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Myers J, Howe M, Jia Z, Quinn K, Meaney C, Lokuge B, Parry N, Vaz D, Zeng J, Berman H. The Impact of a Point-of-Care Ultrasound (POCUS) Program to Diagnose and Manage Ascites in Home-based Palliative Care. J Am Med Dir Assoc 2024; 25:375-380. [PMID: 38000441 DOI: 10.1016/j.jamda.2023.10.014] [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: 06/04/2023] [Revised: 10/09/2023] [Accepted: 10/15/2023] [Indexed: 11/26/2023]
Abstract
OBJECTIVE The objective of this study was to examine the impact of a point-of-care ultrasound (POCUS) program among people with ascites receiving home-based palliative care by measuring the association of POCUS with ascites-related days spent out of the home, compared with outcomes before POCUS implementation. DESIGN Open cohort study. SETTING AND PARTICIPANTS Adults who had an ascites-related procedure (ARP) between January 1, 2014, and December 31, 2015 (ie, pre-POCUS) and January 1, 2019, and December 31, 2020 (ie, POCUS). An ARP was defined as using ultrasound to diagnose suspected ascites or a paracentesis with or without ultrasound guidance to manage ascites. METHODS The main outcome was the rate of ascites-related days spent out of the home, defined as days out of the home for either ARPs or because of ascites-related hospital admissions, relative to the time patients were at risk for spending ascites-related days out of the home. RESULTS Among the 103 pre-POCUS patients (mean age 68.0; 50.4% female), there were 161 ARPs with 12.4% occurring at home. Among the 127 POCUS patients (mean age 74.0; 52.0% female) there were 193 ARPs with 82.4% occurring at home. POCUS was associated with a significantly lower rate of ascites-related days spent outside the home (pre-POCUS rate of 33 days per 1000 patient days vs POCUS rate of 9 days; unadjusted incidence rate ratio (IRR), 3.86; 95% CI, 2.95-5.12; P < .001; adjusted IRR, 3.83; 95% CI, 1.27-11.54; P = .02). POCUS was also associated with a higher likelihood of ARPs occurring in the home [unadjusted odds ratio (OR), 32.44; 95% CI, 18.15-59.90; P < .001; adjusted OR, 48.99; 95% CI, 21.04-114.10; P < .001]. CONCLUSIONS AND IMPLICATIONS The use of POCUS may contribute to maximizing time spent at home for palliative care patients with ascites. These findings support the use of POCUS for home-based palliative care programs.
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Affiliation(s)
- Jeff Myers
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada.
| | - Marnie Howe
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Zhimeng Jia
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Kieran Quinn
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Bhadra Lokuge
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Natalie Parry
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Desiree Vaz
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Joy Zeng
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada
| | - Hershl Berman
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Rydland HT, Bentsen HL, Ervik R, Grønning K, Islam K, Kjerstad E, Skogedal Lindén T. Promoting labour market inclusion of the chronically ill: a scoping review of Scandinavian countries' efforts. Scand J Public Health 2023; 51:1097-1107. [PMID: 35535443 PMCID: PMC10642227 DOI: 10.1177/14034948221096005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 03/03/2022] [Accepted: 04/01/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This article is a scoping review of efforts in labour market inclusion of the chronically ill in the Scandinavian countries, a research area that has received much political as well as research attention in recent years. The aim of the review was to identify promising strategies and the need for further research. METHODS Six electronic databases were searched for literature published between 2015 and 2020. We included peer-reviewed articles that studied the effect of measures, aimed at the workplace or at the individual, that are intended to increase participation. Our search resulted in 2718 articles; our screening procedures resulted in 47 included articles. RESULTS Among the included studies, musculoskeletal problems (17 articles) and mental health problems (29 articles) were the most frequent chronic conditions. Multimodal occupational rehabilitation programmes directed towards the individual employee were the most frequent interventions (30 articles). Return to work (24 articles) and sickness absence (12 articles) were the most common outcomes. About half (25 articles) of the included studies reported a positive impact of the intervention on work inclusion of the chronically ill. CONCLUSIONS Our review found little evidence of how government programmes directed towards the supply side of the labour market succeed in including the chronically ill. Our review further indicated that multidisciplinary workplace interventions have a substantial effect. We also identified a significant lack of research on the effect of various governmental policies and programmes, including local health, work and welfare services, and limited coordination and cooperation between health and work services professions.
