The quality of medical care at the end-of-life in the USA: existing barriers and examples of process and outcome measures

Using Patient-Centered Dissemination and Implementation Frameworks and Strategies in Palliative Care Settings for Improved Quality of Life and Health Outcomes: A Scoping Review

BACKGROUND

There is a need for patient-provider dissemination and implementation frameworks, strategies, and protocols in palliative care settings for a holistic approach when it comes to addressing pain and other distressing symptoms affecting the quality of life, function, and independence of patients with chronic illnesses. The purpose of this scoping review is to explore patient-centered D&I frameworks and strategies that have been adopted in PC settings to improve behavioral and environmental determinants influencing health outcomes through evidence-based programs and protocols.

METHODS

The five step Arksey and O'Malley's (2005) York methodology was adopted as a guiding framework: (1) identifying research questions; (2) searching for relevant studies; (3) selecting studies relevant to the research questions; (4) charting the data; and (5) collating, summarizing, and reporting results.

RESULTS

Only 6 out of the 38 (16%) included studies applied a D&I theory and/or framework. The RE-AIM framework was the most prominently cited (n = 3), followed by the Diffusion of Innovation Model (n = 2), the CONNECT framework (n = 1), and the Transtheoretical Stages of Change Model (n = 1). The most frequently reported ERIC strategy was strategy #6 "Develop and organize quality monitoring systems", as it identified in all 38 of the included studies.

CONCLUSION

This scoping review identifies D&I efforts to translate research into practice in U.S. palliative care settings. Results may contribute to enhancing future D&I initiatives for dissemination/adaptation, implementation, and sustainability efforts aiming to improve patient health outcomes and personal satisfaction with care received.

End-of-life care quality measures: beyond place of death

BACKGROUND

How quality in healthcare is measured shapes care provision, including how and what care is delivered. In end-of-life care, appropriate measurement can facilitate effective care and research, and when used in policy, highlight deficits and developments in provision and endorse the discipline necessity. The most prevalent end-of-life quality metric, place of death, is not a quality measure: it gives no indication of the quality of care or patient experience in the place of death.

AIM

To evaluate alternative measures to place of death for assessing quality of care in end-of-life provision in all settings.

METHOD

We examine current end-of-life care quality measures for use as metrics for quality in end-of-life care. We categorise approaches to measurement as either: clinical instruments, mortality follow-back surveys or organisational data. We review each category using four criteria: care setting, patient population, measure feasibility, care quality.

RESULTS

While many of the measure types were highly developed for their specific use, each had limitations for measuring quality of care for a population. Measures were deficient because they lacked potential for reporting end-of-life care for patients not in receipt of specialist palliative care, were reliant on patient-proxy accounts, or were not feasible across all care settings.

CONCLUSION

None of the current end-of-life care metric categories can currently be feasibly used to compare the quality of end-of-life care provision for all patients in all care settings. We recommend the development of a bespoke measure or judicious selection and combination of existing measures for reviewing end-of-life care quality.

A multi-stage process to develop quality indicators for community-based palliative care using interRAI data

Background

Individuals receiving palliative care (PC) are generally thought to prefer to receive care and die in their homes, yet little research has assessed the quality of home- and community-based PC. This project developed a set of valid and reliable quality indicators (QIs) that can be generated using data that are already gathered with interRAI assessments—an internationally validated set of tools commonly used in North America for home care clients. The QIs can serve as decision-support measures to assist providers and decision makers in delivering optimal care to individuals and their families.

Methods

The development efforts took part in multiple stages, between 2017–2021, including a workshop with clinicians and decision-makers working in PC, qualitative interviews with individuals receiving PC, families and decision makers and a modified Delphi panel, based on the RAND/ULCA appropriateness method.

Results

Based on the workshop results, and qualitative interviews, a set of 27 candidate QIs were defined. They capture issues such as caregiver burden, pain, breathlessness, falls, constipation, nausea/vomiting and loneliness. These QIs were further evaluated by clinicians/decision makers working in PC, through the modified Delphi panel, and five were removed from further consideration, resulting in 22 QIs.

Conclusions

Through in-depth and multiple-stakeholder consultations we developed a set of QIs generated with data already collected with interRAI assessments. These indicators provide a feasible basis for quality benchmarking and improvement systems for care providers aiming to optimize PC to individuals and their families.

Understanding end-of-life care in Australian hospitals

Objective To explore end-of-life care in the ward and intensive care unit (ICU) environment in nine Australian hospitals in a retrospective observational study. Methods In total, 1693 in-hospital deaths, 356 in ICU, were reviewed, including patient demographics, advance care plans, life-sustaining treatments, recognition of dying by clinicians and evidence of the palliative approach to patient care. Results Most patients (n =1430, 84%) were aged ≥60 years, with a low percentage (n =208, 12%) having an end-of-life care plan on admission. Following admission, 82% (n =1391) of patients were recognised as dying, but the time between recognition of dying to death was short (ICU (staying 4-48h) median 0.34 days (first quartile (Q1), third quartile (Q3): 0.16, 0.72); Ward (staying more than 48h) median 2.1 days (Q1, Q3: 0.96, 4.3)). Although 41% (n =621) patients were referred for specialist palliative care, most referrals were within the last few days of life (2.3 days (0.88, 5.9)) and 62% of patients (n =1047) experienced active intervention in their final 48h. Conclusions Late recognition of dying can expose patients to active interventions and minimises timely palliative care. To attain alignment to the National Consensus Statement to improve experiences of end-of-life care, a nationally coordinated approach is needed. What is known about the topic? The majority of Australian patient deaths occur in hospitals whose care needs to align to the Australian Commission on Safety and Quality in Health Care's National Consensus Statement, essential elements of safe and high -quality end -of -life care. What does this paper add? The largest Australian study of hospital deaths reveals only 12% of patients have existing advance care plans, recognition of death is predominantly within the last 48h of life, with 60% receiving investigations and interventions during this time with late symptom relief. What are the implications for practitioners? Given the poor alignment with the National Consensus Statement, a nationally coordinated approach would improve the patient experience of end-of-life care.

Health-Care Provider Planned Responses to Patient Misunderstandings about End-of-Life Care

This study examined health-care provider planned responses to patient misunderstandings about end-of-life care using a multiple goals framework. Plan topics and content alignment with task, identity, and relational goal types were coded. Findings suggested that content was predominately task-oriented and concerned implications of treatment options such as choice outcomes and efficacy rates. A substantial percentage of providers planned to refer further discussion about the misunderstanding to another team member or occupational resource. Despite the prompt of patient misunderstanding, little attention was given to literacy and/or avoidance of medical jargon. Implications for these findings are discussed.

