained by clinical HBPC nurses at the time of HBPC enrollment. We also compared ESAS completed by patients versus if done or assisted by a caregiver (proxy). Results: We enrolled 3533 patients and had 2205 ESAS measurements that met the criteria for analysis at baseline and 1447 at the one-month follow-up assessment. Research staff-obtained ESAS at admission to HBPC was higher overall (indicating more symptoms) than the clinically collected measure whether symptoms were reported by patients (31.7 ± 15.4 vs. 26.0 ± 13.4) or by proxies (36.9 ± 15.6 vs. 26.5 ± 13.5). These differences persisted with follow-up ESAS measures. Conclusions: We identified significant variability in PRO responses between different surveyors and whether proxy interaction was needed suggesting complex issues around PRO measure performance for pragmatic embedded trials. ClinicalTrials.gov Identifier: NCT03694431.
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Affiliation(s)
- Richard A Mularski
- The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | - Brian Mittman
- Department of Research and Evaluation, Kaiser Permanente Southern California, Portland, Oregon, USA
| | - Eric Haupt
- Department of Research and Evaluation, Kaiser Permanente Southern California, Portland, Oregon, USA
| | - Susan Wang
- West Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles, California, USA
| | - Sarah Scholle
- National Committee for Quality Assurance (NCQA), Washington, DC, USA
| | - Carmit McMullen
- The Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA
| | | | - Ernest Shen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Portland, Oregon, USA
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Portland, Oregon, USA
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16
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Quach BI, Qureshi D, Talarico R, Hsu AT, Tanuseputro P. Comparison of End-of-Life Care Between Recent Immigrants and Long-standing Residents in Ontario, Canada. JAMA Netw Open 2021; 4:e2132397. [PMID: 34726744 PMCID: PMC8564577 DOI: 10.1001/jamanetworkopen.2021.32397] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
IMPORTANCE Recent immigrants face unique cultural and logistical challenges that differ from those of long-standing residents, which may influence the type of care they receive at the end of life. OBJECTIVE To compare places of care among recent immigrants and long-standing residents in Canada in the last 90 days of life. DESIGN, SETTING, AND PARTICIPANTS This population-based retrospective cohort study used linked health administrative data on individuals from Ontario, Canada, who died between January 1, 2013, and December 31, 2016, extracted on February 26, 2020. Individuals were categorized by immigration status: recent immigrants (since 1985) and long-standing residents. Data were analyzed from December 27, 2019, to February 26, 2020. EXPOSURES All decedents who immigrated to Canada between 1985 and 2016 were classified as recent immigrants. Subgroup analyses assessed the association of region of origin. MAIN OUTCOMES AND MEASURES The main outcome was place of care, including institutional and noninstitutional settings, in the last 90 days of life. Descriptive statistics were used to compare characteristics and health service utilization among recent immigrants and long-standing residents. Negative binomial regression models estimated the rate ratios (RR) of using acute care and long-term care in the last 90 days of life. RESULTS A total of 376 617 deceased individuals (median [IQR] age, 80 [68-88] years; 187 439 [49.8%] women and 189 178 [50.2%] men) were identified, among whom 22 423 (6.0%) were recent immigrants; recent immigrants were younger than long-standing residents (median [IQR] age, 76 [60-85] years vs 81 [69-88] years; P < .001), more likely to be living in lower income neighborhoods (12 357 immigrants [55.1%] vs 166 017 long-standing residents [46.9%] in the lower 2 income quintiles; P < .001), and had a higher Charlson Index score (score ≥5, 6294 immigrants [28.1%] vs 74 809 long-standing residents [21.1%]; P < .001). In the last 90 days of life, recent immigrants spent more days in intensive care units than long-standing residents (mean [SD], 2.64 [8.73] days vs 1.47 [5.70] days; P < .001), while long-standing residents spent more days using long-term care than recent immigrants (mean [SD], 19.49 [35.81] days vs 10.45 [27.42] days; P < .001). Being a recent immigrant was associated with a greater likelihood of acute inpatient care use (RR, 1.21; 95% CI, 1.18-1.24) and lower likelihood of long-term care use (RR, 0.66; 95% CI, 0.63-0.70), after adjusting for covariates. CONCLUSIONS AND RELEVANCE These findings suggest that at the end of life, recent immigrants were significantly more likely to receive inpatient and intensive care unit services and die in acute care settings compared with long-standing residents. Further research is needed to examine differences in care preference and disparities for immigrant groups of different origins.
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Affiliation(s)
- Bradley I. Quach
- Faculty of Sciences, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
| | - Danial Qureshi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
| | | | - Amy T. Hsu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Peter Tanuseputro
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Bruyère Research Institute, Ottawa, Canada
- ICES, Ottawa, Canada
- Department of Family Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Canada
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17
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Forschner A, Loquai C, Meiss F, Huening S, Pawlowski J, Bradfisch F, Lehr S, Nashan D. Gibt es eine Überbehandlung von Melanompatienten am Ende ihres Lebens? Ergebnisse einer multizentrischen Studie an 193 Melanompatienten. J Dtsch Dermatol Ges 2021; 19:1297-1306. [PMID: 34541790 DOI: 10.1111/ddg.14501_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 02/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Frank Meiss
- Abteilung für Dermatologie und Venerologie, Medizinisches Zentrum - Universität Freiburg, Medizinische Fakultät, Universität Freiburg
| | | | - Johannes Pawlowski
- Abteilung für Dermatologie, Universitätsklinikum Tübingen.,Klinik für Dermatologie, Universitätsklinikum Mainz
| | | | - Saskia Lehr
- Abteilung für Dermatologie und Venerologie, Medizinisches Zentrum - Universität Freiburg, Medizinische Fakultät, Universität Freiburg
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18
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Forschner A, Loquai C, Meiss F, Huening S, Pawlowski J, Bradfisch F, Lehr S, Nashan D. Is there an overtreatment of melanoma patients at the end of their life? Results of a multicenter study on 193 melanoma patients. J Dtsch Dermatol Ges 2021; 19:1297-1305. [PMID: 34357677 DOI: 10.1111/ddg.14501] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 02/23/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND OBJECTIVES There is a lack of data regarding the situation of melanoma patients receiving systemic therapies in their last months of life. PATIENTS AND METHODS All melanoma patients who died in 2016 or 2017 and who had been treated by systemic therapies within the last three months of life were retrospectively analyzed. The study was conducted within the Committee "supportive therapy" of the Work Group Dermatological Oncology (ADO). RESULTS 193 patients from four dermato-oncological centers were included. More than 60 % of the patients had ECOG ≥ 2 and most of them received immune checkpoint inhibitors (ICI) or targeted therapies (TT). 41 patients benefited from the last therapy in terms of radiological and laboratory findings or state of health. Although ECOG was worse in the TT cohort compared to the ICI group, the proportion of patients benefiting from the last therapy with TT was significantly higher and TT therapy could be carried out more often on an outpatient basis. CONCLUSIONS This study indicates that there is a tendency towards an overtreatment at the end of life. Nevertheless, TT might be a reasonable therapeutic option for advanced BRAF mutant melanoma, even in highly palliative situations.
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Affiliation(s)
- Andrea Forschner
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany
| | - Carmen Loquai
- Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | - Frank Meiss
- Department of Dermatology and Venereology, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Svea Huening
- Department of Dermatology, Hospital Dortmund, Dortmund, Germany
| | - Johannes Pawlowski
- Department of Dermatology, University Hospital Tübingen, Tübingen, Germany.,Department of Dermatology, University Hospital Mainz, Mainz, Germany
| | | | - Saskia Lehr
- Department of Dermatology and Venereology, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Dorotheé Nashan
- Department of Dermatology, Hospital Dortmund, Dortmund, Germany
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19
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Wong CHL, Wong W, Lin WL, Au DKY, Wu JCY, Leung TH, Wu IXY, Chung VCH. Prioritizing Chinese medicine clinical research questions in cancer palliative care from patient and caregiver perspectives. Health Expect 2021; 24:1487-1497. [PMID: 34107142 PMCID: PMC8369121 DOI: 10.1111/hex.13289] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/14/2021] [Accepted: 05/12/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Chinese medicine (CM) modalities, including acupuncture and Chinese herbal medicine (CHM), are popular palliative interventions among patients with cancer, but further clinical research is required to assess their effectiveness and safety. OBJECTIVE To prioritize top ten important CM clinical research questions from patients with cancer, cancer survivors and caregivers' perspectives via a face-to-face prioritization workshop in Hong Kong. METHODS A list of 25 CM clinical research questions for cancer palliative care, which were identified from existing systematic reviews (SRs) and overview of SRs, was presented to 17 participants (patients with cancer [n = 5], cancer survivors [n = 6] and caregivers [n = 6]). The participants were then invited to establish consensus on prioritizing top ten research questions. RESULTS Among the top ten priorities, five (50%) focused on acupuncture and related therapies, while five (50%) were on CHM. The three most important research priorities were (i) manual acupuncture plus opioids for relieving pain; (ii) CHM for improving quality of life among patients receiving chemotherapy; and (iii) concurrent use of CHM plus loperamide for reducing stomatitis. CONCLUSION The top ten participant-endorsed CM clinical research priorities for cancer palliative care can guide local researchers on future direction. They can also inform local research funders on patient-centred allocation of limited funding. Under limited research funding, the most important co-prioritized research question from professional and patient perspectives may be addressed first. PATIENT OR PUBLIC CONTRIBUTION Patients with cancer, cancer survivors and caregivers participated in conduct of the study to prioritize CM clinical research questions.
