The need for palliative care for patients with non-cancer diseases: a review of the evidence

Early integration of palliative care versus standard cardiac care for patients with heart failure (EPCHF): a multicentre, parallel, two-arm, open-label, randomised controlled trial

BACKGROUND

Heart failure is a substantial global health concern that severely affects patients' quality of life. We aimed to compare the effects of early integration of palliative care (EIPC) and standard cardiac care on health status and mood of patients with non-terminal heart failure.

METHODS

EPCHF was a multicentre, parallel, two-arm, open-label, randomised controlled trial carried out at University Hospital Bonn and University Hospital Düsseldorf in Germany. Eligible patients (aged 18 years or older) had heart failure, with New York Heart Association class II or more and NT-proBNP concentrations greater than or equal to 400 pg/mL. Patients were randomly assigned (1:1) to receive EIPC with standard cardiac care or standard cardiac care alone. Randomisation was computer-generated with allocation concealment, variable block sizes, and stratification by investigational site. The primary endpoints were health status and mood, measured every 3 months over 12 months using the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-PAL) and the Kansas City Cardiomyopathy Questionnaire (KCCQ), analysed by intention to treat. This trial is registered with DRKS.de, DRKS00013922.

FINDINGS

Between May 21, 2019, and Nov 15, 2021, 843 patients were assessed for eligibility, 205 of whom were enrolled (100 assigned to EIPC and 105 assigned to standard cardiac care). 143 (70%) patients were male and 62 (30%) were female. Over 12 months, both groups significantly improved in FACIT-PAL and KCCQ Overall Summary Score (OSS) with no significant differences between the groups (FACIT-PAL adjusted mean difference 0·98 points [95% CI -1·28 to 3·23]; p=0·40; KCCQ-OSS adjusted mean difference -2·06 points [-7·89 to 3·78]; p=0·49). Nine (9%) patients in the EIPC group and seven (7%) patients in the standard cardiac care group died from any cause, with no significant differences in time to death between the two groups (hazard ratio [HR] 1·32 [95% CI 0·49 to 3·54]; p=0·58). 22 (22%) patients in the EIPC group and 21 (21%) patients in the standard cardiac care group were hospitalised at least once due to heart failure, with no significant differences in time to heart-failure-related hospitalisation between the two groups (HR 1·09 [0·61 to 1·98]; p=0·77). 70 (70%) patients in the EIPC group and 62 (59%) in the standard cardiac care group had any adverse events (p=0·10).

INTERPRETATION

In this open-label, randomised clinical trial, standard cardiac care, featuring guideline-directed optimisation of medical therapy and regular 3-monthly follow-ups was found to be as effective as when combined with EIPC in improving health status and mood in patients with non-terminal heart failure. Future clinical practices should consider EIPC based on individual patient needs.

FUNDING

Federal Ministry of Education and Research.

Dignity in Medicine: Definition, Assessment and Therapy

PURPOSE OF REVIEW

Over the last 20 years, dignity and dignity-conserving care have become the center of investigation, in many areas of medicine, including palliative care, oncology, neurology, geriatrics, and psychiatry. We summarized peer-reviewed literature and examined the definition, conceptualization of dignity, potential problems, and suggested interventions.

RECENT FINDINGS

We performed a review utilizing several databases, including the most relevant studies in full journal articles, investigating the problems of dignity in medicine. It emerged that dignity is a multifactorial construct and that dignity-preserving care should be at the center of the health organization. Dignity should be also regularly assessed through the tools currently available in clinical practice. Among dignity intervention, besides dignity models of care, dignity intervention, such as dignity therapy (DT), life review and reminiscence therapy, have a role in maintaining both the extrinsic (preserved when health care professionals treat the patient with respect, meeting physical and emotional needs, honors the patient's wishes, and makes attempts to maintain privacy and confidentiality) and intrinsic dignity (preserved when the patient has appropriate self-esteem, is able to exercise autonomy and has a sense of hope and meaning). Unified trends across diverse medical contexts highlight the need for a holistic, patient-centered approach in healthcare settings. Challenges compromising dignity are pervasive, underscoring the importance of interventions and systematic efforts to address these issues. Future research and interventions should prioritize the multifaceted nature of dignity, striving to create healthcare environments that foster compassion, respect, and dignity across all medical settings.

The first decade of the Danish Palliative Care Database: improvements and ongoing challenges in the quality and use of specialised palliative care

BACKGROUND

Danish Palliative Care Database comprises five quality indicators: (1) Contact with specialised palliative care (SPC) among referred patients, (2) Waiting time of less than 10 days, (3) Proportion of patients who died from (A) cancer or (B) non-cancer diseases, and had contact with SPC, (4) Proportion of patients completing the patient-reported outcome measure at baseline (EORTC QLQ-C15-PAL), and (5) Proportion of patients discussed at a multidisciplinary conference.

