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Paque K, Baudry L, Van Fraeyenhove F, Heyrman B. Barriers and facilitators to early initiation of palliative care as perceived by nurses working on pneumology and nephrology, a descriptive qualitative study. Scand J Caring Sci 2024. [PMID: 39192524 DOI: 10.1111/scs.13296] [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: 02/27/2024] [Accepted: 08/10/2024] [Indexed: 08/29/2024]
Abstract
AIMS AND OBJECTIVES Initiation of palliative care early in the disease trajectory is beneficial for patients with a life-limiting disease. However, palliative care is still introduced rather late or not at all. Therefore, this study aims to explore barriers and facilitators to early initiation of palliative care as perceived by nurses working on pneumology and nephrology. METHODS A descriptive interview-based study was conducted from a critical realist perspective until data sufficiency was reached. Fifteen nurses presented and discussed a patient for whom palliative care was initiated too late. Template analysis was conducted to develop themes and subthemes. RESULTS Five key themes were extracted: (1) communication, (2) fear, (3) personal beliefs about life and death, (4) ambiguity in terminology and (5) workload and time pressure. Barriers related to poor interdisciplinary communication were therapeutic obstinance, hierarchy, unawareness of the patient's wishes and fear of saying something inappropriate. Other barriers were patients' religious beliefs which often hindered the use of sedatives or morphine and led to discomfort and time restraints. A palliative support team in hospital and advance care planning (ACP) were enablers for early palliative care. STUDY LIMITATIONS This study started from a negative experience, leading to identification of a lot of barriers and only a few facilitators. The limited sample size and the restriction to two wards within one single hospital limit the diversity of perspectives and the generalisability of the findings. CONCLUSION More attention is needed for ACP and interdisciplinary communication. Palliative care, including ACP, and interdisciplinary communication should be included in the basic curricula of all healthcare professional courses. Further research is needed to explore barriers and facilitators to early initiation of palliative care in other healthcare settings and patient populations. This is crucial in order to develop and implement sustainable interventions for specific groups of patients.
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Affiliation(s)
- Kristel Paque
- Faculty of Medicine and Health Science, University of Antwerp, Wilrijk, Belgium
- Hast, Associate Degree Nursing, Hasselt, Belgium
| | - Lars Baudry
- Faculty of Medicine and Health Science, University of Antwerp, Wilrijk, Belgium
- Department of Haematology, ZNA-Middelheim, Antwerp, Belgium
| | | | - Bert Heyrman
- Department of Haematology, ZNA-Middelheim, Antwerp, Belgium
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Qureshi D, Grubic N, Maxwell CJ, Bush SH, Casey G, Isenberg SR, Tanuseputro P, Webber C. Association of Disease Trajectory and Place of Care With End-of-Life Burdensome Transitions: A Retrospective Cohort Study. J Am Med Dir Assoc 2024:105229. [PMID: 39186950 DOI: 10.1016/j.jamda.2024.105229] [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: 01/16/2024] [Revised: 07/18/2024] [Accepted: 07/22/2024] [Indexed: 08/28/2024]
Abstract
OBJECTIVES End-of-life (EOL) transitions to hospital can be burdensome for older adults and may contribute to poor outcomes. We investigated the association of disease trajectory and place of care with EOL burdensome transitions. DESIGN Retrospective cohort study using administrative data. SETTING/PARTICIPANTS Ontarians aged ≥65 years who died between 2015 and 2018 and received long-term care (LTC) or home care 6 months before death. METHODS Disease trajectories were defined based on EOL functional decline: terminal illness, organ failure, frailty, sudden death, and other. Places of care included LTC, EOL home care, and non-EOL home care. Burdensome transitions were defined as early (≥3 hospitalizations for any reason or ≥2 hospitalizations due to pneumonia, urinary tract infection, sepsis, or dehydration in the last 90 days of life) or late (≥1 hospitalizations for any reason in the last 3 days of life). Multinomial logistic regression tested for effect modification between disease trajectory and places of care on burdensome transitions. RESULTS Of 110,776 decedents, 40.7% had organ failure, 37.5% frailty, and 12.8% terminal illness, with the remainder in sudden death or other categories. Most were in LTC (62.5%), and 37.5% received home care, with 6.8% receiving designated EOL home care and 30.7% non-EOL home care. There was a significant interaction (P < .001) between disease trajectory and care settings. Compared with terminal illness, organ failure was associated with increased odds of early transitions across all care settings [odds ratios (ORs) ranging 1.14-1.21]. Frailty was associated with increased odds of early transitions solely for non-EOL home care recipients (OR 1.17, 95% CI 1.06-1.28). Organ failure and frailty were associated with increased odds of late transitions across all settings, with organ failure having greater odds in LTC (organ failure OR 2.29, 95% CI 2.02-2.60, vs frailty OR 1.79, 95% CI 1.58-2.04). CONCLUSIONS and Implications: Disparities exist in burdensome transitions, notably for noncancer decedents with organ failure in LTC. Enhancing palliative care may help reduce burdensome transitions and improve patient outcomes.
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Affiliation(s)
- Danial Qureshi
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | | | - Colleen J Maxwell
- ICES, Ottawa, Ontario, Canada; School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada; School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Genevieve Casey
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada
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Forbat L, Macgregor A, Spilsbury K, McCormack B, Rutherford A, Hanratty B, Hockley J, Davison L, Ogden M, Soulsby I, McKenzie M. Using Palliative Care Needs Rounds in the UK for care home staff and residents: an implementation science study. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-134. [PMID: 39046763 DOI: 10.3310/krwq5829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
Background Care home residents often lack access to end-of-life care from specialist palliative care providers. Palliative Care Needs Rounds, developed and tested in Australia, is a novel approach to addressing this. Objective To co-design and implement a scalable UK model of Needs Rounds. Design A pragmatic implementation study using the integrated Promoting Action on Research Implementation in Health Services framework. Setting Implementation was conducted in six case study sites (England, n = 4, and Scotland, n = 2) encompassing specialist palliative care service working with three to six care homes each. Participants Phase 1: interviews (n = 28 care home staff, specialist palliative care staff, relatives, primary care, acute care and allied health practitioners) and four workshops (n = 43 care home staff, clinicians and managers from specialist palliative care teams and patient and public involvement and engagement representatives). Phase 2: interviews (n = 58 care home and specialist palliative care staff); family questionnaire (n = 13 relatives); staff questionnaire (n = 171 care home staff); quality of death/dying questionnaire (n = 81); patient and public involvement and engagement evaluation interviews (n = 11); fidelity assessment (n = 14 Needs Rounds recordings). Interventions (1) Monthly hour-long discussions of residents' physical, psychosocial and spiritual needs, alongside case-based learning, (2) clinical work and (3) relative/multidisciplinary team meetings. Main outcome measures A programme theory describing what works for whom under what circumstances with UK Needs Rounds. Secondary outcomes focus on health service use and cost effectiveness, quality of death and dying, care home staff confidence and capability, and the use of patient and public involvement and engagement. Data sources Semistructured interviews and workshops with key stakeholders from the six sites; capability of adopting a palliative approach, quality of death and dying index, and Canadian Health Care Evaluation Project Lite questionnaires; recordings of Needs Rounds; care home data on resident demographics/health service use; assessments and interventions triggered by Needs Rounds; semistructured interviews with academic and patient and public involvement and engagement members. Results The programme theory: while care home staff experience workforce challenges such as high turnover, variable skills and confidence, Needs Rounds can provide care home and specialist palliative care staff the opportunity to collaborate during a protected time, to plan for residents' last months of life. Needs Rounds build care home staff confidence and can strengthen relationships and trust, while harnessing services' complementary expertise. Needs Rounds strengthen understandings of dying, symptom management, advance/anticipatory care planning and communication. This can improve resident care, enabling residents to be cared for and die in their preferred place, and may benefit relatives by increasing their confidence in care quality. Limitations COVID-19 restricted intervention and data collection. Due to an insufficient sample size, it was not possible to conduct a cost-benefit analysis of Needs Rounds or calculate the treatment effect or family perceptions of care. Conclusions Our work suggests that Needs Rounds can improve the quality of life and death for care home residents, by enhancing staff skills and confidence, including symptom management, communications with general practitioners and relatives, and strengthen relationships between care home and specialist palliative care staff. Future work Conduct analysis of costs-benefits and treatment effects. Engagement with commissioners and policy-makers could examine integration of Needs Rounds into care homes and primary care across the UK to ensure equitable access to specialist care. Study registration This study is registered as ISRCTN15863801. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR128799) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 19. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Liz Forbat
- Faculty of Social Science, University of Stirling, Stirling, UK
| | - Aisha Macgregor
- Faculty of Social Science, University of Stirling, Stirling, UK
| | | | - Brendan McCormack
- Susan Wakil School of Nursing and Midwifery, The University of Sydney, Sydney, NSW, Australia
- Queen Margaret University Edinburgh, Scotland, UK
- Østfold University College, Norway
| | | | - Barbara Hanratty
- Faculty of Medical Sciences, University of Newcastle, England, UK
| | - Jo Hockley
- College of Medicine and Veterinary Science, University of Edinburgh, UK
| | - Lisa Davison
- Faculty of Social Science, University of Stirling, Stirling, UK
| | - Margaret Ogden
- Patient and Public Involvement and Engagement, Faculty of Social Science, University of Stirling, UK
| | - Irene Soulsby
- Patient and Public Involvement and Engagement, Faculty of Social Science, University of Stirling, UK
| | - Maisie McKenzie
- Patient and Public Involvement and Engagement, Faculty of Social Science, University of Stirling, UK
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Cerni J, Hosseinzadeh H, Mullan J, Westley-Wise V, Chantrill L, Barclay G, Rhee J. Does Geography Play a Role in the Receipt of End-of-Life Care for Advanced Cancer Patients? Evidence from an Australian Local Health District Population-Based Study. J Palliat Med 2023; 26:1453-1465. [PMID: 37252775 PMCID: PMC10658736 DOI: 10.1089/jpm.2022.0555] [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] [Accepted: 04/21/2023] [Indexed: 05/31/2023] Open
Abstract
Objectives: To assess the influence of geographic remoteness on health care utilization at end of life (EOL) by people with advanced cancer in a geographically diverse Australian local health district, using two objective measures of rurality and travel-time estimations to health care facilities. Methods: This retrospective cohort study examined the association between rurality (using the Modified Monash Model) and travel-time estimation, and demographic and clinical factors, with the receipt of >1 inpatient and outpatient health service in the last year of life in multivariate models. The study cohort comprised of 3546 patients with cancer, aged ≥18 years, who died in a public hospital between 2015 and 2019. Results: Compared with decedents from metropolitan areas, decedents from some rural areas had higher rates of emergency department visits (small rural towns: aRR 1.29, 95% CI: 1.07-1.57) and ICU admissions (large rural towns: aRR 1.32, 95% CI: 1.03-1.69), but lower rates of acute hospital admissions (large rural towns: aRR 0.83, 95% CI: 0.76-0.90), inpatient palliative care (PC) (regional centers: aRR 0.85, 95% CI: 0.75-0.97), and inpatient radiotherapy (lowest in small rural towns: aRR 0.07, 95% CI: 0.03-0.18). Decedents from rural and regional centers had lower rates of outpatient chemotherapy and radiotherapy use, yet higher rates of outpatient cancer service utilization (p < 0.05). Shorter travel times (10-<30 minutes) were associated with higher rates of inpatient specialist PC (aRR 1.48, 95% CI: 1.09-1.98). Conclusions: Reporting on a series of inpatient and outpatient services used in the last year of life, measures of rurality and travel-time estimates can be useful tools to estimate geographic variation in EOL cancer care provision, with significant gaps uncovered in inpatient PC and outpatient service utilization in rural areas. Policies aimed at redistributing EOL resources in rural and regional communities to reduce travel times to health care facilities could help to reduce regional disparities and ensure equitable access to EOL care services.
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Affiliation(s)
- Jessica Cerni
- Faculty of Arts, Social Sciences, and Humanities, School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Hassan Hosseinzadeh
- Faculty of Arts, Social Sciences, and Humanities, School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Judy Mullan
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
| | - Victoria Westley-Wise
- Centre for Health Research Illawarra Shoalhaven Population (CHRISP), Illawarra Shoalhaven Local Health District (ISLHD), University of Wollongong, Wollongong, New South Wales, Australia
| | - Lorraine Chantrill
- Department of Medical Oncology and Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Greg Barclay
- Department of Palliative Care, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Joel Rhee
- School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
- Graduate School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia
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Bonares M, Stillos K, Huynh L, Selby D. Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study. Palliat Med 2023; 37:1241-1251. [PMID: 37452565 PMCID: PMC10503238 DOI: 10.1177/02692163231183009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups. AIM To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care. DESIGN Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information. SETTING/PARTICIPANTS Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019. RESULTS The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05-1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019. CONCLUSIONS Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.