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Affiliation(s)
- Charlene H. L. Wong
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongShatinHong Kong
- Jockey Club School of Public Health and Primary CareThe Chinese University of Hong KongShatinHong Kong
| | - Wendy Wong
- National Institution of TCM Constitution and Preventive MedicineBeijing University of Chinese MedicineBeijingChina
- Yat Hei Hong Kong Company LimitedCentralHong Kong
| | - Wai Ling Lin
- Hong Kong Institute of Integrative MedicineThe Chinese University of Hong KongShatinHong Kong
| | - David K. Y. Au
- Hong Kong Institute of Integrative MedicineThe Chinese University of Hong KongShatinHong Kong
| | - Justin C. Y. Wu
- Department of Medicine and TherapeuticsThe Chinese University of Hong KongShatinHong Kong
| | - Ting Hung Leung
- Jockey Club School of Public Health and Primary CareThe Chinese University of Hong KongShatinHong Kong
- School of Chinese MedicineThe Chinese University of Hong KongShatinHong Kong
| | - Irene X. Y. Wu
- Department of Epidemiology and Health StatisticsXiangya School of Public HealthCentral South UniversityChangshaChina
| | - Vincent C. H. Chung
- Jockey Club School of Public Health and Primary CareThe Chinese University of Hong KongShatinHong Kong
- School of Chinese MedicineThe Chinese University of Hong KongShatinHong Kong
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20
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Murphy E, Burns A, Murtagh FEM, Rooshenas L, Caskey FJ. The Prepare for Kidney Care Study: prepare for renal dialysis versus responsive management in advanced chronic kidney disease. Nephrol Dial Transplant 2021; 36:975-982. [PMID: 32940683 PMCID: PMC8160947 DOI: 10.1093/ndt/gfaa209] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Indexed: 11/12/2022] Open
Abstract
Shared decision making in advanced chronic kidney disease (CKD) requires unbiased information on survival and person-centred outcomes known to matter to patients: quality of life, symptom burden and support from family and healthcare professionals. To date, when deciding between dialysis and conservative care, patients have had to rely on evidence from small observational studies. Clinicians recognize that like is not being compared with like in these studies, and interpret the results differently. Furthermore, support differs considerably between renal units. What patients choose therefore depends on which renal unit they attend. To address this, a programme of work has been underway in the UK. After reports on survival and symptoms from a small number of renal units, a national, mixed-methods study-the Conservative Kidney Management Assessment of Practice Patterns Study-mapped out conservative care practices and attitudes in the UK. This led to the Prepare for Kidney Care study, a randomized controlled trial comparing preparation for dialysis versus preparation for conservative care. Although powered to detect a positivist 0.345 difference in quality-adjusted life years between the two treatments, this trial also takes a realist approach with a range of person-centred secondary outcomes and embedded qualitative research. To understand generalizability, it is nested in an observational cohort study, which is nested in a CKD registry. Challenges to recruitment and retention have been rapidly identified and addressed using an established embedded mixed methods approach-the QuinteT recruitment intervention. This review considers the background to and progress with recruitment to the trial.
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Affiliation(s)
- Emma Murphy
- Health Sciences, University of Southampton, Southampton, UK
| | - Aine Burns
- The Royal Free Hospital, Renal Center for Nephrology Royal Free Hospital NHS Trust, London, UK
| | - Fliss E M Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Leila Rooshenas
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Fergus J Caskey
- Population Health Sciences, University of Bristol, Bristol, UK
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21
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Oluyase AO, Higginson IJ, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FEM, Bajwah S. Hospital-based specialist palliative care compared with usual care for adults with advanced illness and their caregivers: a systematic review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Most deaths still take place in hospital; cost-effective commissioning of end-of-life resources is a priority. This review provides clarity on the effectiveness of hospital-based specialist palliative care.
Objectives
The objectives were to assess the effectiveness and cost-effectiveness of hospital-based specialist palliative care.
Population
Adult patients with advanced illnesses and their unpaid caregivers.
Intervention
Hospital-based specialist palliative care.
Comparators
Inpatient or outpatient hospital care without specialist palliative care input at the point of entry to the study, or community care or hospice care provided outside the hospital setting (usual care).
Primary outcomes
Patient health-related quality of life and symptom burden.
Data sources
Six databases (The Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and CareSearch), clinical trial registers, reference lists and systematic reviews were searched to August 2019.
Review methods
Two independent reviewers screened, data extracted and assessed methodological quality. Meta-analysis was carried out using RevMan (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark), with separate synthesis of qualitative data.
Results
Forty-two randomised controlled trials involving 7779 participants (6678 patients and 1101 unpaid caregivers) were included. Diagnoses of participants were as follows: cancer, 21 studies; non-cancer, 14 studies; and mixed cancer and non-cancer, seven studies. Hospital-based specialist palliative care was offered in the following models: ward based (one study), inpatient consult (10 studies), outpatient (six studies), hospital at home or hospital outreach (five studies) and multiple settings that included hospital (20 studies). Meta-analyses demonstrated significant improvement favouring hospital-based specialist palliative care over usual care in patient health-related quality of life (10 studies, standardised mean difference 0.26, 95% confidence interval 0.15 to 0.37; I
2 = 3%) and patient satisfaction with care (two studies, standardised mean difference 0.36, 95% confidence interval 0.14 to 0.57; I
2 = 0%), a significant reduction in patient symptom burden (six studies, standardised mean difference –0.26, 95% confidence interval –0.41 to –0.12; I
2 = 0%) and patient depression (eight studies, standardised mean difference –0.22, 95% confidence interval –0.34 to –0.10; I
2 = 0%), and a significant increase in the chances of patients dying in their preferred place (measured by number of patients with home death) (seven studies, odds ratio 1.63, 95% confidence interval 1.23 to 2.16; I
2 = 0%). There were non-significant improvements in pain (four studies, standardised mean difference –0.16, 95% confidence interval –0.33 to 0.01; I
2 = 0%) and patient anxiety (five studies, mean difference –0.63, 95% confidence interval –2.22 to 0.96; I
2 = 76%). Hospital-based specialist palliative care showed no evidence of causing serious harm. The evidence on mortality/survival and cost-effectiveness was inconclusive. Qualitative studies (10 studies, 322 participants) suggested that hospital-based specialist palliative care was beneficial as it ensured personalised and holistic care for patients and their families, while also fostering open communication, shared decision-making and respectful and compassionate care.
Limitation
In almost half of the included randomised controlled trials, there was palliative care involvement in the control group.
Conclusions
Hospital-based specialist palliative care may offer benefits for person-centred outcomes including health-related quality of life, symptom burden, patient depression and satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death) with little evidence of harm.
Future work
More studies are needed of populations with non-malignant diseases, different models of hospital-based specialist palliative care, and cost-effectiveness.
Study registration
This study is registered as PROSPERO CRD42017083205.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Massimo Costantini
- Palliative Care Unit, Azienda Unità Sanitaria Locale – Istituto di Ricovero e Cura a Carattere Scientifico (USL-IRCCS), Reggio Emilia, Italy
| | - Fliss EM Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
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Webb WA, Mitchell T, Snelling P, Nyatanga B. Life's hard and then you die: the end-of-life priorities of people experiencing homelessness in the UK. Int J Palliat Nurs 2021; 26:120-132. [PMID: 32275478 DOI: 10.12968/ijpn.2020.26.3.120] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND People experiencing homelessness often die young and without adequate support. In the UK, they fail to access palliative care services and their end-of-life priorities remain poorly understood. AIMS To explore the end-of-life concerns, fears, preferences and priorities of a sample of people experiencing homelessness in the UK. METHODS This is an interpretive phenomenology. Data collected through semi-structured, audio-recorded, face-to-face interviews with 21 homeless participants in the UK were analysed iteratively using thematic analysis. Findings have been interpreted through the lens of Merleau-Ponty's philosophy. RESULTS Eight themes are reported: spiritual concerns; practical concerns; fear of needing care; fear of being forgotten; preference for dying suddenly; preference for being somewhere comfortable where people know me; prioritising autonomy and self-determination; and prioritising authenticity. CONCLUSION A strengths-based, trauma-informed, person-centred, collaborative 'compassionate community' approach to care is recommended for people experiencing homelessness at end of life.