PURPOSE

To investigate changes in the quality indicators from 2010 until 2020 in cancer and non-cancer patients. Patients/material: Patients aged 18+ years who died from 2010 until 2020.

METHOD

Register-based study with the Danish Palliative Care Database as the main data source. Indicator changes were reported as percentage fulfilment.

RESULTS

From 2010 until 2020, the proportion of patients with non-cancer diseases in SPC increased slightly (2.5-7.2%). In 2019, fulfilment of the five indicators for cancer and non-cancer were: (1) 81% vs. 73%; (2) 73% vs. 68%; (3A) 50%; (3B) 2%; (4) 73% vs. 66%; (5) 73% vs. 65%. Whereas all other indicators improved, the proportion of patients waiting less than 10 days from referral to contact decreased. Differences between type of unit were found, mainly lower for hospice.

INTERPRETATION

Most patients in SPC had cancer. All indicators except waiting time improved during the 10-year period. The establishment of the Danish Palliative Care Database may have contributed to the positive development; however, SPC in Denmark needs to be improved, especially regarding a reduction in waiting time and enhanced contact for non-cancer patients.

Dying in hospital is worse for non-cancer patients. A regional cross-sectional survey of bereaved relatives' views

OBJECTIVE

The aim of the study is to examine differences in hospital care between patients with cancer and non-cancer conditions in their dying phase, perceived by bereaved relatives.

METHODS

A retrospective cross-sectional post-bereavement survey, with the total population of 351 deceased, 91 cancer patients and 46 non-cancer patients, who spent their last 2 days of life in hospital. A validated German version of the VOICES-questionnaire ('VOICES-LYOL-Cologne') was used.

RESULTS

There were substantial differences between the two groups in the rating of sufficient practical care such as pain relief or support to eat or drink (p = 0.005) and sufficient emotional care needs (p = 0.006) and in the quality of communication with healthcare professionals (p < 0.001), with non-cancer patients scoring lowest in all these dimensions.

CONCLUSION

In all surveyed dimensions on the quality of care in the dying phase, non-cancer patients' relatives rated the provided care worse than those of cancer patients. To compensate any differences in care in the dying phase between diagnosis groups, hospital care should be provided as needs-oriented and non-indication-specific.

Outpatient Palliative Care for Noncancer Illnesses: One Program's Experience with Implementation, Impact, and Lessons Learned

Background: Despite substantial palliative care (PC) needs in people with serious illnesses other than cancer, outpatient PC is less available to these populations. Objectives: Describe the experience, impact, and lessons learned from implementing an outpatient PC service (OPCS) for people with noncancer illnesses. Design: Observational cohort study. Setting/Subjects: Patients seen by an OPCS at a United States academic medical center October 2, 2017-March 31, 2021. Measurements: Patient demographics and clinical characteristics, care processes, rates of advance care planning (ACP), and health care utilization. Results: During the study period, 736 patients were seen. Mean age was 66.7 years, 47.7% were women, and 61.4% were White. Nearly half (44.9%) had a neurologic diagnosis, 19.2% pulmonary, and 11.0% cardiovascular. Patients were most often referred for symptoms other than pain (62.2%), ACP (60.2%), and support for patient/family (48.2%). Three-quarters (74.1%) of visits occurred by video. A PC physician, nurse, social worker, and spiritual care provider addressed nonpain symptoms (for 79.2%), family caregiver needs (70.0%), psychosocial distress (69.9%), ACP (68.8%), care coordination (66.8%), pain (38.2%), and spiritual concerns (27.8%). Rates of advance directives increased from 24.6% to 31.8% (p < 0.001) and Physician Orders for Life-Sustaining Treatment forms from 15.6% to 27.3% (p < 0.001). Of 214 patients who died, 61.7% used hospice, with median hospice length-of-stay >30 days. Comparing the six months before initiating PC to the six months after, hospitalizations decreased by 31.3% (p = 0.001) and hospital days decreased by 29.8% (p = 0.02). Conclusions: Outpatient PC for people with noncancer illnesses is feasible, addresses needs in multiple domains, and is associated with increased rates of ACP and decreased health care utilization. Controlled studies are warranted.

Trend analysis of palliative care consultation service for terminally ill non-cancer patients in Taiwan: a 9-year observational study

Backgrounds

Early integration of palliative care for terminally ill non-cancer patients improves quality of life. However, there are scanty data on Palliative Care Consultation Service (PCCS) among non-cancer patients.

Methods

In this 9-year observational study Data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill non-cancer patients with 9 categories of diagnoses who received PCCS during 2011 to 2019 were enrolled. Trend analysis was performed to evaluate differences in categories of diagnosis throughout study period, duration of PCCS, patient outcomes, DNR declaration, awareness of disease by patients and families before and after PCCS.