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Affiliation(s)
- Michael Bonares
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Kalli Stillos
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lise Huynh
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Debbie Selby
- Division of Palliative Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Adsersen M, Thygesen LC, Neergaard MA, Sjøgren P, Mondrup L, Nissen JS, Clausen LM, Groenvold M. Higher Admittance to Specialized Palliative Care for Patients with High Education and Income: A Nationwide Register-Based Study. J Palliat Med 2023; 26:57-66. [PMID: 36130182 DOI: 10.1089/jpm.2022.0087] [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: 01/11/2023] Open
Abstract
Background: While associations between socioeconomic position, that is, income and education and admittance to specialized palliative care (SPC) have been investigated previously, no prior national studies have examined admittance to all types of SPC, that is, hospital-based palliative care team/units and hospice. Aim: To investigate whether cancer patients' education and income were associated with admittance to SPC (hospital-based palliative care team/unit, hospice). Design: Data sources were several nationwide registers. The association between SPC and education and income, respectively, was investigated using logistic regression analyses. Setting/Participants: Patients dying from cancer in Denmark 2010-12 (n = 41,741). Results: In the study population, 45% had lower secondary school, and 6% had an academic education. Patients with an academic education were more often admitted to SPC than those having lower secondary school (odds ratio [OR] = 1.69; 95% confidence interval [CI]: 1.51-1.89). Patients in the highest income quartile (Q4) were more often admitted than those in the lowest income quartile (Q1) (OR = 1.46; 95% CI: 1.37-1.56). This association was stronger for hospice (OR = 1.67 (95% CI: 1.54-1.81)) than for admittance to hospital-based palliative care team/unit (OR = 1.23 (95% CI: 1.14-1.31)). Compared with patients who had lower secondary school and the lowest income, the OR of admittance to SPC among the most affluent academics was 1.96 (95% CI: 1.71-2.25). Conclusion: This nationwide study indicates that admittance to SPC was clearly associated with education and income. We believe that the associations indicate inequity. Initiatives to improve access for patients with low education or income should be established.
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Affiliation(s)
- Mathilde Adsersen
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lise Mondrup
- The Palliative Team Esbjerg, Sydvestjysk Hospital, Esbjerg, Denmark
| | | | | | - Mogens Groenvold
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Handley T, Jorm C, Symington C, Christie L, Forbes E, Munro A, Cheney R. 'It sort of has the feel of being at home': Mixed-methods evaluation of a pilot community-based palliative end-of-life service in a regional setting. Aust J Rural Health 2022; 30:582-592. [PMID: 35749467 PMCID: PMC9796149 DOI: 10.1111/ajr.12897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 05/11/2022] [Accepted: 05/26/2022] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To evaluate the acceptability and effectiveness of a small community-based hospice on the end-of-life experiences of patients and families. METHODS Mixed-methods study. DESIGN Patient admission data were used to assess utilisation of the hospice. Open-ended interviews with hospice patients and their families/carers were used to understand the emotional effects of the service. SETTING A small palliative end-of-life hospice in a rural town in NSW, Australia, during a 12-month trial period that began in March 2019. Data were collected in October-November 2019. PARTICIPANTS Patients, families and carers who used the hospice during the trial period, as well as staff working at the hospice. MAIN OUTCOME MEASURE(S) Quantitative measures included the number of patients admitted to the hospice, the average length of stay and the overall occupancy rate of the hospice. Quantitative interviews were used to explore the experiences of patients and families who used the hospice, and whether the hospice met their end-of-life needs. RESULTS During the trial, 58 patients were admitted to the hospice. The majority of admissions were less than 7 days. Two patients and nine family members were interviewed about their experiences, and six staff completed interviews. Experiences were consistently positive, with the community setting of the hospice contributing to a peaceful and home-like end-of-life experience. Interviewees described meaningful relationships with staff, a pleasant physical environment and the comprehensive care provided were key elements of this experience. CONCLUSION This model, embedding end-of-life care within a residential aged care facility, facilitated a positive end-of-life experience for residents of this regional community. The development of local models to meet local needs is essential to enabling people nearing the end of life to remain in their location of choice, and ensure that their needs are met at this vulnerable time.
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Affiliation(s)
- Tonelle Handley
- School of Medicine and Public HealthUniversity of NewcastleCallaghanNSWAustralia
| | - Christine Jorm
- School of Medicine and Public HealthUniversity of NewcastleCallaghanNSWAustralia
| | | | | | - Erin Forbes
- School of Medicine and Public HealthUniversity of NewcastleCallaghanNSWAustralia
| | - Alice Munro
- Western NSW Local Health DistrictOrangeNSWAustralia
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Tobin J, Rogers A, Winterburn I, Tullie S, Kalyanasundaram A, Kuhn I, Barclay S. Hospice care access inequalities: a systematic review and narrative synthesis. BMJ Support Palliat Care 2022; 12:142-151. [PMID: 33608254 PMCID: PMC9125370 DOI: 10.1136/bmjspcare-2020-002719] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Revised: 01/09/2021] [Accepted: 01/17/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Inequalities in access to hospice care is a source of considerable concern; white, middle-class, middle-aged patients with cancer have traditionally been over-represented in hospice populations. OBJECTIVE To identify from the literature the demographic characteristics of those who access hospice care more often, focusing on: diagnosis, age, gender, marital status, ethnicity, geography and socioeconomic status. DESIGN Systematic literature review and narrative synthesis. METHOD Searches of Medline, PsycINFO, CINAHL, Web of Science, Assia and Embase databases from January 1987 to end September 2019 were conducted. Inclusion criteria were peer-reviewed studies of adult patients in the UK, Australia, New Zealand and Canada, receiving inpatient, day, outpatient and community hospice care. Of the 45 937 titles retrieved, 130 met the inclusion criteria. Narrative synthesis of extracted data was conducted. RESULTS An extensive literature search demonstrates persistent inequalities in hospice care provision: patients without cancer, the oldest old, ethnic minorities and those living in rural or deprived areas are under-represented in hospice populations. The effect of gender and marital status is inconsistent. There is a limited literature concerning hospice service access for the LGBTQ+ community, homeless people and those living with HIV/AIDS, diabetes and cystic fibrosis. CONCLUSION Barriers of prognostic uncertainty, institutional cultures, particular needs of certain groups and lack of public awareness of hospice services remain substantial challenges to the hospice movement in ensuring equitable access for all.
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Affiliation(s)
- Jake Tobin
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Alice Rogers
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Isaac Winterburn
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Sebastian Tullie
- School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | | | - Isla Kuhn
- Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, Cambridgeshire, UK
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Robinson J, Frey R, Raphael D, Old A, Gott M. Difficulties in navigating the intersection of generalist and specialist palliative care services: A cross-sectional study of bereaved family's experiences of care at home in New Zealand. HEALTH & SOCIAL CARE IN THE COMMUNITY 2022; 30:133-141. [PMID: 33894085 DOI: 10.1111/hsc.13381] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 03/09/2021] [Accepted: 03/15/2021] [Indexed: 06/12/2023]
Abstract
A generalist-specialist model of palliative care is well established as a framework for the provision of community care in resource-rich countries. However, evidence is lacking regarding how the model is experienced by family carers and the extent to which access to both generalist and specialist palliative care is equitable. A cross-sectional postal survey was undertaken to explore bereaved family's experiences of generalist palliative care and its intersection with hospice services in the last 3 months of life. A modified version of the Views of Informal Carers-Evaluation of Services survey was sent to 4,778 bereaved family. Data were collected between February 2017 and October 2018. Chi-square was utilised to identify factors that impacted on experiences of generalist palliative care; analysis of free text data comprising 45,823 words was undertaken using a directed content analysis approach. Eight hundred and twenty-six questionnaires were returned (response rate = 21%). Seventy per cent of people (n = 579) spent some time at home in the last 3 months prior to death. People who received support from hospice were more likely to receive support from multiple other services. Those who received no community services were less likely to feel supported by their general practitioner, less likely to spend the last 2 days of life or die at home. Feeling supported had a strong association with services working well together, being involved in decision-making and being aware of the poor prognosis. The provision of palliative care is complicated by a lack of integration with specialist palliative care and may be the basis of continuing inequities in the provision of community care at the end of life. The assumption at a policy level that "generalists" are willing and able to play a key role in palliative care provision needs to be further challenged.
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Affiliation(s)
- Jackie Robinson
- School of Nursing, University of Auckland, Auckland, New Zealand
- Auckland District Health Board, Auckland, New Zealand
| | - Rosemary Frey
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Deborah Raphael
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Andrew Old
- Waitemata District Health Board, Auckland, New Zealand
| | - Merryn Gott
- School of Nursing, University of Auckland, Auckland, New Zealand
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Cooper AL, Mazzer J, Martin-Robins D, Brown JA. A point prevalence study of palliative care need and referral rates in adult inpatients. J Clin Nurs 2021; 31:3144-3154. [PMID: 34850483 DOI: 10.1111/jocn.16148] [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: 09/20/2021] [Revised: 10/31/2021] [Accepted: 11/15/2021] [Indexed: 11/28/2022]
Abstract
AIM AND OBJECTIVES To gain an understanding of palliative care need and service utilisation in adult inpatients. The objectives were to 1) Determine the size and characteristics of the population of adult inpatients who were appropriate for palliative care referral, 2) Establish what percentage of patients, who were appropriate for a palliative care referral, had been referred to and/or were receiving palliative care. BACKGROUND Internationally there is evidence of high levels of unmet palliative care need. Early access to palliative care is associated with improved outcomes including improved quality of life and reduced healthcare costs. DESIGN An observational point prevalence study was reported using the STROBE guidelines. METHODS Data were collected directly from inpatient medical records at a 578-bed tertiary private-not-for-profit hospital by three Registered Nurses on 3 June 2021. Palliative care need was assessed using the prognostic criteria for the 12 conditions outlined in the Gold Standards Framework. RESULTS A total of 270 inpatients met study inclusion criteria. At a hospital population level, 29% (n = 78) of adult inpatients could have benefitted from palliative care. Of the 78 patients assessed as meeting criteria for palliative care, 29% (n = 23) were currently receiving palliative care with a majority of patients 71% (n = 55) not receiving palliative care. CONCLUSIONS This study prospectively collected data and included all 12 conditions outlined in the Gold Standards Framework and found a high level of palliative care need. There was evidence of a high level of unmet palliative care need across conditions and treating specialities. RELEVANCE TO CLINICAL PRACTICE Estimates of palliative care need can be used to improve access to palliative care and assess operational requirements, including the staffing levels required to meet the level of palliative care need for adult inpatients.
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Affiliation(s)
- Alannah L Cooper
- St John of God Subiaco Hospital, Subiaco, Western Australia, Australia
| | - Jacqueline Mazzer
- St John of God Subiaco Hospital, Subiaco, Western Australia, Australia
| | | | - Janie A Brown
- School of Nursing, Curtin University, Bentley, Western Australia, Australia.,St John of God Midland Public and Private Hospital, Midland, Western Australia, Australia
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11
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Haydon HM, Snoswell CL, Thomas EE, Broadbent A, Caffery LJ, Brydon JA, Smith AC. Enhancing a community palliative care service with telehealth leads to efficiency gains and improves job satisfaction. J Telemed Telecare 2021; 27:625-630. [PMID: 34726990 DOI: 10.1177/1357633x211048952] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Telepalliative care services enable clinicians to provide essential palliation services to people with a life-limiting illness in or closer to home. This study aims to explore the costs, service activity and staff experiences resulting from the introduction of telehealth in a community palliative care service in Queensland, Australia. Pre- and post-activity and cost data from the 2016-2017 and 2019-2020 financial years were examined and staff members interviewed. Accounting for inflation and standard wage increases, the labour costs before and after the addition of telehealth were approximately equal. There were small variations in non-labour costs, but these were not directly attributable to the expansion of the telehealth services. Overall, the service activity increased by 189% for standard doctor and nurse consultations, due to the increased efficiency of telehealth compared to the previous outreach (travel) model. Thematic analysis of the staff interview data generated an overarching theme of Increased Job Satisfaction which staff attributed to the patient-centred nature of the telepalliative care service, the increased peer support and increased professional development. Compared with the traditional in-person service, the new telehealth-supported model resulted in equivalent costs, greater efficiency by allowing palliative care to reach more patients and improved staff job satisfaction.
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Affiliation(s)
- Helen M Haydon
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Centaine L Snoswell
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Emma E Thomas
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Andrew Broadbent
- 3556Gold Coast Specialist and Supportive Palliative Care Service, Gold Coast Hospital, Australia
| | - Liam J Caffery
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
| | - Julie-Ann Brydon
- 3556Gold Coast Specialist and Supportive Palliative Care Service, Gold Coast Hospital, Australia
| | - Anthony C Smith
- Centre for Online Health, 1974The University of Queensland, Australia
- Centre for Health Services Research, 1974The University of Queensland, Australia
- Centre for Innovative Medical Technology, University of Southern Denmark, Denmark
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12
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Todd S, Brandford S, Worth R, Shearn J, Bernal J. Place of death of people with intellectual disabilities: An exploratory study of death and dying within community disability service settings. JOURNAL OF INTELLECTUAL DISABILITIES : JOID 2021; 25:296-311. [PMID: 31714176 DOI: 10.1177/1744629519886758] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
This article describes an exploratory study of deaths of people with intellectual disabilities (IDs) that had occurred in group homes managed by an ID service provider in Australasia. Such settings are increasingly recognised as places for both living and dying. Little is known about the extent to which they encounter the death of a person with ID and with what outcomes. Data were obtained from service records and telephone interviews on 66 deaths occurring within a 2-year period. The findings suggest that death is an important but relatively rare event within ID services. This rate of death was influenced by the age structure of the population. Most of the deaths occurred within a hospital setting. Cause of death did not have much impact upon place of death. However, setting characteristics seemed to have some influence. As an exploratory study, lessons for future population-based research in this area are addressed.