Does inpatient palliative care consultation impact outcomes following hospital discharge? A narrative systematic review

BACKGROUND

While most patients desire to die at home or in a community-based hospice, the transition from hospital to community settings often lacks streamlined coordination of care to ensure that adequate support is provided in the preferred care setting. The impact of hospital-based palliative care consultations on post-discharge care and outcomes has not been extensively studied.

AIM

The aim of this study was to appraise available research on the impact of inpatient palliative care consultations on transitions from hospital to community settings.

DESIGN

We conducted a narrative systematic review and used the Effective Public Health Practice Project tool to appraise the quality of selected studies. Studies were included if they assessed the transition from hospital to community and examined outcomes after an inpatient palliative care consultation. A protocol for this study was registered and published in PROSPERO, Centre for Reviews and Dissemination (ID: CRD42018094924).

DATA SOURCES

We searched for quantitative studies indexed in PubMED, CINAHL and Cochrane and published between 1 January 1 2000 and 11 March 2018.

RESULTS

Our search retrieved 2749 articles. From these, 123 articles were full-text screened and 15 studies met our inclusion criteria. Studies reported that inpatient palliative care consultations are associated with high rates of discharge to community settings, greater provision of services post-discharge, improved coordination and lower rates of rehospitalization.

CONCLUSION

Existing evidence suggest that inpatient palliative care consultations have a positive impact on patient outcomes and transitions to the community, demonstrating the potential to improve patient quality of life and relieve overburdened acute care systems.

Population-Based Quality Indicators for End-of-Life Cancer Care: A Systematic Review

Importance

Improving the quality of cancer care is an international priority. Population-based quality indicators (QIs) are key to this process yet remain almost exclusively used for evaluating care during the early, often curative, stages of disease.

Objectives

To identify all existing QIs for the care of patients with cancer who have advanced disease and/or are at the end of life and to evaluate each indicator's measurement properties and appropriateness for use.

Evidence Review

For this systematic review, 5 electronic databases (MEDLINE, Embase, CINAHL, PsycINFO, and the Cochrane Library) were searched from inception through February 4, 2019, for studies describing the development, review, and/or testing of QIs for the care of patients with cancer who have advanced disease and/or are at the end of life. For each QI identified, descriptive information was extracted and 6 measurement properties (acceptability, evidence base, definition, feasibility, reliability, and validity) were assessed using previously established criteria, with 4 possible ratings: positive, intermediate, negative, and unknown. Ratings were collated and each QI classified as appropriate for use, inappropriate for use, or of limited testing. Among the QIs determined as appropriate for use, a recommended shortlist was generated by excluding those that were specific to patient subgroups and/or care settings; related QIs were identified, and the indicator with the highest rating was retained.

Findings

The search yielded 7231 references, 35 of which (from 28 individual studies) met the eligibility criteria. Of 288 QIs extracted (260 unique), 103 (35.8%) evaluated physical aspects of care and 109 (37.8%) evaluated processes of care. Quality indicators relevant to psychosocial (18 [6.3%]) or spiritual and cultural (3 [1.0%]) care domains were limited. Eighty QIs (27.8%) were determined to be appropriate for use, 116 (40.3%) inappropriate for use, and 92 (31.9%) of limited testing. The measurement properties with the fewest positive assessments were acceptability (38 [13.2%]) and validity (63 [21.9%]). Benchmarking data were reported for only 16 QIs (5.6%). The final 15 recommended QIs came from 6 studies.

Conclusions and Relevance

The findings suggest that only a small proportion of QIs developed for the care of patients with cancer who have advanced disease and/or are at the end of life have received adequate testing and/or are appropriate for use. Further testing may be needed, as is research to establish benchmarking data and to expand QIs relevant to psychosocial, cultural, and spiritual care domains.

Quality Measurement of Serious Illness Communication: Recommendations for Health Systems Based on Findings from a Symposium of National Experts

Background: Communication between clinicians and patients fundamentally shapes the experience of serious illness. There is increasing recognition that health systems should routinely implement structures and processes to assure high-quality serious illness communication (SIC) and measure the effectiveness of their efforts on key outcomes. The absence, underdevelopment, or limited applicability of quality measures related specifically to SIC, and their limited application only to those seen by specialist palliative and hospice care teams, hinder efforts to improve care planning, service delivery, and health outcomes for all seriously ill patients. Objective: We convened an expert stakeholder symposium and subsequently surveyed participants to consider challenges, opportunities, priorities, and strategies to improve quality measurement specific to SIC. Results: We identified several barriers and opportunities to improving quality measurement of SIC. These include issues related to the definition of SIC, methodological challenges related to measuring SIC and related outcomes, underutilization of technologies that can facilitate measurement, and measurement development, and dissemination. Conclusions: Patients, clinicians, and health systems increasingly align around the importance of high-quality communication in serious illness. We offer recommendations for various stakeholder groups to advance SIC quality measurement. Enthusiasm and a sense of urgency among health systems to drive and measure communication improvements inform our proposal for a set of example measures for implementation now.

Emergency Department Use among End-Of-Life Home Care Clients

Emergency department (ED) use is a quality-of-care indicator for community-based end-of-life (EOL) care. This study examined ED use by EOL home care clients. The sample included all EOL home care clients who received care from one community care access centre in Ontario, Canada. Information on health was gathered using the interRAI instrument for palliative care. Data were collected between May 2009 and January 2010. The sample included 93 home care clients. Results showed that 35 percent of clients used the ED within 45 days of assessment. Multivariate analysis identified two determinants of ED use: excessive weight loss and previous hospitalization. Managing terminal illness is often a difficult task, and comprehensive, ongoing assessment of clients’ changing status is critical. Client care and service planning for clients who have lost excessive amounts of weight or who have been recently hospitalized need to be monitored closely to prevent any future avoidable ED use.

The Long-Term effect of A Population-Based Educational Intervention Focusing on End-Of-Life Home Care, Life-Prolongation Treatment, and Knowledge about Palliative Care

Misconceptions and a lack of knowledge are barriers to providing palliative care. This study examined the long-term effect of an educational intervention with the general public focusing on end-of-life home care, life-prolongation treatment, and knowledge about palliative care. We offered a one-hour educational lecture for community residents in 11 districts in Fukushima, Japan. Lecture attendees were asked to complete pre- and post-questionnaires and a six-month postal follow-up questionnaire. A total of 424 respondents completed and returned the follow-up questionnaire. Beliefs about the feasibility of home death did not significantly change. In addition, many of the other significant changes that occurred immediately after the intervention reverted to initial opinions six months later. This population-based educational intervention was not effective for the long term, except that it had a partial influence on certain misconceptions about palliative care. Therefore, other approaches are needed to achieve substantial long-term effects.