Results

In total, 536 non-cancer patients received PCCS from 2011 to 2019 with an average age of 70.7 years. The average duration of PCCS was 18.4 days. The distributions of age, gender, patient outcomes, family’s awareness of disease before PCCS, and patient’s awareness of disease after PCCS were significantly different among the diagnoses. Organic brain disease and Chronic kidney disease (CKD) were the most prevalent diagnoses in patients receiving PCCS in 2019. For DNR declaration, the percentage of patients signing DNR before PCCS remained high throughout the study period (92.8% in 2019). Patient outcomes varied according to the disease diagnoses.

Conclusion

This 9-year observational study showed that the trend of PCCS among non-cancer patients had changed over the duration of the study. An increasing number of terminally ill non-cancer patients received PCCS during late life, thereby increasing the awareness of disease for both patients and families, which would tend to better prepare terminally ill patients for end-of-life as they may consider DNR consent. Early integration of PCCS into ordinary care for terminally non-cancer patients is essential for better quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00879-z.

End-stage organ disease-Healthcare utilisation: Impact of palliative medicine

OBJECTIVES

Although patients living with end-stage organ disease (ESOD) suffer unmet needs from the physical and emotional burdens of living with chronic illness, they are less likely to receive palliative care.The aims of the study were to determine if palliative care referrals reduced healthcare utilisation and if impact on healthcare utilisation was dependent on the timing of the referral.

METHODS

Patients with ESOD who received palliative care support were matched with those who did not using coarsened exact matching and propensity score matching, and compared in this retrospective cohort study. Primary outcomes of interests were reduction in all-cause emergency department (ED) visits and costs, reduction in all-cause tertiary hospital admissions, length of hospital stay and inpatient hospital costs.

RESULTS

Patients with ESOD referred to palliative care experienced a reduction in the frequency of all cause ED visits and inpatient hospital admissions. Significant impact of a palliative care referral was at 3 months, rather than 1 month prior to death with a greater reduction in the frequency of ED visits, inpatient hospital admissions, length of stay and charges (p all <0.05). The most common ESOD referred to palliative care for 1110 matched patients was end-stage renal failure (57.7%), and least commonly for respiratory failure (7.6%).

CONCLUSION

Palliative care can reduce healthcare utilisation, with reduction greatest when the referral is timed earlier in the disease trajectory. Cost savings can be judiciously redirected to the development of palliative care resources for integrated support of patients and caregivers.

Symptom trajectories of non-cancer patients in the last six months of life: Identifying needs in a population-based home care cohort

INTRODUCTION

The end-of-life symptom prevalence of non-cancer patients have been described mostly in hospital and institutional settings. This study aims to describe the average symptom trajectories among non-cancer patients who are community-dwelling and used home care services at the end of life.

MATERIALS AND METHODS

This is a retrospective, population-based cohort study of non-cancer patients who used home care services in the last 6 months of life in Ontario, Canada, between 2007 and 2014. We linked the Resident Assessment Instrument for Home Care (RAI-HC) (standardized home care assessment tool) and the Discharge Abstract Databases (for hospital deaths). Patients were grouped into four non-cancer disease groups: cardiovascular, neurological, respiratory, and renal (not mutually exclusive). Our outcomes were the average prevalence of these outcomes, each week, across the last 6 months of life: uncontrolled moderate-severe pain as per the Pain Scale, presence of shortness of breath, mild-severe cognitive impairment as per the Cognitive Performance Scale, and presence of caregiver distress. We conducted a multivariate logistic regression to identify factors associated with having each outcome respectively, in the last 6 months.

RESULTS

A total of 20,773 non-cancer patient were included in our study, which were analyzed by disease groups: cardiovascular (n = 12,923); neurological (n = 6,935); respiratory (n = 6,357); and renal (n = 3,062). Roughly 80% of patients were > 75 years and half were female. In the last 6 months of life, moderate to severe pain was frequent in the cardiovascular (57.2%), neurological (42.7%), renal (61.0%) and respiratory (58.3%) patients. Patients with renal disease had significantly higher odds for reporting uncontrolled moderate to severe pain (odds ratio [OR] = 1.21; 95% CI: 1.08 to 1.34) than those who did not. Patients with respiratory disease reported significantly higher odds for shortness of breath (5.37; 95% CI, 5.00 to 5.80) versus those who did not. Patients with neurological disease compared to those without were 9.65 times more likely to experience impaired cognitive performance and had 56% higher odds of caregiver distress (OR = 1.56; 95% CI: 1.43 to 1.71).

DISCUSSION

In our cohort of non-cancer patients dying in the community, pain, shortness of breath, impaired cognitive function and caregiver distress are important symptoms to manage near the end of life even in non-institutional settings.