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13
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Monier PA, Chrusciel J, Ecarnot F, Bruera E, Sanchez S, Barbaret C. Duration of palliative care involvement and cancer care aggressiveness near the end of life. BMJ Support Palliat Care 2020:bmjspcare-2020-002641. [PMID: 33355165 DOI: 10.1136/bmjspcare-2020-002641] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 11/05/2020] [Accepted: 11/30/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Previous studies have found an association between aggressive cancer care and lower quality end of life. Despite international recommendations, late or very late referral to palliative care seems frequent. This study aimed to evaluate the association between the duration of involvement of a palliative care team (PCT), and aggressive cancer care, and to identify factors associated with aggressive cancer care. METHODS We performed an observational retrospective study in a single academic teaching hospital. In total, 561 inpatients with solid tumours or haematological malignancies were included. Patients followed by a PCT for at least 1 month before death were classified in the palliative care group. Aggressive cancer care was defined as: hospitalisations and/or a new line of chemotherapy within the last month of life, location of death, the use of chemotherapy in the last 2 weeks and hospice admissions within the last 3 days of life. RESULTS Among the 561 patients, 241 (43%) were referred to the PCT; 89 (16%) were followed by the PCT for a month or more before death. In the last 2 weeks of life, 124 (22%) patients received chemotherapy, 110 (20%) died in an acute care unit. At least one criterion of aggressive cancer care was found in 395 patients overall (71%). Aggressive cancer care was significantly less frequent when the PCT referral occurred >1 month before death (p<0.0001). CONCLUSION More studies are needed to understand reasons for late referrals despite international recommendations encouraging integrative palliative care. ETHICS APPROVAL The study was approved by the Grenoble Teaching Hospital ethics committee, and by the CNIL (French national commission for data privacy; Commission Nationale de l'Informatique et des Libertés) under the number 1987785 v 0. Due to ethical and legal restrictions, data are only available on request.
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Affiliation(s)
- Pierre Antoine Monier
- Department of Supportive and Palliative Care, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France
| | - Jan Chrusciel
- Department of Public Health and Performance, Hôpitaux Champagne Sud, Troyes, France
| | - Fiona Ecarnot
- Department of Cardiology, University Hospital Besançon, Besancon, France
- EA3920, University of Burgundy Franche-Comté, Besançon, France
| | - Eduardo Bruera
- Department of Palliative, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Stephane Sanchez
- Department of Public Health and Performance, Hôpitaux Champagne Sud, Troyes, France
| | - Cecile Barbaret
- Department of Supportive and Palliative Care, Centre Hospitalo-Universitaire de Grenoble, Grenoble, France
- Laboratoire ThEMAS (Techniques pour l'évaluation et la Modélisation des Actions de Santé) TIMC-IMAG (Technique de l'Ingénierie Médicale et de la Compléxité-Informatique, Mathématiques et Applications, Grenoble), Grenoble, France
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14
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Abstract
COPD is a significant health issue around the world. It is ultimately a fatal disease. Patients are under-referred to palliative care. Palliative care can improve breathlessness and provide other psychosocial interventions that can improve quality of life. https://bit.ly/2VQ8FrR.
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Affiliation(s)
- Rebecca Strutt
- Palliative Medicine, Liverpool Hospital, Sydney, Australia.,University of New South Wales, Sydney, Australia
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15
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Philip J, Wiseman R, Eastman P, Li C, Smallwood N. Mapping non-malignant respiratory palliative care services in Australia and New Zealand. AUST HEALTH REV 2020; 44:778-781. [PMID: 32943138 DOI: 10.1071/ah19206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/13/2019] [Indexed: 11/23/2022]
Abstract
Objective Despite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. Methods An online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. Results In all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. Conclusions There is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic? People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add? This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners? Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development.
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Affiliation(s)
- Jennifer Philip
- Department of Medicine, The University of Melbourne, Eastern Hill Campus, Fitzroy, Vic. 3065, Australia; and Palliative Nexus Research Group, St Vincent's Hospital, Victoria Parade, Fitzroy, Vic. 3065, Australia; and Department of Palliative Care, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Vic. 3050, Australia. ; and Corresponding author.
| | - Rachel Wiseman
- Christchurch Hospital, Canterbury District Health Board, Waitaha, PO Box 21212, Edgeware, Christchurch 8143, New Zealand.
| | - Peter Eastman
- Department of Palliative Care, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Vic. 3050, Australia. ; and Barwon Health, Bellarine Street, Geelong, Vic. 3320, Australia
| | - Chi Li
- Albury Wodonga Health, PO Box 156, Wodonga, Vic. 3690, Australia. ; and Alfred Health, 55 Commercial Road, Melbourne, Vic. 3004, Australia
| | - Natasha Smallwood
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Vic. 3050, Australia.
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16
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Robinson J, Frey R, Boyd M, McLeod H, Meehan B, Gott M. InterRAI assessments: opportunities to recognise need for and implementation of palliative care interventions in the last year of life? Australas J Ageing 2020; 40:e22-e28. [PMID: 33739596 DOI: 10.1111/ajag.12840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 06/21/2020] [Accepted: 07/06/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To explore how interRAI assessments could be used to identify opportunities to integrate palliative care into a plan of care. METHODS A population-based, cross-sectional design using unique identifiers to link deaths with a national interRAI database. Data were analysed using logistic regression models and chi-square tests. RESULTS A total of 4869 people died over a 12-month period in one district health board area; 50.9% (n = 2478) received one or more interRAI assessments in the year before death. Diagnosis impacted on the type and timing of interRAI assessments and the recognition of end-stage disease. CONCLUSION People in the last year of life experience frequent interRAI assessments. There are opportunities to identify people who might benefit from a palliative care approach. Future research is needed to understand how interRAI assessors can be supported in the application of assessment items related to palliative care.
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Affiliation(s)
- Jackie Robinson
- School of Nursing, University of Auckland, Auckland, New Zealand.,Auckland District Health Board, Auckland, New Zealand
| | - Rosemary Frey
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Michal Boyd
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Heather McLeod
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Brigette Meehan
- Technical Advisory Services Limited (TAS), interRAI New Zealand, Wellington, New Zealand
| | - Merryn Gott
- School of Nursing, University of Auckland, Auckland, New Zealand
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17
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Cerni J, Rhee J, Hosseinzadeh H. End-of-Life Cancer Care Resource Utilisation in Rural Versus Urban Settings: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17144955. [PMID: 32660146 PMCID: PMC7400508 DOI: 10.3390/ijerph17144955] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 01/02/2023]
Abstract
BACKGROUND Despite the advances in End-of-life (EOL) cancer care, disparities remain in the accessibility and utilisation of EOL cancer care resources. Often explained by socio-demographic factors, geographic variation exists in the availability and provision of EOL cancer care services among EOL cancer decedents across urban versus rural settings. This systematic review aims to synthesise mortality follow-back studies on the patterns of EOL cancer care resource use for adults (>18 years) during end-of-life cancer care. METHODS Five databases were searched and data analysed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria involved; a) original research; b) quantitative studies; c) English language; d) palliative care related service use in adults (>18 years) with any malignancy excluding non-melanoma skin cancers; e) exclusive end of life focus; f) urban-rural focus. Narrative reviews and discussions were excluded. RESULTS 24 studies met the inclusion criteria. End-of-life cancer care service utilisation patterns varied by rurality and treatment intent. Rurality was strongly associated with higher rates of Emergency Department (ED) visits and hospitalisations and lower rates of hospice care. The largest inequities between urban and rural health service utilisation patterns were explained by individual level factors including age, gender, proximity to service and survival time from cancer diagnosis. CONCLUSIONS Rurality is an important predictor for poorer outcomes in end-of-life cancer care. Findings suggest that addressing the disparities in the urban-rural continuum is critical for efficient and equitable palliative cancer care. Further research is needed to understand barriers to service access and usage to achieve optimal EOL care for all cancer patient populations.
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Affiliation(s)
- Jessica Cerni
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2522, Australia;
- Correspondence:
| | - Joel Rhee
- General Practice Academic Unit, School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW 2522, Australia;
- Illawarra Southern Practice Based Research Network (ISPRN), University of Wollongong, Wollongong, NSW 2522, Australia
- Centre for Positive Ageing + Care, HammondCare, Hammondville, NSW 2170, Australia
| | - Hassan Hosseinzadeh
- School of Health and Society, Faculty of Social Sciences, University of Wollongong, Wollongong, NSW 2522, Australia;
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18
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Todd S, Bernal J, Shearn J, Worth R, Jones E, Lowe K, Madden P, Barr O, Forrester Jones R, Jarvis P, Kroll T, McCarron M, Read S, Hunt K. Last months of life of people with intellectual disabilities: A UK population‐based study of death and dying in intellectual disability community services. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2020; 33:1245-1258. [DOI: 10.1111/jar.12744] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 03/09/2020] [Accepted: 03/29/2020] [Indexed: 12/16/2022]
Affiliation(s)
- Stuart Todd
- Care Sciences University of South Wales Pontypridd UK
| | - Jane Bernal
- Care Sciences University of South Wales Pontypridd UK
| | - Julia Shearn
- Care Sciences University of South Wales Pontypridd UK
| | - Rhian Worth
- Care Sciences University of South Wales Pontypridd UK
| | - Edwin Jones
- Care Sciences University of South Wales Pontypridd UK
| | - Kathy Lowe
- Care Sciences University of South Wales Pontypridd UK
| | | | - Owen Barr
- School of Nursing Ulster University Derry UK
| | | | - Paul Jarvis
- Care Sciences University of South Wales Pontypridd UK
| | - Thilo Kroll
- School of Nursing Midwifery and Health Systems University College Dublin Dublin UK
| | - Mary McCarron
- School of Nursing & Midwifery Trinity College Dublin Dublin UK
| | - Sue Read
- School of Nursing & Midwifery University of Keele Newcastle under Lyme UK
| | - Katherine Hunt
- Faculty of Health Sciences Southampton University Southampton UK
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19
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Russell B, Vogrin S, Philip J, Hennessy-Anderson N, Collins A, Burchell J, Le B, Brand C, Hudson P, Sundararajan V. Triaging the Terminally Ill-Development of the Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool. J Pain Symptom Manage 2020; 59:95-104.e11. [PMID: 31419540 DOI: 10.1016/j.jpainsymman.2019.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/04/2019] [Accepted: 08/07/2019] [Indexed: 11/28/2022]
Abstract
CONTEXT Evidence-based resource allocation is receiving increasing attention as we strive for equity, transparency, and cost-effectiveness across health care. In the context of finite resources, which of our patients with terminal illness should be prioritized for urgent palliative care? OBJECTIVES To develop the scoring system for the novel Responding to Urgency of Need in Palliative Care triage tool. METHODS Online international discrete choice experiment involving palliative care clinicians to establish the relative importance of seven key attributes of palliative care triage identified during an earlier qualitative study. RESULTS Participants (n = 772) were mainly female (79.9%) with a decade of clinical experience. All attributes contributed significantly (all P-values < 0.001) and independently to clinician assessment of urgency. This study found physical suffering (coefficient 3.45; 95% confidence interval: 3.24 to 3.66) was the most important determinant of urgency, followed by imminent dying (coefficient 1.56; 1.43 to 1.69), psychological suffering (coefficient 1.49; 1.37 to 1.60), caregiver distress (coefficient 1.47; 1.35 to 1.59), discrepancy between care needs and care arrangements (coefficient 1.14; 1.02 to 1.26), mismatch between current and desired site of care (coefficient 0.94; 0.85 to 1.03), and unmet communication needs (coefficient 0.84; 0.76 to 0.92). CONCLUSION Palliative care triage, which is complex and contextual, has been made more transparent through this discrete choice experiment. The Responding to Urgency of Need in Palliative Care triage tool provides an important step toward evidence-based assessment of priority for palliative care. Further research is underway to determine the validity of the tool in clinical practice and its impact on patient and caregiver outcomes.