Chemotherapy use at the End of Life. A Retrospective Single Centre Experience Analysis

Aims and background

The aim of the study was to evaluate the attitude at our institution in using chemotherapy at the end of life in oncology patients. We compared our habits with other clinical patterns in medical oncology, calculating the temporal interval between the last chemotherapy administration and death of the patient.

Patients and methods

We selected and analyzed 102 patients who received chemotherapy for metastatic or advanced solid tumors (breast, colon, gastric, pancreatic and lung cancers) and who died either in or out of a hospital or hospice from June 2007 to the end of 2009.

Results

We compared 51 patients enrolled in clinical trials with 51 patients not enrolled in clinical trials. Patients of both groups died with advanced cancer between June 2007 and 2009. The following solid tumor types were represented: 48% colorectal cancer, 22% breast cancer, 30% other solid tumors (pancreatic, lung and gastric cancer). The median age at death was 62 years (range, 39 to 84), the male/female ratio was 52:50, and 69% of the patients were married. Most patients, 54%, received 2–3 lines of chemotherapy, 25% received more than 3 lines, and the remaining 21% one line only of chemotherapy. Of the 102 patients identified, 16 (16%) received chemotherapy in the last month of life, and 6 (6%) of these in the last 2 weeks. We speculated that the presence of palliative care services in the territory of residence of patients could influence the time interval between the last chemotherapy and death. We found that 52 patients (51%) lived in areas where palliative care services were not available, 27 (52%) of them received chemotherapy in the last 3 months, 8 (15%) in the last month, and 5(10%) within the last 2 weeks of life. In contrast, of the 49 patients living in the territory served by palliative care units or a hospice, none received chemotherapy during the last 2 weeks of life and 37% received it during the last 3 months of life (P = 0.003).

Conclusions

Among selected patients who died for advanced cancer in our Operative Unit from 2007 to 2009, 50% received chemotherapy in the last 3 months of life. The availability of palliative care services in the territory of residence of patients can influence the interval between the last chemotherapy administration and death. Free full text available at www.tumorionline.it

Dying in the Hospital: Perspectives of family members

Background

Although most patients express a preference to die at home, many (over 30 percent) still die in hospital. This study's purpose was to explore the experience of hospital death from the perspective of patients’ family members.

Methods

Interviews were conducted with family members of patients who had died at hospitals affiliated with a large tertiary referral centre in the United States. Content analysis was used to analyze findings.

Findings

We interviewed 30 family members by phone. Themes were arranged by time frame: before death, time of death, and after death.

Conclusion

Families do not interpret clinical cues leading up to death in the same way healthcare providers do; families need clear and direct explanations from providers. Clinicians should assess patient and family understandings of prognosis and communicate clearly and directly. Family members value being with their loved one at the time of death, and they value spending time with the body after death; this should be facilitated in clinical practice.

Compassion and care at the end of life: oncology nurses' experiences in South-East Iran

BACKGROUND

End of life (EOL) care is newly established in the Iranian context. Context, in this case, refers to the internal and external manifestation of the nurse values, norms and experiences that are learnt throughout life.

AIM

The aim of this study was to explore nurses' experiences of caring for dying patients in Iran.

METHODS

A phenomenological hermeneutic approach, influenced by the philosophy of Ricoeur, was used to analyse 10 oncology nurses' experiences of caring for dying persons.

FINDINGS

Three themes emerged from the analysis: 1) seeing the patient as unique person, 2) being present and open to seeing patients as unique persons and 3) personal and professional development as a result of closeness between nurse and patient. Caring for dying persons means assisting them at the end of their lives.

CONCLUSION

Caring relationships underlie professional palliative care and are essential in EOL care. Proper palliative education and professionally led supervision should be included in the Iranian nursing curriculum.

Barriers to Quality End-of-Life Care for Patients With Blood Cancers

Purpose

Patients with blood cancers have been shown to receive suboptimal care at the end of life (EOL) when assessed with standard oncology quality measures (eg, no chemotherapy ≤ 14 days before death). As they were developed primarily for solid tumors, it is unclear if these measures are appropriate for patients with hematologic malignancies. Moreover, barriers to high-quality EOL care for this specific patient population are largely unknown.

Methods

In 2015, we asked a national cohort of hematologic oncologists about the acceptability of eight standard EOL quality measures. Building on prior qualitative work, we prespecified that measures achieving agreement among at least 55% of respondents would be considered acceptable. We also explored perspectives regarding barriers to quality EOL care.

Results

We received 349 surveys (response rate = 57.3%). Six of the standard measures met the threshold of acceptability, and four were acceptable to > 75% of respondents: hospice admission > 7 days before death, no chemotherapy ≤ 14 days before death, no intubation in the last 30 days of life, and no cardiopulmonary resuscitation in the last 30 days of life. The highest-ranked barriers to quality EOL care reported were “unrealistic patient expectations” (97.3%), “clinician concern about taking away hope” (71.3%), and “unrealistic clinician expectations” (59.0%).

Conclusion

In this large national cohort of hematologic oncologists, standard EOL quality measures were highly acceptable. The top barrier to quality EOL care reported was unrealistic patient expectations, which may be best addressed with more timely and effective advance care discussions.

Population-Based Quality Indicators for Palliative Care Programs for Cancer Patients in Japan: A Delphi Study

CONTEXT

Cancer control programs in Japan strongly endorse the dissemination of palliative care, and various policy measures have been implemented; however, indicators for evaluating palliative care programs have not been defined.

OBJECTIVES

The aim of this study was to develop quality indicators for palliative care programs taking a population-based view to meet the challenge of cancer control in the Japanese population.

METHODS

We conducted a modified Delphi survey. The panelists rated a list of indicators over three iterative rounds according to four perspectives: 1) consistency with the policy target, 2) relevance to the problem, 3) clarity of expression, and 4) measurement feasibility. The criterion for adoption of candidate indicators was set at a total mean score of 7 or more. Finally, the most relevant and important indicators were selected; consensus was defined by agreement of panelists at the panel meeting.

RESULTS

Among 49 panelists surveyed, 48 (98%), 39 (80%), and 43 (88%) responded over the three rounds, respectively. The 15 indicators were identified from 11 domains: patient-reported quality of life, bereaved family-reported quality at the end of life, family care, place of death, bereaved family-reported quality of palliative care, specialized palliative care services, opioid utilization, public perceptions about palliative care, palliative care education to primary care providers, specialist palliative care services, and regional palliative care.

CONCLUSION

Comprehensive quality indicators for palliative care programs were identified. The indicators are currently being used, and the feasibility of measuring change over time will be examined. It is expected that the indicators will be used effectively in the future. It is important to evaluate outcomes of the program, to improve weaknesses, improve outcomes, and promote the welfare of cancer patients.