Empowering families facing end-stage nonmalignant chronic diseases with a holistic, transdisciplinary, community-based intervention: 3 months outcome of the Life Rainbow Program

Objectives

Families facing end-stage nonmalignant chronic diseases (NMCDs) are presented with similar symptom burdens and need for psycho-social–spiritual support as their counterparts with advanced cancers. However, NMCD patients tend to face more variable disease trajectories, and thus may require different anticipatory supports, delivered in familiar environments. The Life Rainbow Programme (LRP) provides holistic, transdisciplinary, community-based end-of-life care for patients with NMCDs and their caregivers. This paper reports on the 3-month outcomes using a single-group, pre–post comparison.

Method

Patients with end-stage NMCDs were screened for eligibility by a medical team before being referred to the LRP. Patients were assessed at baseline (T0), 1 month (T1), and 3 months (T2) using the Integrated Palliative Outcome Scale (IPOS). Their hospital use in the previous month was also measured by presentations at accident and emergency services, admissions to intensive care units, and number of hospital bed-days. Caregivers were assessed at T0 and T2 using the Chinese version of the Modified Caregiver Strain Index, and self-reported health, psychological, spiritual, and overall well-being. Over-time changes in outcomes for patients, and caregivers, were tested using paired-sample t-tests, Wilcoxon-signed rank tests, and chi-square tests.

Results

Seventy-four patients and 36 caregivers participated in this research study. Patients reported significant improvements in all IPOS domains at both 1 and 3 months [ranging from Cohen's d = 0.495 (nausea) to 1.793 (depression and information needs fulfilled)]. Average hospital bed-days in the previous month fell from 3.50 to 1.68, comparing baseline and 1 month (p < 0.05). At 3 months, caregiver strain was significantly reduced (r = 0.332), while spiritual well-being was enhanced (r = 0.333).

Significance

After receiving 3 month's LRP services, patients with end-stage NMCDs and their caregivers experienced significant improvements in the quality of life and well-being, and their hospital bed-days were reduced.

Surgical, Interventional, and Medical Palliation of Portal Hypertension

Seriously ill surgical patients require complex and integrated surgical, interventional, and medical management to balance the risks and benefits that complicate decision-making. Palliative care principles can aid surgeons in these cases. To illustrate this, we describe a scenario of a patient with unresectable hepatocellular carcinoma with portal vein tumor thrombus causing portal hypertension. We discuss options for managing the sequelae of portal hypertension, including varices and ascites. We explore the interventional and surgical options for mitigating or palliating the underlying portal hypertension. Advances in interventional radiological techniques can facilitate the creation of transjugular intrahepatic portosystemic shunts (TIPSs), even with extensive portal vein thrombus. If interventional approaches are not possible, surgical shunts can be considered but carry significant risks that must be weighed against the benefits. To communicate effectively, we outline key steps to breaking bad news. To make shared decisions in challenging cases, we describe how to elicit a patient's hopes, expectations, concerns, and preferences; how to synthesize goals of care from these stated values; and how to use those goals to guide decision-making.

Predictors for place of death among children:A systematic review and meta-analyses of recent literature

Through a systematic review and meta-analyses, we aimed to determine predictors for place of death among children. We searched online databases for studies published between 2008 and 2019 comprising original quantitative data on predictors for place of death among children. Data regarding study design, population characteristics and results were extracted from each study. Meta-analyses were conducted using generic inverse variance method with random effects. Fourteen cohort studies met the inclusion criteria, comprising data on 106,788 decedents. Proportions of home death varied between countries and regions from 7% to 45%. Lower age was associated with higher odds of hospital death in eight studies (meta-analysis was not possible). Children categorised as non-white were less likely to die at home compared to white (pooled OR 0.6; 95% CI 0.5-0.7) as were children of low socio-economic position versus high (pooled OR 0.7; 95% CI 0.6-0.9). Compared to patients with cancer, children with non-cancer diagnoses had lower odds of home death (pooled OR 0.5; 95% CI 0.5-0.5).Conclusion: Country and region of residence, older age of the child, high socio-economic position, 'white' ethnicity and cancer diagnoses appear to be independent predictors of home death among children. What is Known: • Home is often considered an indicator of quality in end-of-life care. • Most terminally ill children die in hospitals. What is New: • Through a systematic review and meta-analyses, this study examined predictors for place of death among children. • Country and region of residence, older age of the child, high socio-economic position, white ethnicity and having a cancer diagnosis appear to be independent predictors of home death among terminally ill children.

The value of dementia care towards the end of life-A contingent valuation study

OBJECTIVES

A dementia nurse specialist (DNS) is expected to improve the quality of care and support to people with dementia nearing, and at, the end of life (EoL) by facilitating some key features of care. The aim of this study was to estimate willingness-to-pay (WTP) values from the general public perspective, for the different levels of support that the DNS can provide.

METHODS

Contingent valuation methods were used to elicit the maximum WTP for scenarios describing different types of support provided by the DNS for EoL care in dementia. In a general population online survey, 1002 participants aged 18 years or more sampled from the United Kingdom provided valuations. Five scenarios were valued with mean WTP value calculated for each scenario along with the relationship between mean WTP and participant characteristics.