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Affiliation(s)
- Bethany Russell
- Palliative Medicine Research Group, University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia; Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - Sara Vogrin
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Jennifer Philip
- Palliative Medicine Research Group, University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Victorian Comprehensive Cancer Centre, Melbourne, Australia; Department of Palliative Care, Royal Melbourne Hospital, Melbourne, Australia
| | | | - Anna Collins
- Palliative Medicine Research Group, University of Melbourne & St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jodie Burchell
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Brian Le
- Victorian Comprehensive Cancer Centre, Melbourne, Australia; Department of Palliative Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Caroline Brand
- Melbourne EpiCentre, University of Melbourne and Melbourne Health, Melbourne, Australia; Department of Preventive Medicine, Monash University, Clayton, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Vrije University Brussels, Brussels, Belgium; School of Health Sciences, University of Melbourne, Melbourne, Australia
| | - Vijaya Sundararajan
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Department of Public Health, La Trobe University, Bundoora, Australia
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20
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Xiong B, Freeman S, Banner D, Spirgiene L. Hospice use and one-year survivorship of residents in long-term care facilities in Canada: a cohort study. BMC Palliat Care 2019; 18:100. [PMID: 31718634 PMCID: PMC6852979 DOI: 10.1186/s12904-019-0480-z] [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: 05/30/2019] [Accepted: 10/18/2019] [Indexed: 02/08/2023] Open
Abstract
Background Hospice care is designed for persons in the final phase of a terminal illness. However, hospice care is not used appropriately. Some persons who do not meet the hospice eligibility receive hospice care, while many persons who may have benefitted from hospice care do not receive it. This study aimed to examine the characteristics of, and one-year survivorship among, residents who received hospice care versus those who did not in long-term care facilities (LTCFs) in Canada. Methods This retrospective cohort study used linked health administrative data from the Canadian Continuing Reporting System (CCRS) and the Discharge Abstract Database (DAD). All persons who resided in a LTCF and who had a Resident Assessment Instrument Minimum Data Set Version 2.0 (RAI-MDS 2.0) assessment in the CCRS database between Jan. 1st, 2015 and Dec 31st, 2015 were included in this study (N = 185,715). Death records were linked up to Dec 31th, 2016. Univariate, bivariate and multivariate analyses were performed. Results The reported hospice care rate in LTCFs is critically low (less than 3%), despite one in five residents dying within 3 months of the assessment. Residents who received hospice care and died within 1 year were found to have more severe and complex health conditions than other residents. Compared to those who did not receive hospice care but died within 1 year, residents who received hospice care and were alive 1 year following the assessment were younger (a mean age of 79.4 [+ 13.5] years vs. 86.5 [+ 9.2] years), more likely to live in an urban LTCF (93.2% vs. 82.6%), had a higher percentage of having a diagnosis of cancer (50.7% vs. 12.9%), had a lower percentage of having a diagnosis of dementia (30.2% vs. 54.5%), and exhibited more severe acute clinical conditions. Conclusions The actual use of hospice care among LTCF residents is very poor in Canada. Several factors emerged as potential barriers to hospice use in the LTCF population including ageism, rurality, and a diagnosis of dementia. Improved understanding of hospice use and one-year survivorship may help LTCFs administrators, hospice care providers, and policy makers to improve hospice accessibility in this target group.
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Affiliation(s)
- Beibei Xiong
- School of Health Sciences, University of Northern British Columbia, Prince George, British Columbia, Canada
| | - Shannon Freeman
- School of Nursing, University of Northern British Columbia, 333 University Way, Prince George, British Columbia, V2N 4Z9, Canada.
| | - Davina Banner
- School of Nursing, University of Northern British Columbia, 333 University Way, Prince George, British Columbia, V2N 4Z9, Canada.,Northern Medical Program, University of Northern British Columbia, Prince George, British Columbia, Canada
| | - Lina Spirgiene
- Department of Nursing and Care, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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21
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Liu WM, Koerner J, Lam L, Johnston N, Samara J, Chapman M, Forbat L. Improved Quality of Death and Dying in Care Homes: A Palliative Care Stepped Wedge Randomized Control Trial in Australia. J Am Geriatr Soc 2019; 68:305-312. [PMID: 31681981 DOI: 10.1111/jgs.16192] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 08/24/2019] [Accepted: 08/27/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Mortality in care homes is high, but care of dying residents is often suboptimal, and many services do not have easy access to specialist palliative care. This study examined the impact of providing specialist palliative care on residents' quality of death and dying. DESIGN Using a stepped wedge randomized control trial, care homes were randomly assigned to crossover from control to intervention using a random number generator. Analysis used a generalized linear and latent mixed model. The trial was registered with ANZCTR: ACTRN12617000080325. SETTING Twelve Australian care homes in Canberra, Australia. PARTICIPANTS A total of 1700 non-respite residents were reviewed from the 12 participating care homes. Of these residents, 537 died and 471 had complete data for analysis. The trial ran between February 2017 and June 2018. INTERVENTION Palliative Care Needs Rounds (hereafter Needs Rounds) are monthly hour-long staff-only triage meetings to discuss residents at risk of dying without a plan in place. They are chaired by a specialist palliative care clinician and attended by care home staff. A checklist is followed to guide discussions and outcomes, focused on anticipatory planning. MEASUREMENTS This article reports secondary outcomes of staff perceptions of residents' quality of death and dying, care home staff confidence, and completion of advance care planning documentation. We assessed (1) quality of death and dying, and (2) staff capability of adopting a palliative approach, completion of advance care plans, and medical power of attorney. RESULTS Needs Rounds are associated with staff perceptions that residents had a better quality of death and dying (P < .01; 95% confidence interval [CI] = 1.83-12.21), particularly in the 10 facilities that complied with the intervention protocol (P < .01; 95% CI = 6.37-13.32). Staff self-reported perceptions of capability increased (P < .01; 95% CI = 2.73-6.72). CONCLUSION The data offer evidence for monthly triage meetings to transform the lives, deaths, and care of older people residing in care homes. J Am Geriatr Soc 68:305-312, 2020.
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Affiliation(s)
- Wai-Man Liu
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Jane Koerner
- University of Canberra, Canberra, Australian Capital Territory, Australia
| | | | - Nikki Johnston
- Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Juliane Samara
- Calvary Public Hospital, Canberra, Australian Capital Territory, Australia
| | - Michael Chapman
- Australian National University, Canberra, Australian Capital Territory, Australia.,ACT Health, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Liz Forbat
- Australian Catholic University, Canberra, Australian Capital Territory, Australia.,University of Stirling, Stirling, United Kingdom
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22
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Brinkman-Stoppelenburg A, Polinder S, Meerum-Terwogt J, de Nijs E, van der Padt-Pruijsten A, Peters L, van der Vorst M, van Zuylen L, Lingsma H, van der Heide A. The COMPASS study: A descriptive study on the characteristics of palliative care team consultation for cancer patients in hospitals. Eur J Cancer Care (Engl) 2019; 29:e13172. [PMID: 31571338 DOI: 10.1111/ecc.13172] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 07/03/2019] [Accepted: 09/04/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To describe the characteristics of palliative care team (PCT) consultation for patients with cancer who are admitted in hospital and to investigate when and why PCTs are consulted. METHODS In this descriptive study in ten Dutch hospitals, the COMPASS study, we compared characteristics of patients with cancer for whom a PCT was or was not consulted (substudy 1). We also collected information about the process of PCT consultations and the disciplines involved (substudy 2). RESULTS In substudy 1, we included 476 patients. A life expectancy <3 months, unplanned hospitalisation and lack of options for anti-cancer treatment increased the likelihood of PCT consultation. In substudy 2, 64% of 550 consultations concerned patients with a life expectancy of <3 months. The most frequently mentioned problems that were identified by the PCTS were complex pain problems (56%), issues around the organisation of care (31%), fatigue (27%) and dyspnoea (27%). There was much variance between hospitals in the disciplines that were involved in consultations. CONCLUSION Palliative care teams in Dutch hospitals are most often consulted for patients with a life expectancy of <3 months who have an unplanned hospital admission because of physical symptoms or problems. We found much variance between hospitals in the composition and activities of PCTs.
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Affiliation(s)
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jetske Meerum-Terwogt
- Department of Internal Medicine, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Ellen de Nijs
- Center of Expertise Palliative Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Liesbeth Peters
- Department of Pulmonary Diseases, Northwest Clinics, Den Helder, The Netherlands
| | - Maurice van der Vorst
- Department of Medical Oncology, Cancer Center Amsterdam, VU University Medical Center, Amsterdam, The Netherlands.,Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Hester Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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23
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Assareh H, Stubbs JM, Trinh LTT, Muruganantham P, Jalaludin B, Achat HM. Variation in Hospital Use at the End of Life Among New South Wales Residents Who Died in Hospital or Soon After Discharge. J Aging Health 2019; 32:708-723. [PMID: 31130055 DOI: 10.1177/0898264319848582] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: Hospital use increases in the last 3 months of life. We aimed to examine its association with where people live and its variation across a large health jurisdiction. Methods: We studied a number of emergency department presentations and days spent in hospital, and in-hospital deaths among decedents who were hospitalized within 30 days of death across 153 areas in New South Wales (NSW), Australia, during 2010-2015. Results: Decedents' demographics and health status were associated with hospital use. Primary care and aged care supply had no or minimal influence, as opposed to the varying effects of areal factors-socioeconomic status, remoteness, and distance to hospital last admitted. Overall, there was an approximate 20% difference in hospital use by decedents across areas. In all, 18% to 57% of areas had hospital use that differed from the average. Discussion: The observed disparity can inform targeted local efforts to strengthen the use of community care services and reduce the burden of end-of-life care on hospitals.
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Affiliation(s)
- Hassan Assareh
- Agency for Clinical Innovation, Chatswood, New South Wales, Australia
| | - Joanne M Stubbs
- Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | - Lieu T T Trinh
- Western Sydney Local Health District, North Parramatta, New South Wales, Australia
| | | | - Bin Jalaludin
- South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Helen M Achat
- Western Sydney Local Health District, North Parramatta, New South Wales, Australia
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24
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Davies JM, Sleeman KE, Leniz J, Wilson R, Higginson IJ, Verne J, Maddocks M, Murtagh FEM. Socioeconomic position and use of healthcare in the last year of life: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002782. [PMID: 31013279 PMCID: PMC6478269 DOI: 10.1371/journal.pmed.1002782] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 03/14/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Low socioeconomic position (SEP) is recognized as a risk factor for worse health outcomes. How socioeconomic factors influence end-of-life care, and the magnitude of their effect, is not understood. This review aimed to synthesise and quantify the associations between measures of SEP and use of healthcare in the last year of life. METHODS AND FINDINGS MEDLINE, EMBASE, PsycINFO, CINAHL, and ASSIA databases were searched without language restrictions from inception to 1 February 2019. We included empirical observational studies from high-income countries reporting an association between SEP (e.g., income, education, occupation, private medical insurance status, housing tenure, housing quality, or area-based deprivation) and place of death, plus use of acute care, specialist and nonspecialist end-of-life care, advance care planning, and quality of care in the last year of life. Methodological quality was evaluated using the Newcastle-Ottawa Quality Assessment Scale (NOS). The overall strength and direction of associations was summarised, and where sufficient comparable data were available, adjusted odds ratios (ORs) were pooled and dose-response meta-regression performed. A total of 209 studies were included (mean NOS quality score of 4.8); 112 high- to medium-quality observational studies were used in the meta-synthesis and meta-analysis (53.5% from North America, 31.0% from Europe, 8.5% from Australia, and 7.0% from Asia). Compared to people living in the least deprived neighbourhoods, people living in the most deprived neighbourhoods were more likely to die in hospital versus home (OR 1.30, 95% CI 1.23-1.38, p < 0.001), to receive acute hospital-based care in the last 3 months of life (OR 1.16, 95% CI 1.08-1.25, p < 0.001), and to not receive specialist palliative care (OR 1.13, 95% CI 1.07-1.19, p < 0.001). For every quintile increase in area deprivation, hospital versus home death was more likely (OR 1.07, 95% CI 1.05-1.08, p < 0.001), and not receiving specialist palliative care was more likely (OR 1.03, 95% CI 1.02-1.05, p < 0.001). Compared to the most educated (qualifications or years of education completed), the least educated people were more likely to not receive specialist palliative care (OR 1.26, 95% CI 1.07-1.49, p = 0.005). The observational nature of the studies included and the focus on high-income countries limit the conclusions of this review. CONCLUSIONS In high-income countries, low SEP is a risk factor for hospital death as well as other indicators of potentially poor-quality end-of-life care, with evidence of a dose response indicating that inequality persists across the social stratum. These findings should stimulate widespread efforts to reduce socioeconomic inequality towards the end of life.
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Affiliation(s)
- Joanna M. Davies
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Katherine E. Sleeman
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Javiera Leniz
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Rebecca Wilson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Julia Verne
- Health Intelligence, Public Health England, Bristol, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
| | - Fliss E. M. Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, United Kingdom
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom
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25
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Vanbutsele G, Deliens L, Cocquyt V, Cohen J, Pardon K, Chambaere K. Use and timing of referral to specialized palliative care services for people with cancer: A mortality follow-back study among treating physicians in Belgium. PLoS One 2019; 14:e0210056. [PMID: 30653508 PMCID: PMC6336236 DOI: 10.1371/journal.pone.0210056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 12/17/2018] [Indexed: 12/25/2022] Open
Abstract
Background Referral to specialized palliative care services (SPCS) occurs often late in the illness trajectory but may differ across cancer types. We examined differences between cancer types in the use and timing of referral to specialized palliative care services (SPCS) and in the reasons for non-referral. Methods We conducted a population-based mortality follow-back survey among physicians who certified a representative sample of deaths in Flanders, Belgium. We focused only on sampled death cases of cancer (n = 2392). The questionnaire asked about the use of the existing types of SPCS and the timing of referral to these services. Results Response rate was 58% (1394/2392). Patients who died from breast, respiratory, head and neck, genitourinary or gastrointestinal cancer had higher chances of using SPCS compared to hematologic cancer patients. The most prevalent reason for non-referral was that regular care sufficiently addressed palliative and supportive care needs (51%). This differed significantly between cancer types ranging from 77,8% for breast cancer and 42.1% for hematologic cancer. A second prevalent reason for not using SPCS was that it was not meaningful (enough) (23.9%), particularly for hematologic malignancies (35,1%) and only in 5.3% for breast cancer. Conclusion Differences in referral across different types of cancer were found. Referral is more often delayed or not initiated for patients with hematologic cancer, possibly due to differences in illness trajectory. An influencing reason is that physicians perceive palliative care as not meaningful or not meaningful enough for these patients which may be linked to the uncertainty in the disease trajectory of hematologic malignancies.