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Affiliation(s)
- Wendy Ann Webb
- Advanced Clinical Practitioner, University of Worcester, UK
| | | | - Paul Snelling
- Principal Lecturer in Adult Nursing, University of Worcester, UK
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23
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Wilson R, Gaughran F, Whitburn T, Higginson IJ, Gao W. Acute care utilisation towards the end of life and the place of death for patients with serious mental disorders: a register-based cohort study in South London. Public Health 2021; 194:79-85. [PMID: 33866148 DOI: 10.1016/j.puhe.2021.02.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 01/26/2021] [Accepted: 02/05/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of the study was to explore acute care utilisation towards end of life by and the place of death for patients with serious mental disorders and to demonstrate any inequalities in end-of-life care faced by this patient group. STUDY DESIGN This is a retrospective cohort study using linked, routinely collected data. METHODS This study used linked data extracted from mental health records, Hospital Episode Statistics and mortality data. Adult cases (≥18 years old) were included if they had a serious mental disorder and died between 2007 and 2015. Multiple imputation was used to manage missing data, and generalised linear models were used to assess multiple adjusted associations between sociodemographic and clinical explanatory variables and acute service use at the end of life and in-hospital deaths. RESULTS A cohort of 1350 adults was analysed. More than half visited the accident and emergency (A&E) department in the last 90 days of life, and a third had a burdensome transition (multiple hospital admissions in the last 90 days of life or at least one in the last three days); the median number of days spent in the hospital was 4 (range: 0-86). Having more comorbidities was a strong correlate of more A&E visits (adjusted odds ratio [OR] = 1.03 [95% confidence interval = 1.02-1.04]), burdensome transitions (adjusted OR = 1.06 [1.04-1.08]) and days spent in the hospital (adjusted OR = 1.04 [1.03-1.05]). Having a diagnosis of schizophrenia spectrum disorder, compared with other serious mental disorder diagnoses, was associated with fewer A&E visits (adjusted OR = 0.78 [0.71-0.88]) and fewer days in the hospital (adjusted OR = 0.77 [0.66-0.89]). Younger age was associated with more A&E visits (adjusted OR = 1.28 [1.07-1.53]) and fewer days spent in the hospital (adjusted OR = 0.70 [0.52-0.95]). Hospital deaths were high (51%), and in a fully adjusted model, they were associated with having more comorbidities (adjusted OR = 1.02 [1.01-1.03]) and accessing acute care at the end of life (including more A&E visits; adjusted OR = 1.07 [1.05-1.10]), burdensome transitions (adjusted OR = 1.53 [1.37-1.71]) and days spent in the hospital (adjusted OR = 2.05 [1.70-247]). CONCLUSION People with comorbidities are more likely to use more burdensome acute health care at the end of life and are more likely to die in the hospital. Hospital deaths could be reduced, and end-of-life care could be improved by targeting patients with comorbidities and who are accessing more acute healthcare services.
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Affiliation(s)
- R Wilson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, United Kingdom
| | - F Gaughran
- Psychosis Studies Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom; National Psychosis Unit, South London and Maudsley NHS Foundation Trust 7th Floor, Psychosis Studies Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London, SE5 8AF, United Kingdom
| | - T Whitburn
- Barts Health NHS Trust, Macmillan Palliative Care Team, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, United Kingdom
| | - I J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, United Kingdom
| | - W Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, United Kingdom.
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Blackwood DH, Vindrola-Padros C, Mythen MG, Columb MO, Walker D. A national survey of anaesthetists' preferences for their own end of life care. Br J Anaesth 2020; 125:1088-1098. [DOI: 10.1016/j.bja.2020.07.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 06/23/2020] [Accepted: 07/12/2020] [Indexed: 01/18/2023] Open
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25
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The Health-Related Quality of Life of Sarcoma Patients and Survivors in Germany-Cross-Sectional Results of a Nationwide Observational Study (PROSa). Cancers (Basel) 2020; 12:cancers12123590. [PMID: 33266287 PMCID: PMC7759994 DOI: 10.3390/cancers12123590] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 11/24/2020] [Accepted: 11/27/2020] [Indexed: 01/17/2023] Open
Abstract
Simple Summary Sarcomas are a rare cancer with many different subtypes. They can occur anywhere in the body and are treated in a multi-disciplinary manner. Large studies on the quality of life of sarcoma patients are rare, so little is known about how patients are doing compared to the general population and which groups of sarcoma patients are particularly affected by quality of life limitations. We assessed the quality of life of 1113 sarcoma patients from Germany. The majority were particularly restricted in their emotional functioning, physical functioning, and the exercise of everyday demands (role function). Many of them experienced pain (56%) and fatigue (51%). We found that patients with leg or bone sarcomas were especially affected by quality of life limitations. We also found that patients who received a retirement pension were less affected by quality of life restrictions than patients who had not retired. Abstract Sarcomas are rare cancers with high heterogeneity in terms of type, location, and treatment. The health-related quality of life (HRQoL) of sarcoma patients has rarely been investigated and is the subject of this analysis. Adult sarcoma patients and survivors were assessed between September 2017 and February 2019 in 39 study centers in Germany using standardized, validated questionnaires (European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30)). Associated factors were analyzed exploratively using multivariable linear regressions. Among 1113 patients, clinically important limitations and symptoms were most pronounced in emotional (63%, 95% CI 60–66%), physical (60%, 95% CI 57–62%), role functioning (51%, 95% CI 48–54%), and pain (56%, 95% CI 53–59%) and fatigue (51%, 95% CI 48–54%). HRQoL differed between tumor locations with lower extremities performing the worst and sarcoma types with bone sarcoma types being most affected. Additionally, female gender, higher age, lower socioeconomic status, recurrent disease, not being in retirement, comorbidities, and being in treatment were associated with lower HRQoL. Sarcoma patients are severely restricted in their HRQoL, especially in functioning scales. The heterogeneity of sarcomas with regard to type and location is reflected in HRQoL outcomes. During treatment and follow-up, close attention has to be paid to the reintegration of the patients into daily life as well as to their physical abilities and emotional distress.
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26
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Timing of GP end-of-life recognition in people aged ≥75 years: retrospective cohort study using data from primary healthcare records in England. Br J Gen Pract 2020; 70:e874-e879. [PMID: 33139331 DOI: 10.3399/bjgp20x713417] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/17/2020] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND High-quality, personalised palliative care should be available to all, but timely recognition of end of life may be a barrier to end-of-life care for older people. AIM To investigate the timing of end-of-life recognition, palliative registration, and the recording of end-of-life preferences in primary care for people aged ≥75 years. DESIGN AND SETTING Retrospective cohort study using national primary care record data, covering 34% of GP practices in England. METHOD ResearchOne data from electronic healthcare records (EHRs) of people aged ≥75 years who died in England between 1 January 2015 and 1 January 2016 were examined. Clinical codes relating to end-of-life recognition, palliative registration, and end-of-life preferences were extracted, and the number of months that elapsed between the code being entered and death taking place were calculated. The timing for each outcome and proportion of relevant EHRs were reported. RESULTS Death was recorded for a total of 13 149 people in ResearchOne data during the 1-year study window. Of those, 6303 (47.9%) records contained codes suggesting end of life had been recognised at a point in time prior to the month of death. Recognition occurred ≥12 months before death in 2248 (17.1%) records. In total, 1659 (12.6%) people were on the palliative care register and 457 (3.5%) were on the register for ≥12 months before death; 2987 (22.7%) records had a code for the patient's preferred place of care, and 1713 (13.0%) had a code for the preferred place of death. Where preferences for place of death were recorded, a care, nursing, or residential home (n = 813, 47.5%) and the individual's home (n = 752, 43.9%) were the most common. CONCLUSION End-of-life recognition in primary care appears to occur near to death and for only a minority of people aged ≥75 years. The findings suggest that older people's deaths may not be anticipated by health professionals, compromising equitable access to palliative care.