RESULTS

The mean WTP varied across scenarios with higher values for the scenarios offering more features. Participants with some experience of dementia were willing to pay more compared with those with no experience. WTP values were higher for high-income groups compared with the lowest income level (P < .05). There was no evidence to suggest that respondent characteristics such as age, gender, family size, health utility or education status influenced the WTP values.

CONCLUSION

The general population values the anticipated improvement in dementia care provided by a DNS. This study will help inform judgements on interventions to improve the quality of EoL care.

Access to Palliative Care during a Terminal Hospitalization

Background: Research shows that access to palliative care can help patients avoid dying in hospital. However, access to palliative care services during the terminal hospitalization, specifically, has not been well studied. Objective: To determine whether access to palliative care varied by disease trajectory among terminal hospitalizations. Design, Setting, Subjects: We conducted a population-based retrospective cohort study of decedents who died in hospital in Ontario, Canada between 2012 and 2015 by using linked administrative databases. Measurements: Using hospital and physician billing codes, we classified access to palliative care in three mutually exclusive groups of patients with terminal hospitalization: (1) main diagnosis for admission was palliative care; (2) main diagnosis was not palliative care, but the patient received palliative care specialist consultation; and (3) the patient did not receive any specialist palliative care. We conducted a logistic regression on odds of never receiving palliative care. Results: We identified 140,475 decedents who died in an inpatient hospital unit, which represents 42% of deaths. Among inpatient hospital deaths, 23% (n = 32,168) had palliative care listed as the main diagnosis for admission, 41% (n = 58,210) received specialist palliative care consultation, and 36% (n = 50,097) never had access to specialist palliative care. In our regression, dying of organ failure or frailty compared with cancer increased the odds of never receiving palliative care by 4.07 (95% confidence interval [CI]: 3.95-4.20) and 4.51 (95% CI: 4.35-4.68) times, respectively. Conclusions: A third of hospital deaths had no palliative care involvement. Access to specialist palliative care is particularly lower for noncancer decedents. Inpatient units play an important role in providing end-of-life care.

End-of-life care needs for noncancer patients who want to die at home in South Korea

AIM

The awareness for the need for end-of-life care has increased among noncancer patients. However, studies on the topic have rarely targeted the needs of noncancer patients who want to die at home. This study assessed the end-of-life care needs of noncancer patients who were receiving care and wanted to die at home.

METHODS

A cross-sectional study design was used and involved 200 participants who were diagnosed as noncancer patients and receiving home care nursing. Data were collected on demographics, disease, Palliative Performance Scale (PPS) scores, and end-of-life care needs, in April and May, 2016.

RESULTS

Among the six areas of care, "supporting fundamental needs" of patients required the most care, followed by "coordination among family or relatives." Multivariate analysis revealed that the duration of home care nursing held a significant association with end-of-life care needs.

CONCLUSION

By reflecting on the comprehensive care needs of patients with chronic illnesses and including them in the care process, it will be possible to provide better quality palliative care to patients at home in the end-of-life stages.

Palliative care for people living with heart failure: European Association for Palliative Care Task Force expert position statement

Contrary to common perception, modern palliative care (PC) is applicable to all people with an incurable disease, not only cancer. PC is appropriate at every stage of disease progression, when PC needs emerge. These needs can be of physical, emotional, social, or spiritual nature. This document encourages the use of validated assessment tools to recognize such needs and ascertain efficacy of management. PC interventions should be provided alongside cardiologic management. Treating breathlessness is more effective, when cardiologic management is supported by PC interventions. Treating other symptoms like pain or depression requires predominantly PC interventions. Advance Care Planning aims to ensure that the future treatment and care the person receives is concordant with their personal values and goals, even after losing decision-making capacity. It should include also disease specific aspects, such as modification of implantable device activity at the end of life. The Whole Person Care concept describes the inseparability of the physical, emotional, and spiritual dimensions of the human being. Addressing psychological and spiritual needs, together with medical treatment, maintains personal integrity and promotes emotional healing. Most PC concerns can be addressed by the usual care team, supported by a PC specialist if needed. During dying, the persons’ needs may change dynamically and intensive PC is often required. Following the death of a person, bereavement services benefit loved ones. The authors conclude that the inclusion of PC within the regular clinical framework for people with heart failure results in a substantial improvement in quality of life as well as comfort and dignity whilst dying.