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Affiliation(s)
- Gaëlle Vanbutsele
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- * E-mail: (GV); (KC); (KP)
| | - 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, Ghent, Belgium
| | - Veronique Cocquyt
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Koen Pardon
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- * E-mail: (GV); (KC); (KP)
| | - Kenneth Chambaere
- End-of-Life Care Research group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- * E-mail: (GV); (KC); (KP)
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26
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Ní Chróinín D, Goldsbury DE, Beveridge A, Davidson PM, Girgis A, Ingham N, Phillips JL, Wilkinson AM, Ingham JM, O'Connell DL. Health-services utilisation amongst older persons during the last year of life: a population-based study. BMC Geriatr 2018; 18:317. [PMID: 30572832 PMCID: PMC6302397 DOI: 10.1186/s12877-018-1006-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 12/05/2018] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Accurate population-based data regarding hospital-based care utilisation by older persons during their last year of life are important in health services planning. We investigated patterns of acute hospital-based service use at the end of life, amongst older decedents in New South Wales (NSW), Australia. METHODS Data from all persons aged ≥70 years who died in the state of NSW Australia in 2007 were included. Several measures of hospital-based service utilisation during the last year of life were assessed from retrospectively linked data comprising data for all registered deaths, cause of death, hospital care during the last year of life (NSW Admitted Patient Data Collection [APDC] and Emergency Department [ED] Data Collection [EDDC]), and the NSW Cancer Registry. RESULTS Amongst 34,556 decedents aged ≥70 years, 82% (n = 28,366) had ≥1 hospitalisation during the last year of life (median 2), and 21% > 3 hospitalisations. Twenty-five percent (n = 5485) of decedents attended ED during the last week of life. Overall, 21% had a hospitalisation > 30 days in the last year of life, and 7% spent > 3 months in hospital; 79% had ≥1 ED attendance, 17% > 3. Nine percent (n = 3239) spent time in an intensive care unit. Fifty-three percent (n = 18,437) died in an inpatient setting. Hospital records had referenced palliative care for a fifth (7169) of decedents. Adjusting for age group, sex, place of residence, area-level socioeconomic status, and cause of death, having > 3 hospitalisations during the last year of life was more likely for persons dying from cancer (35% versus 16% non-cancer deaths, adjusted odds ratio [aOR] 2.33), 'younger' old decedents (29% for age 70-79 and 20% for age 80-89 versus 11% for 90+, aOR 2.42 and 1.77 respectively) and males (25% versus 17% females, aOR 1.38). Patterns observed for other hospital-based service use were similar. CONCLUSIONS This population-based study reveals high use of hospital care among older persons during their last year of life, although this decreased with increasing older age, providing important data to inform health services planning for this population, and highlighting aspects requiring further study.
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Affiliation(s)
- Danielle Ní Chróinín
- Department of Geriatric Medicine, Liverpool Hospital, UNSW, Corner of Elizabeth and Goulburn Streets, Liverpool, Sydney, NSW, 2170, Australia.
| | | | - Alexander Beveridge
- Department of Geriatric Medicine, St. Vincent's Hospital, and St Vincent's Clinical School, UNSW, Sydney, Australia
| | - Patricia M Davidson
- Faculty of Health, University of Technology Sydney, New South Wales, Australia and Johns Hopkins University, Baltimore, MD, USA
| | - Afaf Girgis
- Centre for Oncology Education and Research Translation, Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, UNSW Australia, Sydney, Australia
| | - Nicholas Ingham
- Department of Geriatric Medicine, St. Vincent's Hospital, and UNSW Australia, St Vincent's Clinical School, Faculty of Medicine, Sydney, Australia
| | - Jane L Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Anne M Wilkinson
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, WA, Australia
| | - Jane M Ingham
- UNSW Sydney, Faculty of Medicine, St Vincent's Clinical School Darlinghurst, Sydney, Australia
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27
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Chan LS, Macdonald ME, Cohen SR. Moving Culture beyond Ethnicity: Examining Dying in Hospital through a Cultural Lens. J Palliat Care 2018. [DOI: 10.1177/082585970902500207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Lisa S. Chan
- School of Nursing, McGill University, Montreal, Quebec, Canada
| | - Mary Ellen Macdonald
- School of Nursing and Departments of Pediatrics and Oncology, McGill University, and Montreal Children's Hospital of the McGill University Health Center, Montreal, Quebec, Canada
| | - S. Robin Cohen
- Departments of Oncology and Medicine, McGill University, and Lady Davis Institute for Research, Montreal, Quebec, Canada
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28
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Gao J, Johnston GM, Lavergne MR, McIntyre P. Identifying Population Groups with Low Palliative Care Program Enrolment Using Classification and Regression Tree Analysis. J Palliat Care 2018. [DOI: 10.1177/082585971102700205] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Classification and regression tree (CART) analysis was used to identify subpopulations with lower palliative care program (PCP) enrolment rates. CART analysis uses recursive partitioning to group predictors. The PCP enrolment rate was 72 percent for the 6,892 adults who died of cancer from 2000 and 2005 in two counties in Nova Scotia, Canada. The lowest PCP enrolment rates were for nursing home residents over 82 years (27 percent), a group residing more than 43 kilometres from the PCP (31 percent), and another group living less than two weeks after their cancer diagnosis (37 percent). The highest rate (86 percent) was for the 2,118 persons who received palliative radiation. Findings from multiple logistic regression (MLR) were provided for comparison. CART findings identified low PCP enrolment subpopulations that were defined by interactions among demographic, social, medical, and health system predictors.
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Affiliation(s)
- Jun Gao
- GM Johnston (corresponding author) School of Health Administration, Dalhousie University, and Surveillance and Epidemiology Unit, Cancer Care Nova Scotia, Bethune 568, 1276 South Street, Halifax, Nova Scotia, Canada B3H 2Y9
| | - Grace M. Johnston
- Health Canada, Centre for Vaccine Evaluation, Biologics and Genetic Therapies Directorate, Ottawa, Ontario, Canada
| | - M. Ruth Lavergne
- University of British Columbia, Centre for Health Services and Policy Research, Vancouver, British Columbia, Canada
| | - Paul McIntyre
- Department of Medicine, Dalhousie University, and Palliative Medicine, Capital Health, Halifax, Nova Scotia, Canada
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29
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Kozlov E, Cai A, Sirey JA, Ghesquiere A, Reid MC. Identifying Palliative Care Needs Among Older Adults in Nonclinical Settings. Am J Hosp Palliat Care 2018; 35:1477-1482. [PMID: 29792039 PMCID: PMC6295198 DOI: 10.1177/1049909118777235] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Though palliative care is appropriate for patients with serious illness at any stage of the illness and treatment process, the vast majority of palliative care is currently delivered in inpatient medical settings in the past month of life during an acute hospitalization. Palliative care can have maximal benefit to patients when it is integrated earlier in the illness trajectory. One possible way to increase earlier palliative care use is to screen for unmet palliative care needs in community settings. The goal of this study was to assess the rates of unmet palliative care needs in older adults who attend New York City-based senior centers. The results of this study revealed that 28.8% of participants screened positive for unmet palliative care needs. Lower education and living alone were predictors of positive palliative care screens, but age, gender, marital status, and race were not. This study determined that the rate of unmet palliative care needs in community-based older adults who attend senior center events was high and that living arrangement and education level are both correlates of unmet palliative care needs. Screening for unmet palliative care needs in community settings is a promising approach for moving palliative care upstream to patients who could benefit from the additional supportive services prior to an acute hospitalization.
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Affiliation(s)
- Elissa Kozlov
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY,USA
| | | | - Jo Anne Sirey
- Department of Psychiatry, Weill Cornell Medicine, NY, USA
| | - Angela Ghesquiere
- Brookdale Center for Healthy Aging, Hunter College of the City University of New York, NY, USA
| | - M. Carrington Reid
- Division of Geriatrics and Palliative Medicine, Weill Cornell Medicine, NY,USA
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30
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Adsersen M, Thygesen LC, Neergaard MA, Jensen AB, Sjøgren P, Damkier A, Clausen LM, Groenvold M. Cohabitation Status Influenced Admittance to Specialized Palliative Care for Cancer Patients: A Nationwide Study from the Danish Palliative Care Database. J Palliat Med 2018; 22:164-172. [PMID: 30403554 DOI: 10.1089/jpm.2018.0201] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The utilization of the health care system varies in relation to cohabitation status, but conflicting results have been found in studies investigating the association in relation to specialized palliative care (SPC). OBJECTIVE To investigate the association between cohabitation status and admittance to SPC; to establish whether this association differed between hospital-based palliative care team/units (mainly outpatient/home care) and hospice (mainly inpatient care). DESIGN A nationwide study based on the Danish Palliative Care Database, which is linked with additional registers. MEASUREMENTS The study population included all patients dying from cancer in Denmark between 2010 and 2012 (n = 44,480). The associations were investigated using logistic regression analysis adjusted for sex, age, diagnosis, and geography and standardized absolute prevalences. RESULTS Comparison with cohabiting patients showed that overall admittance to SPC was lowest among patients who were widows/widowers (odds ratio [OR] = 0.86; 95% confidence interval [CI]: 0.81-0.91) and those who had never married (OR = 0.74; 95% CI: 0.68-0.80). Patients living alone were more likely to be admitted to a hospice [e.g., divorced OR = 1.41 (95% CI: 1.31-1.52)] than to a hospital-based palliative care team/unit [e.g., never married OR = 0.64 (95% CI: 0.59-0.70)] compared with cohabiting patients. Standardized prevalences of overall admittance to SPC showed a similar pattern, for example, admittance was highest (41%) for patients cohabiting and lowest (30%) for patients who had never married. CONCLUSION Cohabiting individuals were favored in admittance to SPC. Compared with cohabiting patients it is unlikely that patients living alone have lower needs for SPC: results point toward inequity in admittance to specialist health care, a problem that should be addressed.
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Affiliation(s)
- Mathilde Adsersen
- 1 Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lau Caspar Thygesen
- 2 National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | | | - Per Sjøgren
- 5 Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anette Damkier
- 6 The Palliative Care Team Funen, Department of Oncology, Odense University Hospital, Odense, Denmark
| | | | - Mogens Groenvold
- 1 Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark.,8 Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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31
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Ding J, Johnson CE, Cook A. How We Should Assess the Delivery of End-Of-Life Care in General Practice? A Systematic Review. J Palliat Med 2018; 21:1790-1805. [PMID: 30129811 DOI: 10.1089/jpm.2018.0194] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND The majority of end-of-life (EOL) care occurs in general practice. However, we still have little knowledge about how this care is delivered or how it can be assessed and supported. AIM (i) To review the existing evaluation tools used for assessment of the delivery of EOL care from the perspective of general practice; (ii) To describe how EOL care is provided in general practice; (iii) To identify major areas of concern in providing EOL care in this context. DESIGN A systematic review. DATA SOURCES Systematic searches of major electronic databases (Medline, EMBASE, PsycINFO, and CINAHL) from inception to 2017 were used to identify evaluation tools focusing on organizational structures/systems and process of end-of-life care from a general practice perspective. RESULTS A total of 43 studies representing nine evaluation tools were included. A relatively restricted focus and lack of validation were common limitations. Key general practitioner (GP) activities assessed by the evaluation tools were summarized and the main issues in current GP EOL care practice were identified. CONCLUSIONS The review of evaluation tools revealed that GPs are highly involved in management of patients at the EOL, but there are a range of issues relating to the delivery of care. An EOL care registration system integrated with electronic health records could provide an optimal approach to address the concerns about recall bias and time demands in retrospective analyses. Such a system should ideally capture the core GP activities and any major issues in care provision on a case-by-case basis.
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Affiliation(s)
- Jinfeng Ding
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
| | - Claire E Johnson
- 2 Cancer and Palliative Care Research and Evaluation Unit (CaPCREU), Medical School, University of Western Australia , Perth, Western Australia, Australia
- 3 School of Nursing and Midwifery, Monash University , Melbourne, Victoria, Australia
| | - Angus Cook
- 1 School of Population and Global Health, University of Western Australia , Perth, Western Australia, Australia
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32
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Duggan KJ, Wiltshire J, Strutt R, Boxer MM, Berthelsen A, Descallar J, Vinod SK. Palliative care and psychosocial care in metastatic non-small cell lung cancer: factors affecting utilisation of services and impact on patient survival. Support Care Cancer 2018; 27:911-919. [PMID: 30066201 DOI: 10.1007/s00520-018-4379-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Accepted: 07/24/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Palliative care (PC) and psychosocial care (PSC) are essential services, which can positively impact on quality of life in patients with metastatic lung cancer, when advanced disease and poor prognosis preclude the use of curative therapies. The aims of this study were to describe patterns of PC and PSC and identify factors associated with service utilisation and overall patient survival. METHOD A retrospective Australian cohort of South Western Sydney residents with newly diagnosed stage IV non-small cell lung cancer (NSCLC) in 2006-2012 was identified from the Local Health District Clinical Cancer Registry. Supplemental information was sourced from the area PC database and hospital medical records. Cox regression models with robust variance identified factors associated with PC and PSC and examined patient survival. RESULTS A total of 923 patients were identified. Eighty-three per cent of patients were seen by PC, with 67% seen within 8 weeks of diagnosis. PSC utilisation was 82%. Radiotherapy treatment and residential area were associated with both PC and PSC. Increasing age was associated with early PC referral. Median overall survival was 4 months. PC was associated with patient survival; however, the effect varied over time. CONCLUSION The rate of PC and PSC in our metastatic NSCLC population was high when compared with published data. Despite this, there were gaps in PC and PSC provision in this population, notably with patients not receiving active treatment, and those receiving systemic therapy utilising these services less frequently. PSC and PC contact were not convincingly associated with improved patient survival.