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Scherrens AL, Cohen J, Mahieu A, Deliens L, Deforche B, Beernaert K. The perception of people with cancer of starting a conversation about palliative care: A qualitative interview study. Eur J Cancer Care (Engl) 2020; 29:e13282. [PMID: 32613675 DOI: 10.1111/ecc.13282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 04/14/2020] [Accepted: 06/08/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Communication and patient-centred care are important determinants for timely initiation of palliative care. Therefore, we aimed to understand and explain the behaviour "starting a conversation about palliative care with a professional carer" from the perspective of people with incurable cancer. METHODS A qualitative study using semi-structured face-to-face interviews with 25 people with incurable cancer: 13 not (yet) receiving palliative care and 12 receiving palliative care; 4 started the conversation themselves. Determinants related to the defined behaviour were matched with concepts in existing behavioural theories. RESULTS Both positive and negative stances towards starting a conversation about palliative care with a professional carer were found. Influencing behavioural factors were identified, such as knowledge (e.g. about palliative care), attitude (e.g. association of palliative care with quality of life) and social influence (e.g. relationship with the professional carer). We modelled the determinants into a behavioural model. CONCLUSION The behavioural model developed helps to explain why people with incurable cancer do or do not start a conversation about palliative care with their professional carer. By targeting the modifiable determinants of the model, promising interventions can be developed to help patients taken the initiative in communication about palliative care with a professional carer.
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Affiliation(s)
- Anne-Lore Scherrens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Joachim Cohen
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Annick Mahieu
- Department of Public Health and Primary Care, Ghent University, Belgium
| | - Luc Deliens
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
| | - Benedicte Deforche
- Department of Public Health and Primary Care, Ghent University, Belgium.,Department of Movement and Sport Sciences, Physical activity, nutrition and health research unit, Faculty of Physical Education and Physical Therapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kim Beernaert
- End-of-life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Public Health and Primary Care, Ghent University, Belgium
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Haukland EC, von Plessen C, Nieder C, Vonen B. Adverse events in deceased hospitalised cancer patients as a measure of quality and safety in end-of-life cancer care. BMC Palliat Care 2020; 19:76. [PMID: 32482172 PMCID: PMC7265218 DOI: 10.1186/s12904-020-00579-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 05/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anticancer treatment exposes patients to negative consequences such as increased toxicity and decreased quality of life, and there are clear guidelines recommending limiting use of aggressive anticancer treatments for patients near end of life. The aim of this study is to investigate the association between anticancer treatment given during the last 30 days of life and adverse events contributing to death and elucidate how adverse events can be used as a measure of quality and safety in end-of-life cancer care. METHODS Retrospective cohort study of 247 deceased hospitalised cancer patients at three hospitals in Norway in 2012 and 2013. The Global Trigger Tool method were used to identify adverse events. We used Poisson regression and binary logistic regression to compare adverse events and association with use of anticancer treatment given during the last 30 days of life. RESULTS 30% of deceased hospitalised cancer patients received some kind of anticancer treatment during the last 30 days of life, mainly systemic anticancer treatment. These patients had 62% more adverse events compared to patients not being treated last 30 days, 39 vs. 24 adverse events per 1000 patient days (p < 0.001, OR 1.62 (1.23-2.15). They also had twice the odds of an adverse event contributing to death compared to patients without such treatment, 33 vs. 18% (p = 0.045, OR 1.85 (1.01-3.36)). Receiving follow up by specialist palliative care reduced the rate of AEs per 1000 patient days in both groups by 29% (p = 0.02, IRR 0.71, CI 95% 0.53-0.96). CONCLUSIONS Anticancer treatment given during the last 30 days of life is associated with a significantly increased rate of adverse events and related mortality. Patients receiving specialist palliative care had significantly fewer adverse events, supporting recommendations of early integration of palliative care in a patient safety perspective.
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Affiliation(s)
- Ellinor Christin Haukland
- Department of Oncology and Palliative Medicine, Nordland Hospital Trust, PO Box 1480, 8092, Bodø, Norway. .,Institute of Community Medicine, The Arctic University of Norway, PO Box 6, 9038, Tromsø, Norway.
| | - Christian von Plessen
- Direction Générale de la Santé, Canton Vaud, Switzerland.,Unisanté, Direction Générale de la santé, Avenue de Casèrnes 2, 1018, Lausanne, Switzerland.,Institute for Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Carsten Nieder
- Department of Oncology and Palliative Medicine, Nordland Hospital Trust, PO Box 1480, 8092, Bodø, Norway.,Institute of Clinical Medicine, The Arctic University of Norway, Tromsø, Norway
| | - Barthold Vonen
- Institute of Community Medicine, The Arctic University of Norway, PO Box 6, 9038, Tromsø, Norway.,Centre for Clinical Documentation and Evaluation, Northern Norway Regional Health Authority, PO Box 6, 9038, Tromsø, Norway
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Becqué YN, Rietjens JAC, van der Heide A, Witkamp E. The effectiveness of a nurse-led intervention to support family caregivers in end-of-life care: Study protocol for a cluster randomized controlled trial. J Adv Nurs 2020; 76:1266-1272. [PMID: 32048316 PMCID: PMC7187191 DOI: 10.1111/jan.14326] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 01/14/2020] [Accepted: 02/05/2020] [Indexed: 12/31/2022]
Abstract
Aim To evaluate the feasibility of a structured nurse‐led supportive intervention and its effects on family caregivers in end‐of‐life care at home. Background Family caregivers are crucial in end‐of‐life care. They may experience burden due to the responsibilities associated with caregiving. Some family caregivers feel insufficiently prepared for their caregiver role. Nurses have a unique position to provide supportive interventions at home to reduce caregivers’ burden and improve preparedness. However, few nurse‐led interventions are available to support family caregivers in end‐of‐life care at home. Design We will perform a cluster randomized controlled trial. The clusters consist of twelve home care services, randomly assigned to the intervention group or the control group. Methods The study population consists of family caregivers of patients in the last phase of life. In the intervention group, nurses will systematically assess the supportive needs of family caregivers, using an assessment tool and the method of clinical reasoning. Family members of the control group receive care as usual. Primary outcome is burden measured by the Self‐Rated Burden Scale. Secondary outcomes are preparedness for caregiving, caregiving reactions and acute (hospital) admissions of the patient. In addition, the feasibility of the intervention will be evaluated. The study was funded in October 2016 and was ethically approved in April 2019. Impact Findings from this study will contribute to the scientific and practical knowledge of nursing interventions to support family caregivers in end‐of‐life care. Trial registration The Netherlands Trial Register (NL7702).
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Affiliation(s)
- Yvonne N Becqué
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands.,Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Erica Witkamp
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands.,Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
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30
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The top ten things that must be known about end of life therapy in patients with advanced cancer. MEMO - MAGAZINE OF EUROPEAN MEDICAL ONCOLOGY 2020. [DOI: 10.1007/s12254-020-00572-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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31
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Robinson CA, Bottorff JL, Pesut B, Zerr J. Development and Implementation of the Family Caregiver Decision Guide. QUALITATIVE HEALTH RESEARCH 2020; 30:303-313. [PMID: 31744378 DOI: 10.1177/1049732319887166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Care provided by family is the backbone of palliative care in Canada. The critical roles performed by caregivers can at the same time be intensely meaningful and intensely stressful. However, experiences of caregiving can be enhanced when caregivers feel they are making informed and reflective decisions about the options available to them. With this in mind, the purpose of this five-phase research project was to create a Family Caregiver Decision Guide (FCDG). The Guide entails four steps: thinking about the current caregiving situation, imagining how the caregiving situation may change, exploring available options, and considering best options if caregiving needs change. The FCDG was based on available evidence and was developed and refined using focus groups, cognitive interviewing, and a feasibility and acceptability study. Finally, an interactive version of the Guide was created for online use ( https://www.caregiverdecisionguide.ca ). In this article, we describe the development, evaluation, and utility of the FCDG.
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Affiliation(s)
- Carole A Robinson
- The University of British Columbia, Kelowna, British Columbia, Canada
| | - Joan L Bottorff
- The University of British Columbia, Kelowna, British Columbia, Canada
| | - Barbara Pesut
- The University of British Columbia, Kelowna, British Columbia, Canada
| | - Janelle Zerr
- The University of British Columbia, Kelowna, British Columbia, Canada
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Dionne-Odom JN, Ornstein KA, Kent EE. What do family caregivers know about palliative care? Results from a national survey. Palliat Support Care 2019; 17:643-649. [PMID: 30957733 PMCID: PMC6783327 DOI: 10.1017/s1478951519000154] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Despite their key role in caring for individuals with serious, chronic illness, there have been no national studies examining family caregiver awareness and perceptions of palliative care. Hence, our objectives were to ascertain level of knowledge of palliative care among U.S. family caregivers and describe demographic variation in awareness and perceptions of palliative care. METHOD Using the 2018 National Cancer Institute Health Information National Trends Survey, we identified unpaid family caregivers caring or making healthcare decisions for someone with a medical, behavioral, disability, or other condition. Respondents were asked about their awareness of the term "palliative care" and, if aware, how much they agreed with statements representing common (mis)perceptions about palliative care (e.g., "Palliative care is the same as hospice"). RESULT More than one-half of caregivers (55%) had "never heard" of palliative care; 19.2% knew what palliative care was and "could explain it to someone else." In adjusted models, racial minorities (vs. whites) and those without a college degree were less likely to have heard of palliative care. Among those aware of palliative care, ~40% "strongly" or "somewhat" agreed that "Palliative care is the same as hospice"; another 10.5% "didn't know." Similarly, 40% reported that "When I think of palliative care, I automatically think of death." SIGNIFICANCE OF RESULTS One-half of family caregivers of adults with serious chronic illness have never heard of palliative care. Even among those who had heard of palliative care, the majority do not distinguish it from hospice care and death. Given the role family caregivers may play in decisions to access palliative care, public messaging efforts are needed to clarify palliative care services in a way that is patient- and family-centered.