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Affiliation(s)
| | | | - Rune Ervik
- NORCE Norwegian Research Centre AS, Bergen, Norway
| | - Kjersti Grønning
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Kamrul Islam
- NORCE Norwegian Research Centre AS, Bergen, Norway
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Melekis K, Weisse CS, Alonzo JD, Cheng A. Social Model Hospice Residential Care Homes: Whom Do They Really Serve? Am J Hosp Palliat Care 2023; 40:1317-1323. [PMID: 36599102 DOI: 10.1177/10499091221150769] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Most prefer to die at home, but the Medicare Hospice Benefit does not cover custodial care, making it difficult for terminally ill patients with housing insecurity and/or caregiver instability to access hospice care at home. OBJECTIVES To examine the characteristics of patients who received end-of-life care in community-run, residential care homes (RCHs) operating under the social model hospice. METHODS A retrospective chart review of 500 residents who were admitted to one of three RCHs in Upstate New York over a 15-year period (2004-2019). RESULTS Patients served by the RCHs included 318 (63.6%) women and 182 (36.4%) men aged 34-101 (M = 77.8). The majority (94.9%) were Caucasian and most had cancer diagnoses (71.6%). Prior to admission, most (93%) patients resided in a private residence, and nearly half (47%) lived alone, but most (81.7%) had full- or part-time caregivers. Nearly all patients were admitted either directly from a hospital (47.5%) or private home (47.2%). Over half (52%) were admitted to RCHs within a month of hospice enrollment, and 20.1% enrolled concurrent with admission. While the average length of stay was 21 days, 50% died within 10 days of admission. CONCLUSIONS Community-run RCHs represent a unique approach for improving access to hospice home care for patients with home insecurity and/or caregiver instability, yet most patients had prior caregiver coverage and were admitted from a hospital or home setting, suggesting there is a need for community care settings for patients unable to remain at home in the final weeks or days prior to death.
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Affiliation(s)
- Kelly Melekis
- Department of Social Work, University of Vermont College of Education and Social Services, Burlington, VT, USA
| | - Carol S Weisse
- Department of Psychology, Union College, Schenectady, NY, USA
| | | | - Alice Cheng
- Leadership in Medicine Program, Union College, Schenectady, NY, USA
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Roma M, Sullivan SS, Casucci S. TILE-12 index: an interpretable instrument for identifying older adults at risk for transitions in living environment within the next 12-months. Home Health Care Serv Q 2022; 41:236-254. [PMID: 35392771 DOI: 10.1080/01621424.2022.2052220] [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: 10/18/2022]
Abstract
Few evidence-based tools exist to support identification of older community dwelling adults at risk for unwanted transitions in living environment leading to missed opportunities to modify care plans to support aging-in-place and/or establish end-of-life care goals. An interpretable and actionable tool for assessing a person's risk of experiencing a transition is introduced. Logistic regression analysis of 14,772 transition opportunities (i.e. 12-month periods) for 4,431 respondents to the National Health and Aging Trends Study (NHATS) rounds 1-7. Results were visualized in a nomogram. Unmarried males of increasing age with chronic disease, greater functional dependence, overnight hospitalizations, not living in a single-family home, and limited social network, have elevated risk of experiencing a transition in living environment in a 12-month period. Homecare nurses are uniquely qualified to identify social determinants of health and can use this evidence-based tool to identify individuals who may benefit from transitional care assistance.
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Affiliation(s)
- Makayla Roma
- Industrial and Systems Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Suzanne S Sullivan
- School of Nursing, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Sabrina Casucci
- Industrial and Systems Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
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Busquet-Duran X, Moreno-Gabriel E, Jiménez-Zafra EM, Tura-Poma M, Bosch-DelaRosa O, Moragas-Roca A, Martin-Moreno S, Martínez-Losada E, Crespo-Ramírez S, Lestón-Lado L, Salamero-Tura N, Llobera-Estrany J, Salvago-Leiracha A, López-García AI, Manresa-Domínguez JM, Morandi-Garde T, Persentili-Viure ES, Torán-Monserrat P. Gender and Observed Complexity in Palliative Home Care: A Prospective Multicentre Study Using the HexCom Model. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:12307. [PMID: 34886027 PMCID: PMC8656577 DOI: 10.3390/ijerph182312307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/19/2021] [Accepted: 11/20/2021] [Indexed: 11/26/2022]
Abstract
This study analyses gender differences in the complexity observed in palliative home care through a multicentre longitudinal observational study of patients with advanced disease treated by palliative home care teams in Catalonia (Spain). We used the HexCom model, which includes six dimensions and measures three levels of complexity: high (non-modifiable situation), medium (difficult) and low. Results: N = 1677 people, 44% women. In contrast with men, in women, cancer was less prevalent (64.4% vs. 73.9%) (p < 0.001), cognitive impairment was more prevalent (34.1% vs. 26.6%; p = 0.001) and professional caregivers were much more common (40.3% vs. 24.3%; p < 0.001). Women over 80 showed less complexity in the following subareas: symptom management (41.7% vs. 51,1%; p = 0.011), emotional distress (24.5% vs. 32.8%; p = 0.015), spiritual distress (16.4% vs. 26.4%; p = 0.001), socio-familial distress (62.7% vs. 70.1%; p = 0.036) and location of death (36.0% vs. 49.6%; p < 0.000). Men were more complex in the subareas of "practice" OR = 1.544 (1.25-1.90 p = 0.000) and "transcendence" OR = 1.52 (1.16-1.98 p = 0.002). Observed complexity is related to male gender in people over 80 years of age. Women over the age of 80 are remarkably different from their male counterparts, showing less complexity regarding care for their physical, psycho-emotional, spiritual and socio-familial needs.