How End-Of-Life Home Care Services Are Used from Admission to Death: A Population-Based Cohort Study

Aim: Our goal was to describe the trajectories of end-of-life nursing and personal support worker (PSW) use from home care admission until death. Methods: We studied a historical prospective cohort of end-of-life home care patients in Ontario, Canada, linking administrative databases. We calculated the odds of using any nursing or PSW hours and the incidence rate ratio of services used for each week approaching death, controlling for confounders. Results: Among all patients (n=11,867), the odds of using any nursing and PSW hours increased by 4 percent and 10 percent, respectively, each week closer to death. Among patients using services, the ratio of nursing and PSW hours increased 20 percent and 11 percent, respectively, in the last 4 weeks of life compared to use at 24 weeks before death. Conclusion: Use of nursing and PSW hours increases slightly each week before death and sharply in the last month of life. Understanding the trajectory of home care services use can help decision makers design better end-of-life care.

Attitudes to specialist palliative care and advance care planning in people with COPD: a multi-national survey of palliative and respiratory medicine specialists

Background

Chronic obstructive pulmonary disease (COPD) guidelines recommend early access to palliative care together with optimal, disease-directed therapy for people with advanced disease, however, this occurs infrequently. This study explored the approaches of respiratory and palliative medicine specialists to palliative care and advance care planning (ACP) in advanced COPD.

Methods

An online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom.

Results

Five hundred seventy-seven (33.1%) responses were received, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Most respiratory doctors (140, 80.9%) were very or quite comfortable providing a palliative approach themselves to people with COPD. 113 (63.8%) respiratory doctors recommended referring people with advanced COPD to specialist palliative care, mainly for access to: psychosocial and spiritual care (105, 59.3%), carer support (104, 58.5%), and end-of-life care (94, 53.1%). 432 (98.2%) participants recommended initiating ACP discussions. Palliative medicine doctors were more likely to recommend discussing: what palliative care is (p < 0.0001), what death and dying might be like (p < 0.0001) and prognosis (p = 0.004). Themes highlighted in open responses included: inadequate, fragmented models of care, with limited collaboration or support from palliative care services.

Conclusions

While both specialties recognised the significant palliative care and ACP needs of people with advanced COPD, in reality few patients access these elements of care. Formal collaboration and bi-directional support between respiratory and palliative medicine, are required to address these unmet needs.

Differences in primary palliative care between people with organ failure and people with cancer: An international mortality follow-back study using quality indicators

BACKGROUND

Measuring the quality of palliative care in a systematic way using quality indicators can illuminate differences between patient groups.

AIM

To investigate differences in the quality of palliative care in primary care between people who died of cancer and people who died of organ failure.

DESIGN

Mortality follow-back survey among general practitioners in Belgium, the Netherlands, and Spain (2013-2014), and Italy (2013-2015). A standardized registration form was used to construct quality indicators regarding regular pain measurement, acceptance of the approaching end of life, communication about disease-related topics with patient and next-of-kin; repeated multidisciplinary consultations; involvement of specialized palliative care; place of death; and bereavement counseling.

SETTING/PARTICIPANTS

Patients (18+) who died non-suddenly of cancer, cardiovascular disease, or respiratory disease ( n = 2360).

RESULTS

In all countries, people who died of cancer scored higher on the quality indicators than people who died of organ failure, particularly with regard to pain measurement (between 17 and 35 percentage-point difference in the different countries), the involvement of specialized palliative care (between 20 and 54 percentage points), and regular multidisciplinary meetings (between 12 and 24 percentage points). The differences between the patient groups varied by country, with Belgium showing most group differences (eight out of nine indicators) and Spain the fewest (two out of nine indicators).

CONCLUSION

People who died of organ failure are at risk of receiving lower quality palliative care than people who died of cancer, but the differences vary per country. Initiatives to improve palliative care should have different priorities depending on the healthcare and cultural context.

End-of-life decision-making across cancer types: results from a nationwide retrospective survey among treating physicians

BACKGROUND

The treatment of advanced cancer often involves potentially life-shortening end-of-life decisions (ELDs). This study aimed to examine the prevalence and characteristics of ELDs in different cancer types.

METHODS

A nationwide death certificate study was conducted based on a large random sample of all deaths in Flanders, Belgium, between 1 January and 30 June 2013. All cancer deaths were selected (n = 2392). Attending physicians were sent a questionnaire about ELDs and the preceding decision-making process.

RESULTS

The response rate was 58.3%. Across cancer types, a non-treatment decision occurred in 7.6-14.0%, intensified pain and symptom alleviation in 37.5-41.7%, euthanasia or physician-assisted suicide in 8.7-12.6%, and life shortening without explicit patient request in 1.0-2.4%. ELD prevalence did not differ significantly by cancer type. Reasons for ELDs were most frequently patient's physical suffering and lack of prospect of improvement. 'Anticipated further suffering' and 'unbearable situation for relatives' were reasons more often reported in haematological cancer than in other cancer types. Patient, family, and caregiver involvement in decision-making did not differ across cancer types.

CONCLUSIONS

Euthanasia or physician-assisted suicide rates were relatively high in all cancer types. Neither the prevalence of ELDs nor characteristics of the decision-making process differed substantially between cancer types. This indicates a uniform approach to end-of-life care, including palliative care, across oncological settings.