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Affiliation(s)
- J. Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham (UAB), Birmingham, AL
- Center for Palliative and Supportive Care, UAB Health System, Birmingham, AL
| | - Katherine A. Ornstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Erin E. Kent
- Outcomes Research Branch, Healthcare Delivery Research Program, Division of Cancer Control & Population Science, National Cancer Institute, Bethesda, MD
- ICF International, Fairfax, VA
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Eggenberger T, Howard H, Prescott D, Luck G. Exploring Quality of Life in End-of-Life Discussions. Am J Hosp Palliat Care 2019; 37:465-473. [PMID: 31777266 DOI: 10.1177/1049909119890606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Advance directives (ADs) allow individuals to legally determine their preferences for end-of-life (EOL) medical treatment and designate a health-care proxy to act on their behalf prior to losing the cognitive ability to make informed decisions for themselves. An interprofessional group of researchers (law, nursing, medicine, and social work) conducted an exploratory study to identify the differences in quality-of-life (QOL) language found within the AD state statutes from 50 US states and the District of Columbia. Data were coded using constant comparative analysis. Identified concepts were grouped into 2 focus areas for EOL discussions: communication/awareness of surroundings and activities of daily living. Language regarding communication/awareness of surroundings was present in the half of the statutes. Activities of daily living were addressed in only 18% of the statutes. Only 3 states (Arkansas, Nevada, and Tennessee) specifically addressed QOL. Patients are best served when professionals, regardless of discipline, can share and transform knowledge for patients in times of crisis and loss in ways that are empathetic and precise. Interprofessional collaborative practice (IPCP) comprises multiple health workers from different professional backgrounds working together with patients, families, and communities to deliver the highest quality of care. One of the major competencies of IPCP encompasses values and ethics. Interprofessional collaborative practice is offered as the means to deliver person-centered value-based care when facilitating these crucial dialogs and making recommendations for change.
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Affiliation(s)
- Terry Eggenberger
- Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, FL, USA
| | - Heather Howard
- Phyllis and Harvey Sandler School of Social Work, Florida Atlantic University, Boca Raton, FL, USA
| | | | - George Luck
- Hospice and Palliative Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL, USA
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Smith N, Hunter K, Rajabali S, Fainsinger R, Wagg A. Preferences for Continence Care Experienced at End of Life: A Qualitative Study. J Pain Symptom Manage 2019; 57:1099-1105.e3. [PMID: 30825511 DOI: 10.1016/j.jpainsymman.2019.02.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 11/30/2022]
Abstract
CONTEXT Functional dependence at end of life often leaves individuals requiring help for personal care, including maintaining continence. Current continence guidelines offer little direction for end of life continence care, and little is known of the perspectives of people receiving palliative care. OBJECTIVES The aim of the study was to examine the continence care preferences of people receiving palliative care to understand what approaches to care and what goals of care are important to them. METHODS This is a qualitative descriptive exploratory study with data gathered in individual interviews using a semi-structured interview guide. Participants were receiving bladder and/or bowel care on either tertiary or hospice palliative care units. RESULTS Fourteen Canadian patients (seven female, seven male), six from tertiary and eight from hospice palliative care units, were recruited. From the analysis, three themes were identified: loss of control, finding a way to manage, and caregivers can help and can hinder. Dignity was often lost as a result of having to receive continence care, with most participants following staff recommendations for management approaches as the easiest way. Patients did not recall being asked about their bladder and bowel preferences. CONCLUSIONS As patients approached end of life they were willing to give up dignity if it was required to address symptoms causing them more distress, like pain. Health care professionals and family have an important role in social interactions around continence care. Health care professionals should incorporate patient preferences as best they can and explain the options when treating incontinence at end of life.
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Affiliation(s)
- Nicholas Smith
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
| | - Kathleen Hunter
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
| | - Saima Rajabali
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Robin Fainsinger
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Wagg
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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Abstract
Continuous improvements in the diagnosis and treatment of cancer lead to improved cure rates and longer survival. However, in many patients, the disease becomes chronic. In this context, the patients' quality of life (QOL) becomes a crucial issue. After an introduction about QOL, results from different areas of cancer treatment are presented considering their impact on QOL. Finally, implications are discussed for researchers, clinicians, and patients.
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Hammami MM, Abuhdeeb K, Hammami MB, De Padua SJS, Al-Balkhi A. Prediction of life-story narrative for end-of-life surrogate's decision-making is inadequate: a Q-methodology study. BMC Med Ethics 2019; 20:28. [PMID: 31053127 PMCID: PMC6500001 DOI: 10.1186/s12910-019-0368-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 04/18/2019] [Indexed: 11/29/2022] Open
Abstract
Background Substituted judgment assumes adequate knowledge of patient’s mind-set. However, surrogates’ prediction of individual healthcare decisions is often inadequate and may be based on shared background rather than patient-specific knowledge. It is not known whether surrogate’s prediction of patient’s integrative life-story narrative is better. Methods Respondents in 90 family pairs (30 husband-wife, 30 parent-child, 30 sibling-sibling) rank-ordered 47 end-of-life statements as life-story narrative measure (Q-sort) and completed instruments on decision-control preference and healthcare-outcomes acceptability as control measures, from respondent’s view (respondent-personal) and predicted pair’s view (respondent-surrogate). They also scored their confidence in surrogate’s decision-making (0 to 4 = maximum) and familiarity with pair’s healthcare-preferences (1 to 4 = maximum). Life-story narratives’ prediction was examined by calculating correlation of statements’ ranking scores between respondent-personal and respondent-surrogate Q-sorts (projection) and between respondent-surrogate and pair-personal Q-sorts before (simulation) and after controlling for correlation with respondent-personal scores (adjusted-simulation), and by comparing percentages of respondent-surrogate Q-sorts co-loading with pair-personal vs. respondent-personal Q-sorts. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was determined by percent concordance. Results were compared among subgroups defined by intra-pair relationship, surrogate’s decision-making confidence, and healthcare-preferences familiarity. Results Mean (SD) age was 35.4 (10.3) years, 69% were females, and 73 and 80% reported ≥ very good health and life-quality, respectively. Mean surrogate’s decision-making confidence score was 3.35 (0.58) and 75% were ≥ familiar with pair’s healthcare-preferences. Mean (95% confidence interval) projection, simulation, and adjusted-simulation correlations were 0.68 (0.67–0.69), 0.42 (0.40–0.44), and 0.26 (0.24–0.28), respectively. Out of 180 respondent-surrogate Q-sorts, 24, 9, and 32% co-loaded with respondent-personal, pair-personal, or both Q-sorts, respectively. Accuracy in predicting decision-control preference and healthcare-outcomes acceptability was 47 and 52%, respectively. Surrogate’s decision-making confidence score correlated with adjusted-simulation’s correlation score (rho = 0.18, p = 0.01). There were significant differences among the husband-wife, parent-child, and sibling-sibling subgroups in percentage of respondent-surrogate Q-sorts co-loading with pair-personal Q-sorts (38, 32, 55%, respectively, p = 0.03) and percent agreement on healthcare-outcomes acceptability (55, 35, and 67%, respectively, p = 0.002). Conclusions Despite high self-reported surrogate’s decision-making confidence and healthcare-preferences familiarity, family surrogates are variably inadequate in simulating life-story narratives. Simulation accuracy may not follow the next-of-kin concept and is 38% based on shared background. Electronic supplementary material The online version of this article (10.1186/s12910-019-0368-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Muhammad M Hammami
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia. .,Alfaisal University College of Medicine, Riyadh, Saudi Arabia.