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Affiliation(s)
- Kirsten J Duggan
- South West Sydney Local Health District Clinical Cancer Registry, Liverpool, NSW, Australia. .,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.
| | - Jennifer Wiltshire
- Department of Palliative Care, South Western Sydney Local Health District, Liverpool, NSW, Australia.,Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, NSW, Australia
| | - Rebecca Strutt
- Department of Palliative Care, South Western Sydney Local Health District, Liverpool, NSW, Australia.,Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Miriam M Boxer
- Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Angela Berthelsen
- South West Sydney Local Health District Clinical Cancer Registry, Liverpool, NSW, Australia.,Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Joseph Descallar
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Shalini K Vinod
- Cancer Therapy Centre, South Western Sydney Local Health District, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
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Qureshi D, Tanuseputro P, Perez R, Seow H. Place of Care Trajectories in the Last Two Weeks of Life: A Population-Based Cohort Study of Ontario Decedents. J Palliat Med 2018; 21:1588-1595. [PMID: 30010466 PMCID: PMC6211822 DOI: 10.1089/jpm.2018.0049] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND/OBJECTIVES Place of death is a commonly reported indicator of palliative care quality, but does not provide details of service utilization near end of life. This study aims to explore place of care trajectories in the last two weeks of life in a general population and by disease cohorts. DESIGN/SETTING A retrospective population-based cohort study using linked administrative-health data to examine Ontario decedents between April 1, 2010 and December 31, 2012. MEASUREMENTS Place of care trajectories in the last two weeks of life. RESULTS We identified 235,159 decedents. Of which, 215,533 represented the major cohorts of our analysis-cancer (32%), frailty (29%), and organ failure (31%). Sixty-one percent of all decedents died in hospital-based settings. Place of care utilization trends show us a marked increase in use of palliative-acute hospital care (13%-26%) and acute hospital care (12%-25%) and a small decrease in community care use (15%-12%) in the last two weeks of life. Those with cancer were the largest users of palliative-acute hospital care, while those with organ failure were the largest users of acute-hospital care. CONCLUSIONS Place of care trajectories show a marked rise in care in hospital-based settings from 29% to 61% in the last two weeks of life. Nearly half of all hospital deaths had palliative care as the main service provided. Place of care trajectories differ greatly by disease cohort. Exploring place of care trajectories in the last two weeks of life can illuminate end-of-life utilization patterns not evident when reporting solely place of death.
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Affiliation(s)
- Danial Qureshi
- 1 Department of Health Research Methodology, Evidence and Impact, McMaster University , Hamilton, Ontario, Canada
| | - Peter Tanuseputro
- 2 Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa , Ottawa, Ontario, Canada
| | | | - Hsien Seow
- 4 Department of Oncology, McMaster University , Hamilton, Ontario, Canada
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Chambers S, Healy H, Hoy WE, Kark A, Ratanjee S, Mitchell G, Douglas C, Yates P, Bonner A. Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5. BMC Palliat Care 2018; 17:57. [PMID: 29622009 PMCID: PMC5887240 DOI: 10.1186/s12904-018-0310-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/21/2018] [Indexed: 12/22/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries’ populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent. Methods The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable. Results Participants (n = 19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable. Conclusions Few patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways.
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Affiliation(s)
- Shirley Chambers
- Faculty of Health, Queensland University of Technology, Brisbane, Australia. .,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.
| | - Helen Healy
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Wendy E Hoy
- National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Adrian Kark
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Sharad Ratanjee
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Geoffrey Mitchell
- National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Carol Douglas
- Palliative Care Service, Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia
| | - Patsy Yates
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Centre for Palliative Care Research and Education, Queensland Health, Brisbane, Australia
| | - Ann Bonner
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia
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Fletcher S, Sinclair C, Rhee J, Goh D, Auret K. Rural health professionals' experiences in implementing advance care planning: a focus group study. Aust J Prim Health 2018; 22:423-427. [PMID: 26330201 DOI: 10.1071/py15004] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 07/28/2015] [Indexed: 11/23/2022]
Abstract
Advance care planning (ACP) is described as an ongoing discussion between a patient, their family and healthcare professionals (HCPs) to understand a patient's wishes for future health care. Legislation supporting ACP in Western Australia is relatively new and HCPs are still learning about the process and implementation. This study aimed to provide a rich description of rural health professionals' perceptions and experiences with ACP within the context of their professional role and to identify systemic issues and training needs. Ten focus groups were conducted throughout 2014 with a total of 55 rural participants including general practitioners (n=15), general practice registrars (n=6), practice nurses (n=18), community nurses (n=4) and hospital nurses (n=12) in the south-western regions of Western Australia. Thematic analysis has identified the following themes regarding ACP: benefits to patients and families; professional roles in ACP; barriers and enablers; and systems for communicating ACP. HCPs have self-determined their roles in the ACP process, which currently leaves some components of the process unaccounted for, suggesting that collaboration between HCPs working together in a rural health setting and a standardised system for distributing these documents may assist with the implementation of ACP.
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Affiliation(s)
- Sophie Fletcher
- The Rural Clinical School of Western Australia, UWA Albany Centre, 31 Stirling Terrace, Albany, WA 6330, Australia
| | - Craig Sinclair
- The Rural Clinical School of Western Australia, UWA Albany Centre, 31 Stirling Terrace, Albany, WA 6330, Australia
| | - Joel Rhee
- UNSW Medicine, UNSW Australia, Sydney, NSW 2052, Australia
| | - Desiree Goh
- The Rural Clinical School of Western Australia, M701, Hackett Avenue, Crawley, WA 6009, Australia
| | - Kirsten Auret
- The Rural Clinical School of Western Australia, UWA Albany Centre, 31 Stirling Terrace, Albany, WA 6330, Australia
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Mitchell GK, Senior HE, Rhee JJ, Ware RS, Young S, Teo PC, Murray S, Boyd K, Clayton JM. Using intuition or a formal palliative care needs assessment screening process in general practice to predict death within 12 months: A randomised controlled trial. Palliat Med 2018; 32:384-394. [PMID: 28452570 DOI: 10.1177/0269216317698621] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Population ageing will lead to more deaths with an uncertain trajectory. Identifying patients at risk of dying could facilitate more effective care planning. AIM To determine whether screening for likely death within 12 months is more effective using screening tools or intuition. DESIGN Randomised controlled trial of screening tools (Surprise Question plus the Supportive and Palliative Care Indicators Tool for Surprise Question positive patients) to predict those at risk of death at 12 months compared with unguided intuition (clinical trials registry: ACTRN12613000266763). SETTING/PARTICIPANTS Australian general practice. A total of 30 general practitioners (screening tool = 12, intuition = 18) screened all patients ( n = 4365) aged ≥70 years seen at least once in the last 2 years. RESULTS There were 142 deaths (screening tool = 3.1%, intuition = 3.3%; p = 0.79). General practitioners identified more at risk of dying using Surprise Question (11.8%) than intuition (5.4%; p = 0.01), but no difference with Surprise Question positive then Supportive and Palliative Care Indicators Tool (5.1%; p = 0.87). Surprise Question positive predicted more deaths (53.2%, intuition = 33.7%; p = 0.001), but Surprise Question positive/Supportive and Palliative Care Indicators Tool predictions were similar (5.1%; p = 0.87 vs intuition). There was no difference in proportions correctly predicted to die (Surprise Question = 1.6%, intuition = 1.1%; p = 0.156 and Surprise Question positive/Supportive and Palliative Care Indicators Tool = 1.1%; p = 0.86 vs intuition). Screening tool had higher sensitivity and lower specificity than intuition, but no difference in positive or negative predictive value. CONCLUSION Screening tool was better at predicting actual death than intuition, but with a higher false positive rate. Both were similarly effective at screening the whole cohort for death. Screening for possible death is not the best option for initiating end-of-life planning: recognising increased burden of illness might be a better trigger.
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Affiliation(s)
- Geoffrey K Mitchell
- 1 Faculty of Medicine of Medicine, University of Queensland, Herston, QLD, Australia
| | - Hugh E Senior
- 1 Faculty of Medicine of Medicine, University of Queensland, Herston, QLD, Australia.,2 College of Health, Massey University, Auckland, New Zealand
| | - Joel J Rhee
- 3 HammondCare Centre for Positive Ageing and Care, Sydney, NSW, Australia.,4 School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Robert S Ware
- 5 Menzies Health Institute Queensland, Griffith University, Nathan, QLD, Australia
| | - Sharleen Young
- 1 Faculty of Medicine of Medicine, University of Queensland, Herston, QLD, Australia.,6 West Moreton Hospital and Health Service, Ipswich, QLD, Australia
| | - Patrick Ck Teo
- 4 School of Public Health and Community Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Scott Murray
- 7 Primary Palliative Care Research Group, The Usher Institute for Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Kirsty Boyd
- 7 Primary Palliative Care Research Group, The Usher Institute for Population Health Sciences and Informatics, Edinburgh Medical School, The University of Edinburgh, Edinburgh, UK
| | - Josephine M Clayton
- 8 HammondCare Palliative and Supportive Care Service, Greenwich Hospital, Greenwich, NSW, Australia.,9 School of Medicine, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
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Spilsbury K, Rosenwax L. Community-based specialist palliative care is associated with reduced hospital costs for people with non-cancer conditions during the last year of life. BMC Palliat Care 2017; 16:68. [PMID: 29216873 PMCID: PMC5721619 DOI: 10.1186/s12904-017-0256-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 11/30/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Community-based palliative care is associated with reduced hospital costs for people dying from cancer. It is unknown if reduced hospital costs are universal across multiple life-limiting conditions amenable to palliative care. The aim of this study was to determine if community-based palliative care provided to people dying from non-cancer conditions was associated with reduced hospital costs in the last year of life and how this compared with people dying from cancer. METHOD A retrospective population-based cohort study of all decedents in Western Australia who died January 2009 to December 2010 from a life-limiting condition considered amenable to palliative care. Hospital costs were assigned to each day of the last year of life for each decedent with a zero cost applied to days not in hospital. Day-specific hospital costs averaged over all decedents (cohort averaged) and decedents in hospital only (inpatient averaged) were estimated. Two-part models and generalised linear models were used. RESULTS The cohort comprised 12,764 decedents who, combined, spent 451,236 (9.7%) days of the last year of life in hospital. Overall, periods of time receiving community-based specialist palliative care were associated with a 27% decrease from A$112 (A$110-A$114) per decedent per day to $A82 (A$78-A$85) per decedent per day of CA hospital costs. Community-based specialist palliative care was also associated a reduction of inpatient averaged hospital costs of 9% (7%-10%) to A$1030 per hospitalised decedent per day. Hospital cost reductions were observed for decedents with organ failures, chronic obstructive pulmonary disease, Alzheimer's disease, Parkinson's disease and cancer but not for motor neurone disease. Cost reductions associated with community-based specialist palliative care were evident 4 months before death for decedents with cancer and by one to 2 months before death for decedents dying from other conditions. CONCLUSION Community-based specialist palliative care was associated with hospital cost reductions across multiple life-limiting conditions.
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Affiliation(s)
- Katrina Spilsbury
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Lorna Rosenwax
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, 6845 Australia
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Bereavement support for family caregivers: The gap between guidelines and practice in palliative care. PLoS One 2017; 12:e0184750. [PMID: 28977013 PMCID: PMC5627900 DOI: 10.1371/journal.pone.0184750] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 08/30/2017] [Indexed: 11/28/2022] Open
Abstract
Background Standards for bereavement care propose that support should be matched to risk and need. However, studies in many countries demonstrate that palliative care services continue to adopt a generic approach in offering support to bereaved families. Objective To identify patterns of bereavement support in palliative care services based upon the experience of bereaved people from a population based survey and in relation to clinical practice guidelines. Design An anonymous postal survey collected information from clients of six funeral providers in four Australian states (2014–15), 6 to 24 months after the death of their family member or friend, with 1,139 responding. Responses from 506 bereaved relatives of people who had terminal illnesses were analysed. Of these, 298 had used palliative care services and 208 had not. Results More people with cancer (64%) had received palliative care in comparison to other illnesses such as heart disease, dementia and organ failure (4–10%). The support for family caregivers before and after their relative’s death was not considered optimal. Only 39.4% of the bereaved reported being specifically asked about their emotional/ psychological distress pre-bereavement, and just half of the bereaved perceived they had enough support from palliative care services. Half of the bereaved had a follow up contact from the service at 3–6 weeks, and a quarter had a follow-up at 6 months. Their qualitative feedback underlined the limited helpfulness of the blanket approach to bereavement support, which was often described as “not personal” or “generic”, or “just standard practice”. Conclusions Timeliness and consistency of relationship is crucial to building rapport and trust in the service’s ability to help at post-bereavement as well as a focus on the specific rather than the generic needs of the bereaved. In light of these limitations, palliative care services might do better investing their efforts principally in assessing and supporting family caregivers during the pre-bereavement period and developing community capacity and referral pathways for bereavement care. Our findings suggest that bereavement support in Australian palliative care services has only a tenuous relationship with guidelines and assessment tools, a conclusion also drawn in studies from other countries, emphasizing the international implications of our study.