The positioning of palliative care in acute care: A multiperspective qualitative study in the context of metastatic melanoma

OBJECTIVE

The positioning and meaning of palliative care within the healthcare system lacks clarity which adds a level of complexity to the process of transition to palliative care. This study explores the transition to the palliative care process in the acute care context of metastatic melanoma.

METHOD

A theoretical framework drawing on interpretive and critical traditions informs this research. The pragmatism of symbolic interactionism and the critical theory of Habermas brought a broad orientation to the research. Integration of the theoretical framework and grounded-theory methods facilitated data generation and analysis of 29 interviews with patients, family carers, and healthcare professionals.

RESULTS

The key analytical findings depict a scope of palliative care that was uncertain for users of the system and for those working within the system. Becoming "palliative" is not a defined event; nor is there unanimity around referral to a palliative care service. As such, ambiguity and tension contribute to the difficulties involved in negotiating the transition to palliative care.

SIGNIFICANCE OF RESULTS

Our findings point to uncertainty around the scopes of practice in the transition to palliative care. The challenge in the transition process lies in achieving greater coherency of care within an increasingly specialized healthcare system. The findings may not only inform those within a metastatic melanoma context but may contribute more broadly to palliative practices within the acute care setting.

Negotiating the equivocality of palliative care: a grounded theory of team communicative processes in inpatient medicine

In the majority of U.S. hospitals, inpatient medicine teams make palliative care decisions in the absence of a formalized palliative system. Using a grounded theory approach, interviews with inpatient team members were systematically analyzed to uncover how participants conceptualize palliative care and how they regard the communicative structures that underlie its delivery. During analysis, Weick's model of organizing emerged as a framework that fit the data. The 39 participant inpatient team members discussed palliative care as primarily a communicative process. Themes describing the meaning of palliative care emerged around the concepts of receiver of care, timeline of care, and location of care. The emerging model included four stages in the communicative processes of inpatient palliative care: (a) interpret the need, (b) initiate the conversation, (c) integrate the processes, and (d) identify what works. In contrast to stable, focused palliative care teams or hospice care teams, which have prescribed patient populations and processes, the inpatient medicine team faces the equivocality of providing palliative care within a broader practice. This research offers a four-phase model to show how these inpatient teams communicate within this context. Implications for the provision of palliative care are discussed.

Retrospective studies of end-of-life resource utilization and costs in cancer care using health administrative data: a systematic review

BACKGROUND

There has been an increase in observational studies using health administrative data to examine the nature, quality, and costs of care at life's end, particularly in cancer care.

AIM

To synthesize retrospective observational studies on resource utilization and/or costs at the end of life in cancer patients. We also examine the methods and outcomes of studies assessing the quality of end-of-life care.

DESIGN

A systematic review according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (A Measurement Tool to Assess Systematic Reviews) methodology.

DATA SOURCES

We searched MEDLINE, Embase, CINAHL, and York Centre for Research and Dissemination (1990-2011). Independent reviewers screened abstracts of 14,424 articles, and 835 full-text manuscripts were further reviewed. Inclusion criteria were English-language; at least one resource utilization or cost outcome in adult cancer decedents with solid tumors; outcomes derived from health administrative data; and an exclusive end-of-life focus.

RESULTS

We reviewed 78 studies examining end-of-life care in over 3.7 million cancer decedents; 33 were published since 2008. We observed exponential increases in service use and costs as death approached; hospital services being the main cost driver. Palliative services were relatively underutilized and associated with lower expenditures than hospital-based care. The 15 studies using quality indicators demonstrated that up to 38% of patients receive chemotherapy or life-sustaining treatments in the last month of life and up to 66% do not receive hospice/palliative services.

CONCLUSION

Observational studies using health administrative data have the potential to drive evidence-based palliative care practice and policy. Further development of quality care markers will enhance benchmarking activities across health care jurisdictions, providers, and patient populations.

Consensus on quality indicators to assess the organisation of palliative cancer and dementia care applicable across national healthcare systems and selected by international experts

Background

Large numbers of vulnerable patients are in need of palliative cancer and dementia care. However, a wide gap exists between the knowledge of best practices in palliative care and their use in everyday clinical practice. As part of a European policy improvement program, quality indicators (QIs) have been developed to monitor and improve the organisation of palliative care for patients with cancer and those with dementia in various settings in different European countries.

Method

A multidisciplinary, international panel of professionals participated in a modified RAND Delphi procedure to compose a set of palliative care QIs based on existing sets of QIs on the organisation of palliative care. Panellists participated in three written rounds, one feedback round and one meeting. The panel’s median votes were used to identify the final set of QIs.

Results

The Delphi procedure resulted in 23 useful QIs. These QIs represent key elements of the organisation of good clinical practice, such as the availability of palliative care teams, the availability of special facilities to provide palliative care for patients and their relatives, and the presence of educational interventions for professionals. The final set also includes QIs that are related to the process of palliative care, such as documentation of pain and other symptoms, communication with patients in need of palliative care and their relatives, and end-of-life decisions.

Conclusion

International experts selected a set of 23 QIs for the organisation of palliative care. Although we particularly focused on the organisation of cancer and dementia palliative care, most QIs are generic and are applicable for other types of diseases as well.

The impact of a tumor diagnosis on patients' attitudes toward advance directives

BACKGROUND

Although advance care planning and the completion of advance directives (ADs) are important tools to avoid unwanted aggressive care once patients have lost their decision-making capacity, only a minority of cancer patients are admitted with completed ADs, and little is known about patients' wishes regarding AD consultations.

METHODS

For 1 year, every new patient admitted to the hematology/oncology outpatient clinic of the University Hospital Regensburg received a self-administered questionnaire comprising a self-evaluation of AD knowledge and questions about preferences regarding consultation partners and the time of consultation. Disease-related data were collected from medical records. Statistics were calculated with SPSS.

RESULTS

Of the 500 questionnaires handed out, 394 (75%) were evaluable and analyzed. Twenty-eight percent of the participants had completed an AD (living will or health care proxy). Ninety-two percent of the participants without ADs had never received a consultation offer from any professional involved. Only 20% perceived a clear relation between cancer and AD consultations. More than 50% of the participants without ADs were in favor of consultations 'now' or 'in a few weeks', while more than 40% objected to AD consultations.

CONCLUSIONS

Oncology patients have a large unmet demand for AD consultations. However, a relevant percentage of these patients object to AD consultations. Structured and early AD consultation offers should be made, and early discussions about indications for aggressive treatment should take place.

Rate of use and determinants of withdrawal of care among patients with subarachnoid hemorrhage in the United States

BACKGROUND

The use of "withdrawal of care" and impact upon outcomes among patients with subarachnoid hemorrhage (SAH) is not well studied.