| | - Kafa Abuhdeeb
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | | | - Sophia J S De Padua
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
| | - Areej Al-Balkhi
- Clinical Studies and Empirical Ethics Department, King Faisal Specialist Hospital and Research Centre, P O Box # 3354 (MBC 03), Riyadh, 11211, Saudi Arabia
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Becqué YN, Rietjens JAC, van Driel AG, van der Heide A, Witkamp E. Nursing interventions to support family caregivers in end-of-life care at home: A systematic narrative review. Int J Nurs Stud 2019; 97:28-39. [PMID: 31132687 DOI: 10.1016/j.ijnurstu.2019.04.011] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Revised: 04/11/2019] [Accepted: 04/15/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Family caregivers are crucial in end-of-life care. However, family caregiving may involve a significant burden with various negative health consequences. Although nurses are in a unique position to support family caregivers at home, little is known about which nursing interventions are effective in this context. Therefore, this study aims to provide insight into nursing interventions currently available to support family caregivers in end-of-life care at home and to describe their effects. METHODS A systematic search was conducted in Embase, Medline Ovid, Web of Science, Cochrane Central, CINAHL and Google Scholar. This review included quantitative studies published from January 2003 until December 2018 reporting on nursing interventions to support adult family caregivers in end-of-life care at home. Data were extracted on intervention modalities, intervention components, and family caregivers' outcomes. Methodological quality of the studies was assessed with the Cochrane Risk of Bias Tool. RESULTS Out of 1531 titles, nine publications were included that reported on eight studies/eight interventions. Of the eight studies, three were randomised controlled trials, one a pilot randomised trial, one a non-randomised trial, and three were single-group prospective studies. Four intervention components were identified: psychoeducation, needs assessment, practical support with caregiving, and peer support. Psychoeducation was the most commonly occurring component. Nursing interventions had a positive effect on the preparedness, competence, rewards, and burden of family caregivers. Multicomponent interventions were the most effective with, potentially, the components 'needs assessment' and 'psychoeducation' being the most effective. CONCLUSIONS Although only eight studies are available on nursing interventions to support family caregivers in end-of-life care at home, they show that interventions can have a positive effect on family caregivers' outcomes. Multicomponent interventions proved to be the most successful, implying that nurses should combine different components when supporting family caregivers.
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Affiliation(s)
- Yvonne N Becqué
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, the Netherlands; Department of Public Health, Erasmus University Medical Center Rotterdam, the Netherlands.
| | - Judith A C Rietjens
- Department of Public Health, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Anne Geert van Driel
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, the Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus University Medical Center Rotterdam, the Netherlands
| | - Erica Witkamp
- Research Centre Innovations in Care, Rotterdam University of Applied Sciences, the Netherlands; Department of Public Health, Erasmus University Medical Center Rotterdam, the Netherlands
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van Bruchem-Visser RL, Mattace-Raso FUS, de Beaufort ID, Kuipers EJ. Percutaneous endoscopic gastrostomy in older patients with and without dementia: Survival and ethical considerations. J Gastroenterol Hepatol 2019; 34:736-741. [PMID: 30551264 DOI: 10.1111/jgh.14573] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 11/27/2018] [Accepted: 12/01/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Notwithstanding multiple recommendations in guidelines, percutaneous endoscopic gastrostomy (PEG)-tube placement is still performed in patients with dementia. In this study, we aim to investigate survival in patients with and without dementia after PEG-tube placement. METHODS We conducted a retrospective multicenter study in four different hospitals in the Netherlands. Furthermore, we explored the ethical considerations that may play a role in the decision whether or not to insert a PEG tube in a patient with dementia. RESULTS Three-hundred-and-three patients were included, mean age of 77.4 years. Forty-two (13.9%) patients had dementia. Short-term complications did not differ between patients with and without cognitive disorders (P 0.224). However, patients with dementia survived significantly shorter after PEG placement than did patients without dementia. Adjusted for age and sex, patients with dementia had a 49% increased risk of mortality (hazard ratio 1.49, 95% confidence interval 1.01-2.19). In our exploratory literature search, we found that several ethical concerns and considerations play a role in the decision process of PEG placement. These considerations are both medical and nonmedical and include beliefs regarding the benefits of a PEG tube, a lack of knowledge about the natural course of dementia in both professionals and family of patients, and a fear of letting a patient die hungry. CONCLUSIONS Patients with dementia had higher mortality rates after PEG placement than patients without dementia. Although multiple ethical concerns and considerations play a role, insertion of a PEG tube in patients with dementia is not appropriate.
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Affiliation(s)
| | | | - Inez Duconia de Beaufort
- Medical Ethics and Philosophy of Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Ernst Johan Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Turrillas P, Teixeira MJ, Maddocks M. A Systematic Review of Training in Symptom Management in Palliative Care Within Postgraduate Medical Curriculums. J Pain Symptom Manage 2019; 57:156-170.e4. [PMID: 30287198 DOI: 10.1016/j.jpainsymman.2018.09.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/18/2018] [Accepted: 09/20/2018] [Indexed: 11/23/2022]
Abstract
CONTEXT Symptom management is a priority area within palliative care core competencies for generalist providers. Although several educational initiatives exist, a comprehensive evidence synthesis on the effectiveness of symptom management training on trainees' learning and patient-reported outcomes is lacking. OBJECTIVES The objective of this study was to determine the effectiveness of training in symptom management in palliative care providers in nonpalliative specialties. METHODS This is a systematic review following Best Evidence Medical Education methods from searches of MEDLINE, EMBASE, ERIC, CINAHL, PsycINFO, Cochrane database of systematic, Clinical Trials.gov, and ISRCTN databases to September 2017. Prospective controlled studies testing the impact of symptom management educational interventions on physicians in training in nonpalliative specialties were included. Data were summarized narratively, grouped by curriculum description, and effectiveness on trainees' learning or patient-reported outcomes. RESULTS Of 5062 records identified, six studies met the inclusion criteria: two randomized controlled trials and four quasi-experimental. Pain management and use of opioids and their side effects were most frequently covered. Clinical decision support tools, Web-based teaching, palliative care rotation, and mixed educational methods were used. Most studies used self-reported, original, or modified evaluation instruments, although psychometric properties were seldom reported. Despite methodological considerations, all educational methods improved trainees' learning outcomes. However, the effects on trainees' behavior and patient-related outcomes were not evaluated. CONCLUSION Current educational training programs in symptom management appear to improve trainees' comfort, preparedness, and knowledge in assessing and managing patients' symptoms at the end of life. More rigorous research to evaluate the impact of this training on residents and organizational performance is now required.
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Affiliation(s)
- Pamela Turrillas
- Department of Palliative Care, Policy, and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK.
| | - Maria Joao Teixeira
- Department of Palliative Care, Policy, and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Matthew Maddocks
- Department of Palliative Care, Policy, and Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
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Hechtner M, Eichler M, Wehler B, Buhl R, Sebastian M, Stratmann J, Schmidberger H, Gohrbandt B, Peuser J, Kortsik C, Nestle U, Wiesemann S, Wirtz H, Wehler T, Bals R, Blettner M, Singer S. Quality of Life in NSCLC Survivors - A Multicenter Cross-Sectional Study. J Thorac Oncol 2018; 14:420-435. [PMID: 30508641 DOI: 10.1016/j.jtho.2018.11.019] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 11/18/2018] [Accepted: 11/19/2018] [Indexed: 12/20/2022]
Abstract
INTRODUCTION The objective was to assess quality of life (QoL) in lung cancer survivors, compare it to the general population, and identify factors associated with global QoL, physical functioning, emotional functioning, fatigue, pain, and dyspnea. METHODS Data from NSCLC patients who had survived 1 year or longer after diagnosis were collected cross-sectionally in a multicenter study. QoL was assessed with the European Organisation for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ)-C30 and the lung cancer module QLQ-LC13 across different clinical subgroups and compared to age- and sex-standardized general population reference values. Multivariable linear regression analyses were performed to test the associations of patient-, tumor-, and treatment-related factors with the six primary QoL scales. RESULTS Six hundred fifty-seven NSCLC patients participated in the study with a median time since diagnosis of 3.7 years (range, 1.0-21.2 years). Compared to the age- and sex-standardized general population, clinically meaningful differences in the QoL detriment were found on almost all domains: lung cancer survivors had clinically relevant poorer global QoL (10 points, p < 0.001). Whereas in 12 months or longer treatment-free patients this detriment was small (8.3), it was higher in patients currently in treatment (16.0). Regarding functioning and symptom scales, respective detriments were largest for dyspnea (41 points), role function (33 points), fatigue (27 points), social function (27 points), physical function (24 points), and insomnia (21 points) observed across all subgroups. The main factor associated with poorer QoL in all primary QoL scales was mental distress (β |19-31|, all p < 0.001). Detriments in QoL across multiple primary QoL scales were also observed with current treatment (β |8-12|, p < 0.01), respiratory comorbidity (β |4-5|, p < 0.01), and living on a disability pension (β |10-11|, p < 0.01). The main factor associated with better QoL in almost all primary QoL scales was higher physical activity (β |10-20|, p < 0.001). Better QoL was also observed in patients with high income (β |10-14|, p < 0.01). CONCLUSIONS Lung cancer survivors experience both functional restrictions and symptoms that persist long term after active treatment ends. This substantiates the importance of providing long-term supportive care.