Development and validation of a casemix classification to predict costs of specialist palliative care provision across inpatient hospice, hospital and community settings in the UK: a study protocol

INTRODUCTION

Provision of palliative care is inequitable with wide variations across conditions and settings in the UK. Lack of a standard way to classify by case complexity is one of the principle obstacles to addressing this. We aim to develop and validate a casemix classification to support the prediction of costs of specialist palliative care provision.

METHODS AND ANALYSIS

Phase I: A cohort study to determine the variables and potential classes to be included in a casemix classification. Data are collected from clinicians in palliative care services across inpatient hospice, hospital and community settings on: patient demographics, potential complexity/casemix criteria and patient-level resource use. Cost predictors are derived using multivariate regression and then incorporated into a classification using classification and regression trees. Internal validation will be conducted by bootstrapping to quantify any optimism in the predictive performance (calibration and discrimination) of the developed classification. Phase II: A mixed-methods cohort study across settings for external validation of the classification developed in phase I. Patient and family caregiver data will be collected longitudinally on demographics, potential complexity/casemix criteria and patient-level resource use. This will be triangulated with data collected from clinicians on potential complexity/casemix criteria and patient-level resource use, and with qualitative interviews with patients and caregivers about care provision across difference settings. The classification will be refined on the basis of its performance in the validation data set.

ETHICS AND DISSEMINATION

The study has been approved by the National Health Service Health Research Authority Research Ethics Committee. The results are expected to be disseminated in 2018 through papers for publication in major palliative care journals; policy briefs for clinicians, commissioning leads and policy makers; and lay summaries for patients and public.

TRIAL REGISTRATION NUMBER

ISRCTN90752212.

Barriers and facilitators influencing death at home: A meta-ethnography

BACKGROUND

In many countries, achieving a home death represents a successful outcome from both a patient welfare and commissioning viewpoint. Significant variation exists in the proportion of home deaths achieved internationally, with many countries unable to meet the wishes of a large number of patients. This review builds on previous literature investigating factors influencing home death, synthesising qualitative research to supplement evidence that quantitative research in this field may have been unable to reach.

AIM

To identify and understand the barriers and facilitators influencing death at home.

DESIGN

Meta-ethnography.

DATA SOURCES

The review adhered to the PRISMA guidelines. A systematic literature search was conducted using five databases: PubMed, EMBASE, Ovid, CINAHL and PsycINFO. Databases were searched from 2006 to 2016. Empirical, UK-based qualitative studies were included for analysis.

RESULTS

A total of 38 articles were included for analysis. Seven overarching barriers were identified: lack of knowledge, skills and support among informal carers and healthcare professionals; informal carer and family burden; recognising death; inadequacy of processes such as advance care planning and discharge; as well as inherent patient difficulties, either due to the condition or social circumstances. Four overarching facilitators were observed: support for patients and healthcare professionals, skilled staff, coordination and effective communication.

CONCLUSION

Future policies and clinical practice should develop measures to empower informal carers as well as emphasise earlier commencement of advance care planning. Best practice discharge should be recommended in addition to addressing remaining inequity to enable non-cancer patients greater access to palliative care services.

A person-centred approach in medicine to reduce the psychosocial and existential burden of chronic and life-threatening medical illness

The psychiatric, psychosocial, and existential/spiritual pain determined by chronic medical disorders, especially if in advanced stages, have been repeatedly underlined. The right to approach patients as persons, rather than symptoms of organs to be repaired, has also been reported, from Paul Tournier to Karl Jaspers, in opposition and contrast with the technically-enhanced evidence-based domain of sciences that have reduced the patients to 'objects' and weakened the physician's identity deprived of its ethical value of meeting, listening, and treating subjects. The paper will discuss the main psychosocial and existential burden related to chronic and advanced medical illnesses, and the diagnostic and therapeutic implications for a dignity preserving care within a person-centred approach in medicine, examined in terms of care of the person (of the person's whole health), for the person (for the fulfilment of the person's health aspirations), by the person (with physicians extending themselves as total human beings), and with the person (working respectfully with the medically ill person).

Discrepancies in the Viewpoints of Different German Health Care Providers on Palliative Care

In many countries with highly developed health care systems, significant improvements in end-of-life care are strongly recommended. Up to the present, the assessment of perceived deficits predominantly reflects the point of view of experts in the palliative and hospice movement, with very little being known about the perspective of other professionals. The aim of this study was to assess the points of view of a wide range of different health care providers who treated or interacted with palliative care patients. The authors subsequently performed 597 semistructured telephone interviews with a wide range of German health care professionals. Overall, the assessment of the current situation was better than expected, although statistically significant differences existed among the groups surveyed. However, there is an unquestionable need for improvement, although opinions regarding the extent of these deficits depend significantly on the individual respondents’ roles and professional orientation.