OBJECTIVE

To identify the rate and determinants of "withdrawal of care" among SAH patients.

METHODS

We determined the frequency of "withdrawal of care" and compared the demographic, clinical characteristics, and in-hospital outcomes among patients with SAH stratified by use of "withdrawal of care."

RESULTS

"Withdrawal of care" during hospitalization was instituted in 8912 (3.4%) of the 266,067 patients with SAH. In the stepwise logistic regression, age >65 (odds ratio [OR] 4.5, 95% confidence interval [95% CI] 3.3-6.1), women (OR 1.2, 95% CI 1.0-1.3), African American (OR 0.7, 95% CI 0.5-0.8), Hispanic ethnicity (OR 0.4, 95% CI 0.3-0.6), renal failure (OR 1.6, 95% CI 1.2-1.9), intracerebral hemorrhage (OR 2.0, 95% CI 1.7-2.4, All Patient Refined Diagnosis-Related Groups severity score of extreme loss of function (OR 40.1, 95% CI 6.0-270.7), All Patient Refined Diagnosis-Related Groups severity score of severe loss of function (OR 15.0, 95% CI 2.1-103.8), insurance status of private health maintenance organization (OR 0.7, 95% CI 0.5-0.9), and hospital region south United States (OR 0.7, 95% CI 0.5-0.8), were significant predictors of "withdrawal of care" among patients with SAH. In-hospital mortality was significantly greater, but mean hospitalization charges and length of stay were significantly lower among those with "withdrawal of care."

CONCLUSIONS

Although "withdrawal of care" was effective in limiting hospital charges and resource use, caution is needed to avoid disproportionately high mortality. The prominent relationship between race/ethnicity, insurance status, and hospital location with "withdrawal of care" raises concerns that factors other than severity of disease influence decision making.

Physician-perceived contradictions in end-of-life communication: toward a self-report measurement scale

Communication is undoubtedly a critical element of competent end-of-life care. However, physicians commonly lack communication skills in this particular care context. Theoretically grounded, evidence-based guidelines are needed to enhance physicians' communication with patients and their families in this important time of their lives. To address this need, this study tests and validates a Contradictions in End-of-Life Communication (CEOLC) scale, which disentangles the relational contradictions physicians commonly experience when communicating with end-of-life patients. Exploratory factors analysis confirmed the presence of eight physician-perceived dialectical tensions, reflecting three latent factors of (1) integration, (2) expression, and (3) dominance. Furthermore, a number of significant intercultural differences were found in cross-cultural comparisons of the scale in U.S., Swiss, and Italian physician samples. Thus, this investigation introduces a heuristic assessment tool that aids a better understanding of the dialectical contradictions physicians experience in their interactions with end-of-life patients. The CEOLC scale can be used to gather empirical evidence that may eventually support the development of evidence-based guidelines and skills training toward improved end-of-life care.

Barriers and facilitators to care for the terminally ill: a cross-country case comparison study of Canada, England, Germany, and the United States

BACKGROUND

Why do many patients not die at their preferred location?

AIM

Analyze system-level characteristics influencing the ability to implement best practices in delivering care for terminally ill adults (barriers and facilitators).

DESIGN

Cross-country comparison study from a "most similar-most different" perspective, triangulating evidence from a scoping review of the literature, document analyses, and semi-structured key informant interviews.

SETTING

Case study of Canada, England, Germany, and the United States.

RESULTS

While similar with regard to leading causes of death, patient needs, and potential avenues to care, different models of service provision were employed in the four countries studied. Although hospice and palliative care services were generally offered with standard care along the disease continuum and in various settings, and featured common elements such as physical, psycho-social, and spiritual care, outcomes (access, utilization, etc.) varied across jurisdictions. Barriers to best practice service provision included legislative (including jurisdictional), regulatory (e.g. education and training), and financial issues as well as public knowledge and perception ("giving up hope") challenges. Advance care planning, dedicated and stable funding toward hospice and palliative care, including caregiver benefits, population aging, and standards of practice and guidelines to hospice and palliative care, were identified as facilitators.

CONCLUSION

Successful implementation of effective and efficient best practice approaches to care for the terminally ill, such as shared care, requires concerted action to align these system-level characteristics; many factors were identified as being essential but not sufficient. Policy implementation needs to be tailored to the respective health-care system(s), monitored, and fine-tuned.

Relational dialectics theory: Disentangling physician-perceived tensions of end-of-life communication

Existing literature evidences the centrality of interpersonal communication during end-of-life care, but several barriers currently compromise its effectiveness. One of them is a common lack of communication skills among physicians in this challenging context. Several strategies have been suggested to enhance end-of-life interactions; however, a solid theoretical framework is needed for the development of effective systematic guidelines and interventions that can facilitate this goal. The present research study addresses this gap, choosing to focus particularly on the physician's perspective. It relies on Baxter and Montgomery's (1996) Relational Dialectics Theory to illuminate the complexity of reality doctors commonly face in interactions with their patients during end-of-life care. Semistructured interviews were conducted with 11 physicians in a southern canton of Switzerland who had experienced at least one end-of-life encounter with a patient. The interviews probed whether and under what conditions Baxter and Montgomery's theoretical contradictions translate to physicians' end-of-life communication with their patients and the patients' family members. The results replicated and extended the original theoretical contradictions, evidencing that Relational Dialectics Theory is very applicable to end-of-life conversations. Thus, this study adds a theoretically framed, empirically grounded contribution to the current literature on the communicative challenges physicians commonly face during end-of-life interactions with their patients and their patients' family members.

Quality indicators for palliative care: update of a systematic review

CONTEXT

In 2007, a systematic review revealed a number of quality indicators referring mostly to palliative care outcomes and processes. Psychosocial and spiritual aspects were scarcely represented. Most publications lacked a detailed description of the development process. With many initiatives and further developments expected, an update is needed.

OBJECTIVES

This update gives an overview of the published quality indicators for palliative care and identifies any new developments since 2007 regarding the number and type of indicators developed and the methodology applied.

METHODS

The same literature search as in the 2007 review was used to identify relevant publications up to October 2011. Publications describing development processes or characteristics of quality indicators for palliative care were selected by two reviewers independently.

RESULTS

The literature search resulted in 435 hits in addition to the 650 hits found in the previous review. Thirteen new publications were selected in addition to the 16 publications selected earlier, describing 17 sets of quality indicators containing 326 indicators. These cover all domains of palliative care as defined by the U.S. National Consensus Project. Most indicators refer to care processes or outcomes. The extent to which methodological characteristics are described varies widely.