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Affiliation(s)
- Marlene Hechtner
- University Medical Center, Johannes Gutenberg University, Mainz, Germany; German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, Germany; German Cancer Research Center (DKFZ), Heidelberg, Germany.
| | - Martin Eichler
- University Medical Center, Johannes Gutenberg University, Mainz, Germany; German Cancer Consortium (DKTK), partner site Frankfurt/Mainz, Germany; University Hospital Carl Gustav Carus Dresden, Germany
| | - Beatrice Wehler
- University Medical Center, Johannes Gutenberg University, Mainz, Germany; Saarland University Medical Center, Homburg, Germany
| | - Roland Buhl
- University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Martin Sebastian
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Jan Stratmann
- University Hospital Frankfurt, Goethe University, Frankfurt, Germany
| | - Heinz Schmidberger
- University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | | | | | | | - Ursula Nestle
- University Medical Center Freiburg, Albert-Ludwig-University, Freiburg Germany; Maria Hilf Hospital Moenchengladbach, Moenchengladbach, Germany
| | - Sebastian Wiesemann
- University Medical Center Freiburg, Albert-Ludwig-University, Freiburg Germany
| | - Hubert Wirtz
- Leipzig University Hospital, Leipzig University, Leipzig, Germany
| | - Thomas Wehler
- Saarland University Medical Center, Homburg, Germany
| | - Robert Bals
- Saarland University Medical Center, Homburg, Germany
| | - Maria Blettner
- University Medical Center, Johannes Gutenberg University, Mainz, Germany
| | - Susanne Singer
- University Medical Center, Johannes Gutenberg University, Mainz, Germany; University Cancer Center Mainz, Mainz, Germany
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Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-e653. [DOI: 10.1016/s1470-2045(18)30415-7] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
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Gupta N, Kumar V, Garg R, Bharati SJ, Mishra S, Bhatnagar S. Initial Perceptions about Palliative Care in Patients with Advanced Cancer: A Prospective Cross-Sectional Audit. Indian J Palliat Care 2018; 24:512-516. [PMID: 30410267 PMCID: PMC6199839 DOI: 10.4103/ijpc.ijpc_94_18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION There is enough evidence to suggest that early introduction to palliative care (PC) for patients with advanced cancer is beneficial. However, despite this, the patients often come late to PC physicians. There are a number of studies examining the preferences and practices of the physicians with respect to PC. However, there is limited literature exploring the patients' preferences and awareness regarding the PC services. This audit was done to identify the understanding and perceptions of PC in patients visiting PC outpatient department (OPD) and identify strategies to enhance their understanding. MATERIALS AND METHODS This prospective cross-sectional study was conducted in 200 advanced cancer patients visiting PC OPD in a tertiary care hospital. The patients were asked to fill a questionnaire to assess their knowledge and expectations form PC on their first visit. RESULTS Majority of the patients were from nearby areas and around 20% of them had to travel more than 300 km to receive palliative consultation. Unfortunately, majority of the patients had not heard the term PC before and were not aware of its meaning. Most of them (90%) were send to control pain which was too severe to be managed by the oncologists. We think that the major reason for the lack of awareness about PC services is limited availability across the country and lack of coordinated approach. CONCLUSIONS The main problem identified in the audit was the inadequate information, lack of PC setups, and late referral of the patients to PC. Hence, we should make a model where PC services are integrated with the curative services and offered throughout the illness after cancer diagnosis.
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Affiliation(s)
- Nishkarsh Gupta
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
- Address for correspondence: Dr. Nishkarsh Gupta, Room No 139, Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India. E-mail:
| | - Vinod Kumar
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Rakesh Garg
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sachidanand Jee Bharati
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Seema Mishra
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesiology and Palliative Medicine, Dr. BRAIRCH, AIIMS, New Delhi, India
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Gadebusch Bondio M, Wagner AJM, Krieger R, Weiß L, Kinnebrock S. [Advance Care Planning (ACP). A Systematic Review of ACP Behavior by Women and Men in Germany]. DAS GESUNDHEITSWESEN 2018; 82:748-760. [PMID: 30064152 DOI: 10.1055/a-0652-5556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The desire to retain control over one's life until the end has become highly important in our society. Women and men of different ages and of diverse social, cultural, and educational backgrounds increasingly decide in advance about prospective medical treatment (Advance Care Planning, ACP). OBJECTIVES Identification and analysis of literature on advance care planning behavior of men and women in Germany. The focus is on gender-specific differences. MATERIALS AND METHODS Systematic review of empirical studies with gender-specific data on advance care planning behavior in Germany. In-depth analysis of 21 of the 479 retrieved articles. RESULTS The analysis reveals that Advance Care Planning behavior is influenced by interacting factors such as gender, age, cultural and ethnic background, religion, and education. Gender alone does not explain the prevalence of ACP behavior. This prima facie negative result is partly due to the study designs. Heterogeneous data and a lack of gender sensitivity leave the question concerning the relationships between ACP behavior and gender mostly unanswered. CONCLUSIONS The analyzed studies reduce gender to a dualistic classification system, dismiss individual role models and positions and also neglect geographic and cultural contexts. There is a need for studies sensitive to gender and culture.
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Affiliation(s)
| | | | - Rico Krieger
- Medizinische Fakultät, Technische Universität München, München
| | - Leonard Weiß
- Medizinische Fakultät, Rheinische Friedrich-Wilhelms-Universität Bonn, Bonn
| | - Susanne Kinnebrock
- Institut für Medien, Wissen und Kommunikation, Universität Augsburg, Augsburg
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Alt-Epping B, Haas AL, Jansky M, Nauck F. Symptomlinderung durch Tumortherapie? Schmerz 2018; 32:90-98. [DOI: 10.1007/s00482-018-0270-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Long-term quality of life in inoperable non-small cell lung cancer patients treated with conventionally fractionated compared to hyperfractionated accelerated radiotherapy – Results of the randomized CHARTWEL trial. Radiother Oncol 2018; 126:283-290. [DOI: 10.1016/j.radonc.2017.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 12/03/2017] [Accepted: 12/04/2017] [Indexed: 12/25/2022]
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Dixon J, Karagiannidou M, Knapp M. The Effectiveness of Advance Care Planning in Improving End-of-Life Outcomes for People With Dementia and Their Carers: A Systematic Review and Critical Discussion. J Pain Symptom Manage 2018; 55:132-150.e1. [PMID: 28827062 DOI: 10.1016/j.jpainsymman.2017.04.009] [Citation(s) in RCA: 103] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 03/09/2017] [Accepted: 04/11/2017] [Indexed: 12/18/2022]
Abstract
CONTEXT End-of-life care for people with dementia can be poor, involving emergency hospital admissions, burdensome treatments of uncertain value, and undertreatment of pain and other symptoms. Advance care planning (ACP) is identified, in England and elsewhere, as a means of improving end-of-life outcomes for people with dementia and their carers. OBJECTIVE To systematically and critically review empirical evidence concerning the effectiveness of ACP in improving end-of-life outcomes for people with dementia and their carers. METHODS Systematic searches of academic databases (CINAHL Plus with full text, PsycINFO, SocINDEX with full text, and PubMed) were conducted to identify research studies, published between January 2000-January 2017 and involving statistical methods, in which ACP is an intervention or independent variable, and in which end-of-life outcomes for people with dementia and/or their carers are reported. RESULTS A total of 18 relevant studies were identified. Most found ACP to be associated with some improved end-of-life outcomes. Studies were predominantly, but not exclusively, from the U.S. and care home-based. Type of ACP and outcome measures varied. Quality was assessed using National Institute of Health and Care Excellence quality appraisal checklists. Over half of the studies were of moderate to high quality. Three were randomized controlled trials, two of which were low quality. CONCLUSION There is a need for more high-quality outcome studies, particularly using randomized designs to control for confounding. These need to be underpinned by sufficient development work and process evaluation to clarify the appropriateness of outcome measures, explore implementation issues and identify "active elements."