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Spilsbury K, Rosenwax L, Arendts G, Semmens JB. The impact of community-based palliative care on acute hospital use in the last year of life is modified by time to death, age and underlying cause of death. A population-based retrospective cohort study. PLoS One 2017; 12:e0185275. [PMID: 28934324 PMCID: PMC5608395 DOI: 10.1371/journal.pone.0185275] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 09/08/2017] [Indexed: 01/23/2023] Open
Abstract
Objective Community-based palliative care is known to be associated with reduced acute care health service use. Our objective was to investigate how reduced acute care hospital use in the last year of life varied temporally and by patient factors. Methods A retrospective cohort study of the last year of life of 12,763 Western Australians who died from cancer or one of seven non-cancer conditions. Outcome measures were rates of hospital admissions and mean length of hospital stays. Multivariate analyses involved time-to-event and population averaged log-link gamma models. Results There were 28,939 acute care overnight hospital admissions recorded in the last year of life, an average of 2.3 (SD 2.2) per decedent and a mean length of stay of 9.2 (SD 10.3) days. Overall, the rate of hospital admissions was reduced 34% (95%CI 1–66) and the mean length of stay reduced 6% (95%CI 2–10) during periods of time decedents received community-based palliative care compared to periods of time not receiving this care. Decedents aged <70 years receiving community-based palliative care showed a reduced rate of hospital admission around five months before death, whereas for older decedents the reduction in hospital admissions was apparent a year before death. All decedents who were receiving community-based palliative care tended towards shorter hospital stays in the last month of life. Decedents with neoplasms had a mean length of stay three weeks prior to death while not receiving community-based palliative care of 9.6 (95%CI 9.3–9.9) days compared to 8.2 (95% CI 7.9–8.7) days when receiving community-based palliative care. Conclusion Rates of hospital admission during periods of receiving community-based palliative care were reduced with benefits evident five months before death and even earlier for older decedents. The mean length of hospital stay was also reduced while receiving community-based palliative care, mostly in the last month of life.
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Affiliation(s)
- Katrina Spilsbury
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Lorna Rosenwax
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, Perth, Australia
- * E-mail:
| | - Glenn Arendts
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Australia
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Australia
| | - James B. Semmens
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
- Institute for Health Research, The University of Notre Dame, Fremantle, Australia
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Adsersen M, Thygesen LC, Neergaard MA, Bonde Jensen A, Sjøgren P, Damkier A, Groenvold M. Admittance to specialized palliative care (SPC) of patients with an assessed need: a study from the Danish palliative care database (DPD). Acta Oncol 2017; 56:1210-1217. [PMID: 28557612 DOI: 10.1080/0284186x.2017.1332425] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Admittance to specialized palliative care (SPC) has been discussed in the literature, but previous studies examined exclusively those admitted, not those with an assessed need for SPC but not admitted. The aim was to investigate whether admittance to SPC for referred adult patients with cancer was related to sex, age, diagnosis, geographic region or referral unit. MATERIAL AND METHODS A register-based study with data from the Danish Palliative Care Database (DPD). From DPD we identified all adult patients with cancer, who died in 2010-2012 and who were referred to and assessed to have a need for SPC (N = 21,597).The associations were investigated using logistic regression models, which also evaluated whether time from referral to death influenced the associations. RESULTS In the adjusted analysis, we found that admittance was higher for younger patients [e.g., 50-59 versus 80 + years: odds ratio (OR) = 2.03; 1.78-2.33]. There was lower odds of admittance for patients with hematological malignancies and patients from two regions: Capital Region of Denmark and Region of Southern Denmark. Lower admittance among men and patients referred from hospital departments was explained by later referral. CONCLUSIONS In this first nationwide study of admittance to SPC among patients with a SPC need, we found difference in admittance according to age, diagnosis and region. This indicates that prioritization of the limited resources means that certain subgroups with a documented need have reduced likelihood of admission to SPC.
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Affiliation(s)
- Mathilde Adsersen
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, NV , Denmark
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anette Damkier
- The Palliative Care Team Funen, Department of Oncology, Odense University Hospital, Odense, Denmark
| | - Mogens Groenvold
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, NV , Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Frenette M, Saint-Arnaud J, Serri K. Levels of Intervention: How Are They Used in Quebec Hospitals? JOURNAL OF BIOETHICAL INQUIRY 2017; 14:229-239. [PMID: 28324205 DOI: 10.1007/s11673-017-9778-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 10/21/2016] [Indexed: 06/06/2023]
Abstract
In order to promote better practices and communication around end-of-life decision-making, several Canadian hospitals in the province of Quebec have developed a tool called "Levels of Intervention" (LOI). No work to date has been published demonstrating improvement since these forms were implemented. The purpose of the present study was to obtain information about the use of LOI forms across Quebec hospitals and to identify gaps in practice as well as areas for improvement. A retrospective study was undertaken of 299 charts of patients who had died in three Quebec hospitals with a LOI ordered. Results were analysed through a principlism ethical framework. High compliance with the level of intervention ordered at the time of death was recorded, as well as high involvement of patient and/or family, demonstrating the efficiency of LOI in promoting respect for autonomy. Other results show delays in end-of-life care discussions in the course of the hospitalization. Only a small proportion of patients who died had a palliative care consultation, which may reflect equity issues in access to care. This study highlights the importance of the LOI in Quebec and the role it is playing in respect for end-of-life preferences as well as in the involvement of patients and families in the decision-making process. Training specific to end-of-life decision-making conversations would help support the LOI form's use, as would developing provincial or national guidelines on the use of LOI to standardize organizational policies and practice around end-of-life care.
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Affiliation(s)
- Marjolaine Frenette
- Public Health School (local 3035), University of Montreal, C. P. 6128, succ. Centre-ville, Montréal, Québec, H3C 3J7, Canada.
| | - Jocelyne Saint-Arnaud
- Department of Social and Preventive Medicine, Public Health School, University of Montreal and Center for Research in Ethics (CRÉ), President Clinical Ethics Committee, Sacré-Coeur Hospital, Montreal, QC, Canada
| | - Karim Serri
- Sacré-Coeur Hospital and University of Montreal, Montreal, QC, Canada
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Chan LS, Macdonald ME, Carnevale FA, Cohen SR. 'I'm only dealing with the acute issues': How medical ward 'busyness' constrains care of the dying. Health (London) 2017; 22:451-468. [PMID: 28552003 DOI: 10.1177/1363459317708822] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute hospital units are a common location of death. Curative characteristics of the acute medical setting make it difficult to provide adequate palliative care; these characteristics include an orientation to life-prolonging treatment, an emphasis on routine or task-oriented care and a lack of priority on emotional engagement with patients. Indeed, research shows that dying patients in acute medical units often experience unmet needs at the end of life, including uncontrolled symptoms (e.g. pain, breathlessness), inadequate emotional support and poor communication. A focused ethnography was conducted on an acute medical ward in Canada to better understand how this curative/life-prolonging care environment shapes the care of dying patients. Fieldwork was conducted over a period of 10 months and included participant-observation and interviews with patients, family members and staff. On the acute medical ward, a 'logic of care' driven by discourses of limited resources and the demanding medical unit created a context of busyness. Staff experienced an overwhelming workload and felt compelled to create priorities, which reflected taken-for-granted values regarding the importance of curative/life-prolonging care over palliative care. This could be seen through the way staff prioritized life-prolonging practices and rationalized inconsistent and less attentive care for dying patients. These values influenced care of the dying through delaying a palliative approach to care, limiting palliative care to those with cancer and providing highly interventive end-of-life care. Awareness of these taken-for-granted values compels a reflective and critical approach to current practice and how to stimulate change.
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Affiliation(s)
- Lisa S Chan
- McGill University, Canada; Lady Davis Institute for Medical Research, Canada
| | - Mary Ellen Macdonald
- McGill University, Canada; Montreal Children's Hospital and McGill University Health Centre, Canada
| | - Franco A Carnevale
- McGill University, Canada; Montreal Children's Hospital and McGill University Health Centre, Canada
| | - S Robin Cohen
- McGill University, Canada; Lady Davis Institute for Medical Research, Canada
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Adsersen M, Thygesen LC, Jensen AB, Neergaard MA, Sjøgren P, Groenvold M. Is admittance to specialised palliative care among cancer patients related to sex, age and cancer diagnosis? A nation-wide study from the Danish Palliative Care Database (DPD). BMC Palliat Care 2017; 16:21. [PMID: 28330507 PMCID: PMC5363002 DOI: 10.1186/s12904-017-0194-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Specialised palliative care (SPC) takes place in specialised services for patients with complex symptoms and problems. Little is known about what determines the admission of patients to SPC and whether there are differences in relation to institution type. The aims of the study were to investigate whether cancer patients' admittance to SPC in Denmark varied in relation to sex, age and diagnosis, and whether the patterns differed by type of institution (hospital-based palliative care team/unit, hospice, or both). METHODS This was a register-based study of adult patients living in Denmark who died from cancer in 2010-2012. Data sources were the Danish Palliative Care Database, Danish Register of Causes of Death and Danish Cancer Registry. The associations between the explanatory variables (sex, age, diagnosis) and admittance to SPC were investigated using logistic regression. RESULTS In the study population (N = 44,548) the overall admittance proportion to SPC was 37%. Higher odds of overall admittance to SPC were found for women (OR = 1.23; 1.17-1.28), younger patients (<40 compared with 80+ years old) (OR = 6.44; 5.19-7.99) and patients with sarcoma, pancreatic and stomach cancers, whereas the lowest were for patients with haematological malignancies. The higher admission found for women was most pronounced for hospices compared to hospital-based palliative care teams/units, whereas higher admission of younger patients was more pronounced for hospital-based palliative care teams/units. Patients with brain cancer were more often admitted to hospices, whereas patients with prostate cancer were more often admitted to hospital-based palliative care teams/units. CONCLUSION It is unlikely that the variations in relation to sex, age and cancer diagnoses can be fully explained by differences in need. Future research should investigate whether the groups having the lowest admittance to SPC receive sufficient palliative care elsewhere.
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Affiliation(s)
- Mathilde Adsersen
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, 20D, Bispebjerg Bakke 23, Copenhagen, NV, 2400, Denmark.
| | - Lau Caspar Thygesen
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
| | | | | | - Per Sjøgren
- Section of Palliative Medicine, Department of Oncology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mogens Groenvold
- Research Unit, Department of Palliative Medicine, Bispebjerg Hospital, University of Copenhagen, 20D, Bispebjerg Bakke 23, Copenhagen, NV, 2400, Denmark.,Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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44
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Chapman M, Johnston N, Lovell C, Forbat L, Liu WM. Avoiding costly hospitalisation at end of life: findings from a specialist palliative care pilot in residential care for older adults. BMJ Support Palliat Care 2016; 8:102-109. [PMID: 27496356 DOI: 10.1136/bmjspcare-2015-001071] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/12/2016] [Accepted: 07/14/2016] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Specialist palliative care is not a standardised component of service delivery in nursing home care in Australia. Specialist palliative care services can increase rates of advance care planning, decrease hospital admissions and improve symptom management in such facilities. New approaches are required to support nursing home residents in avoiding unnecessary hospitalisation and improving rates of dying in documented preferred place of death. This study examined whether the addition of a proactive model of specialist palliative care reduced resident transfer to the acute care setting, and achieved a reduction in hospital deaths. METHODS A quasi-experimental design was adopted, with participants at 4 residential care facilities. The intervention involved a palliative care nurse practitioner leading 'Palliative Care Needs Rounds' to support clinical decision-making, education and training. Participants were matched with historical decedents using propensity scores based on age, sex, primary diagnosis, comorbidities and the Aged Care Funding Instrument rating. Outcome measures included participants' hospitalisation in the past 3 months of life and the location of death. RESULTS The data demonstrate that the intervention is associated with a substantial reduction in the length of hospital stays and a lower incidence of death in the acute care setting. While rates of hospitalisation were unchanged on average, length of admission was reduced by an average of 3.22 days (p<0.01 and 95% CI -5.05 to -1.41), a 67% decrease in admitted days. CONCLUSIONS The findings have significant implications for promoting quality outcomes through models of palliative care service delivery in residential facilities.