CONCLUSION

Recent developments in measuring quality of palliative care using quality indicators are mainly quantitative in nature, with a substantial number of new indicators being found. However, the quality of the development process varies considerably between sets. More consistent and detailed methodological descriptions are needed for the further development of these indicators and improved quality measurement of palliative care.

A population-based survey on perceptions of opioid treatment and palliative care units: OPTIM study

This study aimed to clarify the general public's perceptions of opioids and palliative care units (PCUs) and explore factors related to such perceptions. A cross-sectional, anonymous questionnaire was administered to 8000 people. Although a majority agreed with positive perceptions of opioids and PCUs, some also agreed with negative perceptions, such as opioids are addictive and shorten life (28% and 27%, respectively). Multiregression analyses revealed that respondents with a better knowledge of PCUs had higher positive perceptions than those without such knowledge (P <.001). The higher positive perceptions were associated with a higher sense of security regarding regional cancer care (P < .001). Providing the general public with adequate knowledge about palliative care may improve perceptions of palliative care and the sense of security.

Towards a standardized method of developing quality indicators for palliative care: protocol of the Quality indicators for Palliative Care (Q-PAC) study

Background

In recent years, there have been several studies, using a wide variety of methods, aimed at developing quality indicators for palliative care. In this Quality Indicators for Palliative Care study (Q-PAC study) we have applied a scientifically rigorous method to develop a comprehensive and valid quality indicator set which can contribute to a standardized method for use in other countries.

Methods and design

Firstly, an extensive literature review identified existing international quality indicators and relevant themes for measuring quality in palliative care. Secondly, the most relevant of these were selected by an expert panel. Thirdly, those prioritized by the experts were scored by a second multidisciplinary expert panel for usability and relevance, in keeping with the RAND/UCLA-method, combining evidence with consensus among stakeholders. This panel included carers and policymakers as well as patients and next-of-kin. Fourthly, the draft set was tested and evaluated in practice for usability and feasibility; the indicators were then translated into questionnaires presented to patients, next-of-kin and care providers. To encourage the acceptance and use of the indicators, stakeholders, including national palliative care organizations, were involved throughout the whole project.

Conclusion

Our indicator development trajectory resulted in a set of quality indicators applicable to all patients in all palliative care settings. The set includes patient and relative perspectives and includes outcome, process and structure indicators. Our method can contribute internationally to a more standardized and rigorous approach to developing quality indicators for palliative care.

Quality of care in palliative sedation: audit and compliance monitoring of a clinical protocol

CONTEXT

The European Association for Palliative Care and the U.S. National Hospice and Palliative Care Organization have published statements that recommend an audit of palliative sedation practices.

OBJECTIVES

The aim was to assess the feasibility of a quality care project in palliative sedation.

METHODS

We carried out an audit of adherence to a guideline regarding palliative sedation, undertaken as a yearly assessment during two years, of a sample of patient charts. With an audit tool, the charts were evaluated as to the presence of the ethical sedation checklist, information that justified palliative sedation, patient and/or family agreement, and the appropriateness of treatment in concordance with the clinical protocol. An educational program and result feedback meetings were used as the implementation strategy.

RESULTS

Roughly 25% of the medical charts of patients who died in the palliative care unit were evaluated, 94 in 2007 and 110 in 2008. In 2007 and 2008, 63% and 57% of the patients, respectively, whose median age was 65 years, were sedated, with a median length of two days. The main reason for sedation was agitation concomitant with respiratory failure in roughly 60% and 75% of the cases in 2007 and 2008, respectively. Agreement of the patient/family about sedation was collected from 100% of the cases. The concordance of procedures with the sedation guideline was 100% in both years.

CONCLUSION

Our quality-of-care strategy was shown to obtain a higher level of compliance with the palliative sedation guideline for at least two years.

Utilization of supportive and palliative care services among oncology outpatients at one academic cancer center: determinants of use and barriers to access

Abstract Background: Cancer causes significant symptom burden and diminished quality of life. Despite the expansion of supportive and palliative care services (SPCS), little is known about rates of utilization and barriers to access to these services among oncology outpatients.

METHODS

We performed a cross-sectional survey in three outpatient medical oncology clinics. Patients with a diagnosis of breast, lung, or gastrointestinal (GI) cancer and a Karnofsky score of ≥60 were included. Patients reported their use of SPCS and any perceived barriers. Multivariable logistic regression was used to identify factors associated with SPCS use.

RESULTS

Among 313 participants, (50.5%) had not used SPCS since cancer diagnosis. The most common services used were nutrition (26.5%), psychiatric/psychological counseling (29.7%), and physical therapy (15.1%). Pain/palliative care and cancer rehabilitation consultations were used by 8.5% and 4.1% of participants, respectively. In multivariate analysis, graduate education was associated with greater SPCS use (adjusted odds ratio [AOR] 2.14, 95% confidence interval [CI] 1.08-4.26) compared with those with high school or less, whereas having lung cancer was associated with less SPCS use (AOR 0.48, 95% CI 0.24-0.96) when compared with those having breast cancer. The biggest reported barriers to using SPCS were a lack of awareness (22.4%) and lack of physician referral (23%).

CONCLUSIONS

Approximately half of these patients had not accessed SPCS since cancer diagnosis and cite lack of awareness and physician nonreferral as barriers. Further research is needed to understand patients' needs and beliefs regarding SPCS, and how to integrate SPCS into conventional treatments to improve cancer care.

Association of age, gender, and race with intensity of end-of-life care for Medicare beneficiaries with cancer

PURPOSE

To measure intensity of end-of-life (EOL) care for Medicare cancer patients and variations in care by age, gender, and race.

PATIENTS AND METHODS

This retrospective cohort analysis of Medicare claims (20% sample) examined 235,821 Medicare Parts A and B fee-for-service patients dying with poor-prognosis cancers between 2003 and 2007. Logistic regression models quantified associations between care intensity and age, gender, and race. Measures included hospitalizations, emergency department (ED) visits, intensive care unit (ICU) admissions, in-hospital deaths, late-life chemotherapy administration, overall and late hospice enrollment within six months of death.

RESULTS

Within 30 days of death, 61.3% of patients were hospitalized, 10.2% were hospitalized more than once, 10.2% visited an ED more than once, 23.7% had ICU admissions, and 28.8% died in-hospital. Within two weeks of death, 6% received chemotherapy. In their final six months, 55.2% accessed hospice, 15.1% within three days of death. Older age (≥75 versus <75) was associated with lower odds ratios (ORs) of 0.49 to 0.89 for aggressive care, and an OR of 0.92 (95% CI 0.89-0.95) for late hospice enrollment. Female gender was associated with lower ORs (0.82 to 0.86) for aggressive care, and an OR of 0.84 (95% CI 0.81-0.86) for late hospice enrollment. Black (versus nonblack) race was associated with higher ORs (1.08 to 1.38) for aggressive acute care, lower ORs for late chemotherapy, OR 0.76 (95% CI 0.71-0.81), and late hospice enrollment, OR 0.81 (95% CI 0.76-0.86).