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Affiliation(s)
- Josie Dixon
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, United Kingdom.
| | - Maria Karagiannidou
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, United Kingdom
| | - Martin Knapp
- Personal Social Services Research Unit (PSSRU), London School of Economics and Political Science (LSE), London, United Kingdom
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Higginson IJ, Daveson BA, Morrison RS, Yi D, Meier D, Smith M, Ryan K, McQuillan R, Johnston BM, Normand C. Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries. BMC Geriatr 2017; 17:271. [PMID: 29169346 PMCID: PMC5701500 DOI: 10.1186/s12877-017-0648-4] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 10/19/2017] [Indexed: 11/10/2022] Open
Abstract
Background Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death. Methods We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors. Results One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40–9.90) and living with someone (OR 2.19, 1.33–3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14–5.03). Conversely, functional independence (OR 1.05, 1.04–1.06) and valuing quality of life (OR 3.11, 2.89–3.36) were associated with dying at home. There was a mismatch between preferences and achievements – of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference. Conclusion Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply ‘achieved preferences’. Electronic supplementary material The online version of this article (10.1186/s12877-017-0648-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Irene J Higginson
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK.
| | - Barbara A Daveson
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK
| | - R Sean Morrison
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029-6574, USA
| | - Deokhee Yi
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK.
| | - Diane Meier
- Department of Geriatrics and Palliative Medicine, Mount Sinai School of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, New York, NY, 10029-6574, USA
| | - Melinda Smith
- Cicely Saunders Institute Of Palliative Care, Policy & Rehabilitation, King's College London, and King's College Hospital, Bessemer Road, London, SE5 9PJ, UK
| | - Karen Ryan
- Mater Misericordiae Hospital, Eccles Street, Dublin 7, Ireland
| | | | - Bridget M Johnston
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
| | - Charles Normand
- The Centre of Health Policy and Management, Trinity College Dublin, Room 0.21, 3-4 Foster Place, College Green, Dublin 2, Ireland
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Yarnell CJ, Fu L, Manuel D, Tanuseputro P, Stukel T, Pinto R, Scales DC, Laupacis A, Fowler RA. Association Between Immigrant Status and End-of-Life Care in Ontario, Canada. JAMA 2017; 318:1479-1488. [PMID: 28973088 PMCID: PMC5710367 DOI: 10.1001/jama.2017.14418] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE People who immigrate face unique health literacy, communication, and system navigation challenges, and they may have diverse preferences that influence end-of-life care. OBJECTIVE To examine end-of-life care provided to immigrants to Canada in the last 6 months of their life. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study (April 1, 2004, to March 31, 2015) included 967 013 decedents in Ontario, Canada, using validated linkages between health and immigration databases to identify immigrant (since 1985) and long-standing resident cohorts. EXPOSURES All decedents who immigrated to Canada between 1985 and 2015 were classified as recent immigrants, with subgroup analyses assessing the association of time since immigration, and region of birth, with end-of-life care. MAIN OUTCOMES AND MEASURES Location of death and intensity of care received in the last 6 months of life. Analysis included modified Poisson regression with generalized estimating equations, adjusting for age, sex, socioeconomic position, causes of death, urban and rural residence, and preexisting comorbidities. RESULTS Among 967 013 decedents of whom 47 514 (5%) immigrated since 1985, sex, socioeconomic status, urban (vs rural) residence, and causes of death were similar, while long-standing residents were older than immigrant decedents (median [interquartile range] age, 75 [58-84] vs 80 [68-87] years). Recent immigrant decedents were overall more likely to die in intensive care (15.6% vs 10.0%; difference, 5.6%; 95% CI, 5.2%-5.9%) after adjusting for differences in age, sex, income, geography, and cause of death (relative risk, 1.30; 95% CI, 1.27-1.32). In their last 6 months of life, recent immigrant decedents experienced more intensive care admissions (24.9% vs 19.2%; difference, 5.7%; 95% CI, 5.3%-6.1%), hospital admissions (72.1% vs 68.2%; difference, 3.9%; 95% CI, 3.5%-4.3%), mechanical ventilation (21.5% vs 13.6%; difference, 7.9%; 95% CI, 7.5%-8.3%), dialysis (5.5% vs 3.4%; difference, 2.1%; 95% CI, 1.9%-2.3%), percutaneous feeding tube placement (5.5% vs 3.0%; difference, 2.5%; 95% CI, 2.3%-2.8%), and tracheostomy (2.3% vs 1.1%; difference, 1.2%; 95% CI, 1.1%-1.4%). Relative risk of dying in intensive care for recent immigrants compared with long-standing residents varied according to recent immigrant region of birth from 0.84 (95% CI, 0.74-0.95) among those born in Northern and Western Europe to 1.96 (95% CI, 1.89-2.05) among those born in South Asia. CONCLUSIONS AND RELEVANCE Among decedents in Ontario, Canada, recent immigrants were significantly more likely to receive aggressive care and to die in an intensive care unit compared with other residents. Further research is needed to understand the mechanisms behind this association.
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Affiliation(s)
| | - Longdi Fu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Doug Manuel
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- University of Ottawa, Ottawa, Ontario, Canada
| | | | - Therese Stukel
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Ruxandra Pinto
- Programme in Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Damon C. Scales
- University of Toronto Department of Medicine, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Programme in Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Andreas Laupacis
- University of Toronto Department of Medicine, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Programme in Trauma, Emergency, and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Li Ka Shing Knowledge institute of St Michael’s Hospital, Toronto, Ontario, Canada
| | - Robert A. Fowler
- University of Toronto Department of Medicine, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine and Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Collins A, McLachlan SA, Philip J. Initial perceptions of palliative care: An exploratory qualitative study of patients with advanced cancer and their family caregivers. Palliat Med 2017; 31:825-832. [PMID: 28367679 DOI: 10.1177/0269216317696420] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Despite evidence for early integration of palliative care for people with advanced cancer and their families, patterns of late engagement continue. Prior research has focused on health professionals' attitudes to palliative care with few studies exploring the views of patients and their carers. AIM To explore initial perceptions of palliative care when this is first raised with patients with advanced cancer and their families in Australian settings. DESIGN Cross-sectional, prospective, exploratory qualitative design, involving narrative-style interviews and underpinned by an interpretative phenomenological framework. SETTING/PARTICIPANTS Purposively sampled, English-speaking, adult patients with advanced cancer ( n = 30) and their nominated family caregivers ( n = 25) recruited from cancer services at a tertiary metropolitan hospital in Melbourne, Victoria, Australia. RESULTS Three major themes evolved which represent the common initial perceptions of palliative care held by patients with advanced cancer and their carers when this concept is first raised: (1) diminished care, (2) diminished possibility and (3) diminished choice. Palliative care was negatively associated with a system of diminished care which is seen as a 'lesser' treatment alternative, diminished possibilities for hope and achievement of ambitions previously centred upon cure and diminished choices for the circumstances of one's care given all other options have expired. CONCLUSION While there is an increasing move towards early integration of palliative care, this study suggests that patient and caregiver understandings have not equally progressed. A targeted public health campaign is warranted to disentangle understandings of palliative care as the 'institutional death' and to reframe community rhetoric surrounding palliative care from that of disempowered dying to messages of choice, accomplishment and possibility.
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Affiliation(s)
- Anna Collins
- 1 Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,2 Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Sue-Anne McLachlan
- 2 Department of Medicine, The University of Melbourne, Parkville, VIC, Australia.,3 Medical Oncology, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Jennifer Philip
- 1 Palliative Care, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia.,2 Department of Medicine, The University of Melbourne, Parkville, VIC, Australia.,4 Victorian Comprehensive Cancer Centre, Melbourne, VIC, Australia
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Brereton L, Clark J, Ingleton C, Gardiner C, Preston L, Ryan T, Goyder E. What do we know about different models of providing palliative care? Findings from a systematic review of reviews. Palliat Med 2017; 31:781-797. [PMID: 28376681 DOI: 10.1177/0269216317701890] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND A wide range of organisational models of palliative care exist. However, decision makers need more information about which models are likely to be most effective in different settings and for different patient groups. AIM To identify the existing range of models of palliative care that have been evaluated, what is already known and what further information is essential if the most effective and cost-effective models are to be identified and replicated more widely. DESIGN A review of systematic and narrative reviews according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Study quality was assessed using the AMSTAR (A MeaSurement Tool to Assess Reviews) tool. DATA SOURCES MEDLINE, EMBASE, PsycINFO, CINAHL, Cochrane Library, Web of Science and ASSIA were searched for reviews about models of service provision from 2000 to 2014 and supplemented with Google searches of the grey literature. RESULTS Much of the evidence relates to home-based palliative care, although some models are delivered across care settings. Reviews report several potential advantages and few disadvantages of models of palliative care delivery. However, under-reporting of the components of intervention and comparator models are major barriers to the evaluation and implementation of models of palliative care. CONCLUSION Irrespective of setting or patient characteristics, models of palliative care appear to show benefits and some models of palliative care may reduce total healthcare costs. However, much more detailed and systematic reporting of components and agreement about outcome measures is essential in order to understand the key components and successfully replicate effective organisational models.
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Affiliation(s)
- Louise Brereton
- 1 School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK.,2 College of Social Science, University of Lincoln, Lincoln, UK
| | - Joseph Clark
- 1 School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK.,3 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Christine Ingleton
- 4 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Clare Gardiner
- 4 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Louise Preston
- 1 School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Tony Ryan
- 4 School of Nursing and Midwifery, The University of Sheffield, Sheffield, UK
| | - Elizabeth Goyder
- 1 School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
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