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Affiliation(s)
- Michael Chapman
- Department of Palliative Care, Canberra Regional Cancer Centre, Canberra Hospital, Canberra, Australian Capital Territory, Australia.,Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Nikki Johnston
- Clare Holland House, Calvary Health Care ACT, Canberra, Australian Capital Territory, Australia
| | - Clare Lovell
- Clare Holland House, Calvary Health Care ACT, Canberra, Australian Capital Territory, Australia
| | - Liz Forbat
- Director for the Calvary Centre for Palliative Care Research, Calvary Health Care Bruce and the Australian Catholic University, Canberra, Australian Capital Territory, Australia
| | - Wai-Man Liu
- Research School of Finance, Actuarial Studies & Statistics, Australian National University, Canberra, Australian Capital Territory, Australia
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45
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Smallwood N, Le B, Currow D, Irving L, Philip J. Management of refractory breathlessness with morphine in patients with chronic obstructive pulmonary disease. Intern Med J 2016; 45:898-904. [PMID: 26332621 DOI: 10.1111/imj.12857] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 06/15/2015] [Indexed: 11/30/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive, incurable illness, which leads to significant morbidity over long periods of time and mortality. Treatment aims to reduce symptoms, improve exercise capacity and quality of life, reduce exacerbations, slow disease progression and reduce mortality. However, breathlessness is common in patients with advanced COPD and remains undertreated. As all reversible causes of breathlessness are being optimally managed, consideration should be given to specific non-pharmacological and pharmacological treatment strategies for breathlessness. Low dose morphine has been shown to reduce safely and effectively breathlessness in patients with severe COPD and refractory dyspnoea. However, despite numerous guidelines recommending opioids in this clinical setting, many barriers limit their uptake by clinicians. Integration of palliative care earlier in the disease course can help to improve symptom control for people with severe COPD and refractory breathlessness. A multidisciplinary approach involving both respiratory and palliative care teams offers a new model of care for these patients.
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Affiliation(s)
- N Smallwood
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - B Le
- Department of Palliative Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - D Currow
- Palliative and Supportive Services, Division of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - L Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - J Philip
- Centre for Palliative Care, St Vincent's Hospital, Melbourne, Victoria, Australia
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46
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Rosenwax L, Spilsbury K, McNamara BA, Semmens JB. A retrospective population based cohort study of access to specialist palliative care in the last year of life: who is still missing out a decade on? BMC Palliat Care 2016; 15:46. [PMID: 27165411 PMCID: PMC4862038 DOI: 10.1186/s12904-016-0119-2] [Citation(s) in RCA: 78] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/27/2016] [Indexed: 12/31/2022] Open
Abstract
Background Historically, specialist palliative care has been accessed by a greater proportion of people dying with cancer compared to people with other life-limiting conditions. More recently, a variety of measures to improve access to palliative care for people dying from non-cancer conditions have been implemented. There are few rigorous population-based studies that document changes in palliative care service delivery relative to the number of patients who could benefit from such services. Method A retrospective cohort study of the last year of life of persons with an underlying cause of death in 2009–10 from cancer, heart failure, renal failure, liver failure, chronic obstructive pulmonary disease, Alzheimer’s disease, motor neurone disease, Parkinson’s disease, Huntington’s disease and/or HIV/AIDS. The proportion of decedents receiving specialist palliative care was compared to a 2000–02 cohort. Logistic regression models were used identify social and demographic factors associated with accessing specialist palliative care. Results There were 12,817 deaths included into the cohort; 7166 (56 %) from cancer, 527 (4 %) from both cancer and non-cancer conditions and 5124 (40 %) from non-cancer conditions. Overall, 46.3 % of decedents received community and/or hospital based specialist palliative care; a 3.5 % (95 % CI 2.3–4.7) increase on specialist palliative care access reported ten years earlier. The majority (69 %; n = 4928) of decedents with cancer accessed palliative care during the last year of life. Only 14 % (n = 729) of decedents with non-cancer conditions accessed specialist palliative care, however, this represented a 6.1 % (95 % CI 4.9–7.3) increase on the specialist palliative care access reported for the same decedent group ten years earlier. Compared to decedents with heart failure, increased odds of palliative care access was observed for decedents with cancer (OR 10.5; 95 % CI 9.1–12.2), renal failure (OR 1.5; 95 % CI 1.3–1.9), liver failure (OR 2.3; 95 % CI 1.7–3.3) or motor neurone disease (OR 4.5; 95 % CI 3.1–6.6). Living in major cities, being female, having a partner and living in a private residence was associated with increased odds of access to specialist palliative care. Conclusion There is small but significant increase in access to specialist palliative care services in Western Australia, specifically in patients dying with non-cancer conditions. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0119-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lorna Rosenwax
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, 6845, Australia.
| | - Katrina Spilsbury
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Beverley A McNamara
- School of Occupational Therapy and Social Work, Faculty of Health Sciences, Curtin University, GPO Box U1987, Perth, 6845, Australia
| | - James B Semmens
- Centre for Population Health Research, Faculty of Health Sciences, Curtin University, Perth, Australia
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47
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Health service use and costs in the last 6 months of life in elderly decedents with a history of cancer: a comprehensive analysis from a health payer perspective. Br J Cancer 2016; 114:1293-302. [PMID: 27115468 PMCID: PMC4891509 DOI: 10.1038/bjc.2016.75] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 11/27/2015] [Accepted: 12/04/2015] [Indexed: 01/02/2023] Open
Abstract
Background: There is growing interest in end-of-life care in cancer patients. We aim to characterise health service use and costs in decedents with cancer history and examine factors associated with resource use and costs at life's end. Methods: We used routinely collected claims data to quantify health service use and associated costs in two cohorts of elderly Australians diagnosed with cancer: one cohort died from cancer (n=4271) and the other from non-cancer causes (n=3072). We used negative binomial regression to examine the factors associated with these outcomes. Results: Those who died from cancer had significantly higher rates of hospitalisations and medicine use but lower rates of emergency department use than those who died from non-cancer causes. Overall health care costs were significantly higher in those who died from cancer than those dying from other causes; and 40% of costs were expended in the last month of life. Conclusions: We analysed health services use and costs from a payer perspective, and highlight important differences in patterns of care by cause of death in patients with a cancer history. In particular, there are growing numbers of highly complex patients approaching the end of life and the heterogeneity of these populations may present challenges for effective health service delivery.
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48
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Szekendi MK, Vaughn J, Lal A, Ouchi K, Williams MV. The Prevalence of Inpatients at 33 U.S. Hospitals Appropriate for and Receiving Referral to Palliative Care. J Palliat Med 2016; 19:360-72. [PMID: 26788621 DOI: 10.1089/jpm.2015.0236] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The extent of unmet need for palliative care in U.S. hospitals remains largely unknown. We conducted a multisite cross-sectional, retrospective point prevalence analysis to determine the size and characteristics of the population of inpatients at 33 U.S. hospitals who were appropriate for palliative care referral, as well as the percentage of these patients who were referred for and/or received palliative care services. We also conducted a qualitative assessment of barriers and facilitators to referral, focusing on organizational characteristics that might influence palliative care referral practices. METHODS Patients appropriate for palliative care referral were defined as adult (≥18 years) patients with any diagnosis of a poor-prognosis cancer, New York Heart Association class IV congestive heart failure, or oxygen-dependent chronic obstructive pulmonary disease who had inpatient status in 1 of 33 hospitals on May 13, 2014. Qualitative assessment involved interviews of palliative care team members and nonpalliative care frontline providers. RESULTS Nearly 19% of inpatients on the point prevalence day were deemed appropriate for palliative care referral. Of these, approximately 39% received a palliative care referral or services. Delivery of palliative care services to these patients varied widely among participating hospitals, ranging from approximately 12% to more than 90%. Factors influencing differences in referral practices included nonstandardized perceptions of referral criteria and variation in palliative care service structures. CONCLUSION This study provides useful information to guide providers, administrators, researchers, and policy experts in planning for optimal provision of palliative care services to those in need.
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Affiliation(s)
- Marilyn K Szekendi
- 1 Member Relations and Insights, University HealthSystem Consortium (UHC), Chicago, Illinois
| | - Jocelyn Vaughn
- 1 Member Relations and Insights, University HealthSystem Consortium (UHC), Chicago, Illinois
| | - Ashima Lal
- 2 Department of Palliative Care, Roswell Park Cancer Institute , Buffalo, New York
| | - Kei Ouchi
- 3 Department of Emergency Medicine, Brigham & Women's Hospital , Boston, Massachusetts
| | - Mark V Williams
- 4 Center for Health Services Research, University of Kentucky , Lexington, Kentucky
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49
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Goldsbury DE, O'Connell DL, Girgis A, Wilkinson A, Phillips JL, Davidson PM, Ingham JM. Acute hospital-based services used by adults during the last year of life in New South Wales, Australia: a population-based retrospective cohort study. BMC Health Serv Res 2015; 15:537. [PMID: 26637373 PMCID: PMC4669596 DOI: 10.1186/s12913-015-1202-8] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 11/30/2015] [Indexed: 12/27/2022] Open
Abstract
Background There is limited information about health care utilisation at the end of life for people in Australia. We describe acute hospital-based services utilisation during the last year of life for all adults (aged 18+ years) who died in a 12-month period in Australia’s most populous state, New South Wales (NSW). Methods Linked administrative health data were analysed for all adults who died in NSW in 2007 (the most recent year for which cause of death information was available for linkage for this study). The data comprised linked death records (2007), hospital admissions and emergency department (ED) presentations (2006–2007) and cancer registrations (1994–2007). Measures of hospital-based service utilisation during the last year of life included: number and length of hospital episodes, ED presentations, admission to an intensive care unit (ICU), palliative-related admissions and place of death. Factors associated with these measures were examined using multivariable logistic regression. Results Of the 45,749 adult decedents, 82 % were admitted to hospital during their last year of life: 24 % had >3 care episodes (median 2); 35 % stayed a total of >30 days in hospital (median 17); 42 % were admitted to 2 or more different hospitals. Twelve percent of decedents spent time in an ICU with median 3 days. In the metropolitan area, 80 % of decedents presented to an ED and 18 % had >3 presentations. Overall 55 % died in a hospital or inpatient hospice. Although we could not quantify the extent and type of palliative care, 24 % had mention of “palliative care” in their records. The very elderly and those dying from diseases of the circulatory system or living in the least disadvantaged areas generally had lower hospital service use. Conclusions These population-wide health data collections give a highly informative description of NSWhospital-based end-of-life service utilisation. Use of hospital-based services during the last year of life was common, with substantial variation across sociodemographic groups, especially defined by age, cause of death and socioeconomic classification of the decedents’ place of residence. Further research is now needed to identify the contributors to these findings. Gaps in data collection were identified - particularly for palliative care and patient-reported outcomes. Addressing these gaps should facilitate improved monitoring and assessment of service use and care.
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Affiliation(s)
- David E Goldsbury
- Cancer Research Division, Cancer Council New South Wales, Sydney, Australia.
| | - Dianne L O'Connell
- Cancer Research Division, Cancer Council New South Wales, Sydney, Australia. .,Sydney School of Public Health, University of Sydney, Sydney, Australia. .,School of Medicine and Public Health, University of Newcastle, Newcastle, Australia.
| | - Afaf Girgis
- Centre for Oncology Education and Research Translation (CONCERT), Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, University of New South Wales, Sydney, Australia.
| | - Anne Wilkinson
- School of Nursing and Midwifery, Faculty of Health, Engineering and Science, Edith Cowan University, Perth, Western Australia, Australia.
| | - Jane L Phillips
- Faculty of Health, University of Technology Sydney, Sydney, Australia.
| | | | - Jane M Ingham
- Sacred Heart Health Service, St Vincent's Health Network, Sydney, Australia. .,UNSW Australia, Faculty of Medicine, St Vincent's Hospital Clinical School, Sydney, Australia.
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Philip J, Hudson P, Bostanci A, Street A, Horey DE, Aranda S, Zordan R, Rumbold BD, Moore G, Sundararajan V. Metastatic non-small cell lung cancer: a benchmark for quality end-of-life cancer care? Med J Aust 2015; 202:139-43. [PMID: 25669476 DOI: 10.5694/mja14.00579] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 09/18/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To investigate the quality of end-of-life care for patients with metastatic non-small cell lung cancer (NSCLC). DESIGN AND PARTICIPANTS Retrospective cohort study of patients from first hospitalisation for metastatic disease until death, using hospital, emergency department and death registration data from Victoria, Australia, between 1 July 2003 and 30 June 2010. MAIN OUTCOME MEASURES Emergency department and hospital use; aggressiveness of care including intensive care and chemotherapy in last 30 days; palliative and supportive care provision; and place of death. RESULTS Metastatic NSCLC patients underwent limited aggressive treatment such as intensive care (5%) and chemotherapy (< 1%) at the end of life; however, high numbers died in acute hospitals (42%) and 61% had a length of stay of greater than 14 days in the last month of life. Although 62% were referred to palliative care services, this occurred late in the illness. In a logistic regression model adjusted for year of metastasis, age, sex, metastatic site and survival, the odds ratio (OR) of dying in an acute hospital bed compared with death at home or in a hospice unit decreased with receipt of palliative care (OR, 0.25; 95% CI, 0.21-0.30) and multimodality supportive care (OR, 0.65; 95% CI, 0.56-0.75). CONCLUSION Because early palliative care for patients with metastatic NSCLC is recommended, we propose that this group be considered a benchmark of quality end-of-life care. Future work is required to determine appropriate quality-of-care targets in this and other cancer patient cohorts, with particular focus on the timeliness of palliative care engagement.
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Affiliation(s)
| | - Peter Hudson
- St Vincent's Hospital, Melbourne, VIC, Australia
| | | | | | | | | | | | | | - Gaye Moore
- St Vincent's Hospital, Melbourne, VIC, Australia
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