CONCLUSIONS

Seniors dying with poor-prognosis cancer experience high-intensity care with rates varying by age, gender, and race.

Volunteers as Facilitators of Communication About Pain

Often unskilled for the hospice caregiving role, family members who provide patient care at home need support to facilitate pain management. Volunteers who serve as members of the hospice team may be able to complement staff efforts to discuss pain with caregivers. A pilot project was developed to determine if volunteers could be trained to facilitate communication about pain with family caregivers. Two hospice volunteers were trained and three family caregivers received the intervention in their homes. Caregivers and volunteers were interviewed about the experience. Both caregivers and volunteers reported a rewarding and positive experience. Caregivers prioritized the need to talk with someone, and volunteers preferred working with caregivers instead of administrative support duties. Volunteers could be trained to deliver the intervention material, but information from volunteer visits was not immediately reported to hospice staff members. Future research should assess the benefits of using hospice volunteers to support clinical efforts.

The use of palliative care services associated with better dying circumstances. Results from an epidemiological population-based study in the brussels metropolitan region

CONTEXT

There is some consensus that a "good death" is one which occurs at home, in the presence of loved ones, and is free of distress. Involvement of palliative care services is assumed to improve these circumstances.

OBJECTIVES

This population-based study describes characteristics of the end of life of patients dying in Brussels and examines their associations with the involvement of palliative care services.

METHODS

In 2007, an anonymous large-scale mortality follow-back survey was conducted in Brussels by mailing questionnaires regarding end-of-life care and characteristics to the attending physicians of a representative sample of 1961 deaths.

RESULTS

Response rate was 41% (n=701). Of all deaths, 59% were nonsudden. Of these, 12% took place at home. For 27%, the attending physician was informed about the patient's preferred place of death. When the preference to die at home was known, 66% died at home. At the moment of death, in 47% of nonsudden deaths, loved ones were present. In a quarter of deaths, palliative care services were involved. Involvement with palliative care services was more likely for cancer patients than noncancer patients and was associated with the attending physicians more often being informed about the preferred place of death, with patients more often dying at home, with loved ones more often being present, and with a better feeling of well-being on the last day.

CONCLUSION

Overall, circumstances at the very end of life are suboptimal in Brussels. This study provides a case for stronger involvement of palliative care as a focal point for policies to improve end-of-life circumstances in a metropolitan area such as Brussels.

Quality improvement in hospice: adding a big job to an already big job?

Hospice organizations are adopting quality measurement and quality improvement (QI) practices to comply with the Medicare Conditions of Participation effective January 31, 2009. However, little is known about organizational best practices or specific needs during implementation. This study identified and described the barriers and facilitators to QI implementation in hospice. Using semistructured interviews with a national sample of key informants (n = 52) concerning facilitators and barriers to QI in hospice, 4 major themes emerged from the data regarding participants' experiences and perceptions: (1) external factors constrain QI implementation; (2) internal factors limit capacity for QI; (3) research on best practices is limited; and (4) traditional QI may not be a good fit for hospice. Though challenging, participants provided recommendations that they believed would facilitate QI in hospice. Categorizing barriers and facilitators as within or outside an organization's control may help organizations assess their capabilities and locate resources to address areas for improvement.

A Month in an Acute Palliative Care Unit

Background: Few cancer centers have developed acute palliative care units (APCUs). The purpose of this study is to highlight clinical interventions and financial outcomes during a typical 1-month period on an APCU. Methods: We evaluated consecutive patients admitted to our APCU from February 1 to 28, 2009, regarding demographic information, sources of and reasons for admissions, resuscitation status, clinical interventions, disposition, and reimbursement data. Results: Forty-two patients were admitted during a 1-month period. Of these, 30 (71%) were referred from the inpatient palliative care consultation team. In all, 10 (24%) patients had a full code status on admission, and 8 had their status changed to do not resuscitate (DNR) prior to discharge. A total of 11 (26%) patients were discharged home with hospice care, 12 (29%) died on the APCU, and 10 (24%) were discharged home with outpatient follow-up visits. All patients received intravenous medications and the majority received intravenous antibiotics. All patients met acute care criteria for hospitalization, and financial reimbursement was satisfactory and comparable to that of other oncology patients. Conclusion: The APCU model is designed for the care of very complex advanced cancer patients. Palliative interventions are given simultaneously with other medical interventions. The APCU is labor intensive and well reimbursed.

End-of-life care in nursing homes: the importance of CNA staff communication

OBJECTIVE

Staff communication has been shown to influence overall nursing home (NH) performance. However, no empirical studies have focused specifically on the impact of CNA communication on end-of-life (EOL) care processes. This study examines the relationship between CNA communication and nursing home performance in EOL care processes.

DESIGN

Secondary data analysis of 2 NH surveys conducted in 2006-2007.

SETTING

One hundred seven nursing homes in New York State.

PARTICIPANTS

Participants were 2636 CNAs and 107 directors of nursing (DON).

MEASUREMENTS

The measures of EOL care processes-EOL assessment and care delivery (5-point Likert scale scores)-were obtained from survey responses provided by 107 DONs. The measure of CNA communication was derived from survey responses obtained from 2636 CNAs. Other independent variables included staff education, hospice use intensity, staffing ratio, staff-resident ethnic overlap index, facility religious affiliation, and ownership.

METHODS

The reliability and validity of the measures of EOL care processes and CNA communication were tested in the current study sample. Multivariate linear regression models with probability weights were used. The analysis was conducted at the facility level.

RESULTS

We found better CNA communication to be significantly associated with better EOL assessment (P = .043) and care delivery (P = .098). Two potentially modifiable factors-staff education and hospice use intensity-were associated with NHs' performance in EOL care processes. Facilities with greater ethnic overlap between staff and residents demonstrated better EOL assessment (P = .051) and care delivery scores (P = .029).

CONCLUSION

Better CNA communication was associated with better performance in EOL care processes. Our findings provide specific insights for NH leaders striving to improve EOL care processes and ultimately the quality of care for dying residents.

Physician factors associated with discussions about end-of-life care

BACKGROUND

Guidelines recommend advanced care planning for terminally ill patients with <1 year to live. Few data are available regarding when physicians and their terminally ill patients typically discuss end-of-life issues.

METHODS

A national survey was conducted of physicians caring for cancer patients about timing of discussions regarding prognosis, do not resuscitate (DNR) status, hospice, and preferred site of death with their terminally ill patients. Logistic regression was used to identify physician and practice characteristics associated with earlier discussions.