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Affiliation(s)
- Xavier Busquet-Duran
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Eduard Moreno-Gabriel
- Research Support Unit Metropolitana Nord, Primary Care Research Institute Jordi Gol (IDIAPJGol), 08303 Mataró, Spain; (J.M.M.-D.); (P.T.-M.)
| | - Eva Maria Jiménez-Zafra
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Magda Tura-Poma
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Olga Bosch-DelaRosa
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Anna Moragas-Roca
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Susana Martin-Moreno
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Emilio Martínez-Losada
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Silvia Crespo-Ramírez
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Lola Lestón-Lado
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Núria Salamero-Tura
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Joana Llobera-Estrany
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Ariadna Salvago-Leiracha
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Ana Isabel López-García
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Josep María Manresa-Domínguez
- Research Support Unit Metropolitana Nord, Primary Care Research Institute Jordi Gol (IDIAPJGol), 08303 Mataró, Spain; (J.M.M.-D.); (P.T.-M.)
- Department of Nursing, Autonomous University of Barcelona, 08193 Barcelona, Spain
| | - Teresa Morandi-Garde
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Eda Sara Persentili-Viure
- Home Care Program, Granollers Support Team (PADES), Vallès Oriental Primary Care Service, Catalan Health Institute, 08520 Granollers, Spain; (E.M.J.-Z.); (M.T.-P.); (O.B.-D.); (A.M.-R.); (S.M.-M.); (E.M.-L.); (S.C.-R.); (L.L.-L.); (N.S.-T.); (J.L.-E.); (A.S.-L.); (A.I.L.-G.); (T.M.-G.); (E.S.P.-V.)
| | - Pere Torán-Monserrat
- Research Support Unit Metropolitana Nord, Primary Care Research Institute Jordi Gol (IDIAPJGol), 08303 Mataró, Spain; (J.M.M.-D.); (P.T.-M.)
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Saunders S, Weiss ME, Meaney C, Killackey T, Varenbut J, Lovrics E, Ernecoff N, Hsu AT, Stern M, Mahtani R, Wentlandt K, Isenberg SR. Examining the course of transitions from hospital to home-based palliative care: A mixed methods study. Palliat Med 2021; 35:1590-1601. [PMID: 34472398 DOI: 10.1177/02692163211023682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospital-to-home transitions in palliative care are fraught with challenges. To assess transitions researchers have used patient reported outcome measures and qualitative data to give unique insights into a phenomenon. Few measures examine care setting transitions in palliative care, yet domains identified in other populations are likely relevant for patients receiving palliative care. AIM Gain insight into how patients experience three domains, discharge readiness, transition quality, and discharge-coping, during hospital-to-home transitions. DESIGN Longitudinal, convergent parallel mixed methods study design with two data collection visits: in-hospital before and 3-4 weeks after discharge. Participants completed scales assessing discharge readiness, transition quality, and post discharge-coping. A qualitative interview was conducted at both visits. Data were analyzed separately and integrated using a merged transformative methodology, allowing us to compare and contrast the data. SETTING AND PARTICIPANTS Study was set in two tertiary hospitals in Toronto, Canada. Adult inpatients (n = 25) and their caregivers (n = 14) were eligible if they received a palliative care consultation and transitioned to home-based palliative care. RESULTS Results were organized aligning with the scales; finding low discharge readiness (5.8; IQR: 1.9), moderate transition quality (66.7; IQR: 33.33), and poor discharge-coping (5.0; IQR: 2.6), respectively. Positive transitions involved feeling well supported, managing medications, feeling well, and having healthcare needs met. Challenges in transitions were feeling unwell, confusion over medications, unclear healthcare responsibilities, and emotional distress. CONCLUSIONS We identified aspects of these three domains that may be targeted to improve transitions through intervention development. Identified discrepancies between the data types should be considered for future research exploration.
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Affiliation(s)
- Stephanie Saunders
- Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Chris Meaney
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Tieghan Killackey
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada
| | - Jaymie Varenbut
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada
| | - Emily Lovrics
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada
| | - Natalie Ernecoff
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Amy T Hsu
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Ramona Mahtani
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada.,Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, ON, Canada
| | - Kirsten Wentlandt
- Division of Palliative Care, University Health Network, Toronto, ON, Canada
| | - Sarina R Isenberg
- Department of Family & Community Medicine, University of Toronto, Toronto, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
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