RESULTS

Among 4074 respondents, 65% would discuss prognosis "now" (defined as patient has 4 months to 6 months to live, asymptomatic). Fewer would discuss DNR status (44%), hospice (26%), or preferred site of death (21%) immediately, with most physicians waiting for patient symptoms or until there are no more treatments to offer. In multivariate analyses, younger physicians more often discussed prognosis, DNR status, hospice, and site of death "now" (all P < .05). Surgeons and oncologists were more likely than noncancer specialists to discuss prognosis "now" (P = .008), but noncancer specialists were more likely than cancer specialists to discuss DNR status, hospice, and preferred site of death "now" (all P < .001).

CONCLUSIONS

Most physicians report they would not discuss end-of-life options with terminally ill patients who are feeling well, instead waiting for symptoms or until there are no more treatments to offer. More research is needed to understand physicians' reasons for timing of discussions and how their propensity to aggressively treat metastatic disease influences timing, as well as how the timing of discussions influences patient and family experiences at the end of life.

Measuring end-of-life care processes in nursing homes

PURPOSE

The objectives of this study were to develop measures of end-of-life (EOL) care processes in nursing homes and to validate the instrument for measuring them.

DESIGN AND METHODS

A survey of directors of nursing was conducted in 608 eligible nursing homes in New York State. Responses were obtained from 313 (51.5% response rate) facilities. Secondary data on structural characteristics of the nursing homes were obtained from the Online Survey Certification and Reporting System. Exploratory factor analyses and internal consistency reliability analyses were performed. Multivariate regression models with fixed and random effects were estimated.

RESULTS

Four EOL process domains were identified-assessment, delivery, communication and coordination of care among providers, and communication with residents and families. The scales measuring these EOL process domains demonstrated acceptable to high internal consistency reliability and face, content, and construct validity. Facilities with more EOL quality assurance or monitoring mechanisms in place and greater emphasis on EOL staff education had better scores on EOL care processes of assessment, communication and coordination among providers, and care delivery. Facilities with better registered nurse and certified nurse aide staffing ratios and those with religious affiliation also scored higher on selected care process measures.

IMPLICATIONS

This study offers a new validated tool for measuring EOL care processes in nursing homes. Our findings suggest wide variations in care processes across facilities, which in part may stem from lack of gold standards for EOL practice in nursing homes.

Quality indicators for palliative care: a systematic review

Research has demonstrated a greater understanding of the needs of terminally ill patients and their families, but it also has been found that the palliative care is not optimal. Because of a lack of quality indicators in palliative care, the quality of the care is often not assessed. The aim of this systematic review was to give an overview of published quality indicators for palliative care in all patient groups and settings, to determine whether these quality indicators cover all domains of palliative care, to describe the different types of quality indicators, and to determine the methodological characteristics of the quality indicators. Relevant studies were identified by searching computerized databases up to December 2007. Publications describing the development process or characteristics of quality indicators for palliative care were selected by two reviewers independently. An additional selection criterion was that numerators and denominators were either defined or could be deduced from the descriptions. The data extraction involved the general description and type of the quality indicator, target population, and applicable setting. We identified 650 publications, of which 16 met the inclusion criteria. These publications described eight sets of quality indicators. These sets contained 142 overlapping quality indicators, covering all but one domain (cultural aspects) of palliative care. Most quality indicators referred to the outcomes or processes of palliative care. The methodological characteristics of the quality indicators varied considerably. We conclude that a substantial number of quality indicators for palliative care are available, but most have not been described in detail. More detailed methodological specifications are needed to accurately monitor the quality of palliative care.

Length of Survival in Hospice for Cancer Patients Referred From a Comprehensive Cancer Center

This retrospective study examined 180 hospice patients referred from a comprehensive cancer center over 6 months in 2002 to (1) identify the variables associated with shorter length of survival (LOS) in hospice and (2) examine the LOS in hospice for those who previously participated in clinical trials and/or phase I studies. The median LOS in hospice for this cohort was 35 days. In multivariate analysis, low Palliative Performance Score (PPS) at hospice enrollment and male gender were associated with shorter LOS in hospice: males with low PPS had the shortest LOS while females with high PPS had the longest LOS. No correlation was found between the LOS in hospice and prior participation in clinical trials and/or phase I studies.

Advance care planning in adults with cystic fibrosis

BACKGROUND

Because many patients with cystic fibrosis (CF) continue to survive into adulthood, discussion of end-of-life care decisions between clinicians and patients becomes a crucial part of CF adult care. Advance care planning (ACP) promotes alignment of patient care at the end of life with an individual's goals, however minimal research exists on ACP in CF.

METHODS

We surveyed adults enrolled in the Project on Adult Care in Cystic Fibrosis (PAC-CF). We assessed experiences with ACP processes and communication and sought to identify factors associated with completion of an advance directive.

RESULTS

The mean age of respondents (n = 234) was 34 years and the mean forced expiratory volume in 1 second (FEV(1)) was 64% predicted. Seventy-four percent reported that they had spoken to someone, generally a family member, about the care they would want if they became too ill to make decisions for themselves. However, only 30% reported completing an advance directive. Although 79% reported feeling comfortable talking to their clinician about ACP, only 28% said that their CF clinicians have asked about ACP. Having specific wishes about treatment decisions (odds ratio [OR] 7.8, 95% confidence interval [CI] 1.9-32.1) and reporting that a clinician had discussed ACP (OR 4.4, 95% CI 1.5-12.6) were significantly associated with reporting the completion of an advance directive.

DISCUSSION

Though the majority of adults with CF report thinking about and communicating with family about advance care wishes, only a minority report completing an advance directive. Few adults with CF report being asked about ACP by their clinicians. Formulating specific wishes and discussing ACP with a clinician are strongly associated with completing an advance directive. Efforts to improve clinician communication with CF adults around ACP are needed to ensure that discussion of advance directives becomes an integral component of adult CF care.

Review Article: Goals of Care Toward the End of Life: A Structured Literature Review

Goals of care are often mentioned as an important component of end-of-life discussions, but there are diverse assessments regarding the type and number of goals that should be considered. To address this lack of consensus, we searched MEDLINE (1967—2007) for relevant articles and identified the number, phrasing, and type of goals they addressed. An iterative process of categorization resulted in a list of 6 practical, comprehensive goals: (1) be cured, (2) live longer, (3) improve or maintain function/quality of life/ independence, (4) be comfortable, (5) achieve life goals, and (6) provide support for family/caregiver. These goals can be used to articulate goal-oriented frameworks to guide decision making toward the end of life and thereby harmonize patients' treatment choices with their values and medical conditions.