Dignity and Distress towards the End of Life across Four Non-Cancer Populations

OBJECTIVE

The purpose of this study was to identify four non-cancer populations that might benefit from a palliative approach; and describe and compare the prevalence and patterns of dignity related distress across these diverse clinical populations.

DESIGN

A prospective, multi-site approach was used.

SETTING

Outpatient clinics, inpatient facilities or personal care homes, located in Winnipeg, Manitoba and Edmonton, Alberta, Canada.

PARTICIPANTS

Patients with advanced Amyotrophic Lateral Sclerosis (ALS), Chronic Obstructive Pulmonary Disease (COPD), End Stage Renal Disease (ESRD); and the institutionalized alert frail elderly.

MAIN OUTCOME MEASURE

In addition to standardized measures of physical, psychological and spiritual aspects of patient experience, the Patient Dignity Inventory (PDI).

RESULTS

Between February 2009 and December 2012, 404 participants were recruited (ALS, 101; COPD, 100; ESRD, 101; and frail elderly, 102). Depending on group designation, 35% to 58% died within one year of taking part in the study. While moderate to severe loss of sense of dignity did not differ significantly across the four study populations (4-11%), the number of PDI items reported as problematic was significantly different i.e. ALS 6.2 (5.2), COPD 5.6 (5.9), frail elderly 3.0 (4.4) and ESRD 2.3 (3.9) [p < .0001]. Each of the study populations also revealed unique and distinct patterns of physical, psychological and existential distress.

CONCLUSION

People with ALS, COPD, ESRD and the frail elderly face unique challenges as they move towards the end of life. Knowing the intricacies of distress and how they differ across these groups broadens our understanding of end-of-life experience within non-cancer populations and how best to meet their palliative care needs.

Palliative care consultation services in hospitals in the Netherlands: the design of the COMPASS study

BACKGROUND

Patients with an advanced incurable disease are often hospitalised for some time during the last phase of life. Care in hospitals is generally focussed at curing disease and prolonging life and may therefore not in all cases adequately address the needs of such patients. We present the COMPASS study, a study on the effects and costs of consultation teams for palliative care in hospitals. This observational study aims to investigate the use, effects and costs of PCT consultation services for hospitalized patients with incurable cancer in the Netherlands.

METHODS/DESIGN

The study consists of 3 parts: 1. A questionnaire, interviews and a focus group discussion to investigate the characteristics of PCT consultation in 12 hospitals. PCTs will register their activities to calculate the costs of PCT consultation. 2. Cancer patients for whom the attending physician would not be surprised that they would die within 12 month will be included in a medical file search in three hospitals. Medical records will be investigated to compare care, treatment and hospital costs between patients with and patients without PCT consultation. 3. In the other nine hospitals, we will perform a longitudinal study, and compare quality of life between 100 patients for whom a PCT was consulted with 200 patients without PCT consultation. Propensity score matching will be used to adjust for differences between both patient groups. Patients will be followed for three months after inclusion. Quality of life will be assessed with the Palliative Outcome Scale, the EuroQol-5d and the EORTC-QLQ-C15 PAL. Satisfaction with care in the hospital is measured with the IN-PATSAT32. The cost impact of PCT consultation will also be explored.

DISCUSSION

This is the first multicenter study on PCT consultation in the Netherlands. The study will give valuable insight in the process, effects and costs of PCT consultation in hospitals. It is anticipated that PCT consultation has a positive effect on patients' quality of life and satisfaction with care and will lead to less hospital care costs.

Comparison of terminally ill cancer- vs. non-cancer patients in specialized palliative home care in Germany - a single service analysis

Background

Palliative care (PC) is no longer offered with preference to cancer patients (CA), but also to patients with non-malignant, progressive diseases. Taking current death statistics into account, PC in Europe will face a growing number of patients dying from non-cancer diseases (NCA). More insights into specialized palliative home care (SPHC) in NCAs are needed.

Methods

Retrospective analysis and group comparisons between CAs and NCAs of anonymous data of all patients cared for between December 2009 and June 2012 by one SPHC team in Germany. Patient-, disease- and care-related data are documented in clinical routine by specialized PC physicians and nurses in the Information System Palliative Care 3.0 ® (ISPC®).

Results

Overall, 502 patients were cared for by the SPHC team; from 387 patients comprehensive data sets were documented. These 387 data sets (CA: N = 300, 77.5 % and NCA: N = 87, 22.5 %) are used for further analysis here. NCAs were significantly older (81 vs. 73 years; p < .001), than CAs and most often suffered from diseases of the nervous system (40 %). They needed significantly more assistance with defecation (87 vs. 74 %; p < .001) and urination (47 vs. 29 %; p < .001) and were more often affected from impaired vigilance (30 vs. 11 %; p < .001) than CAs. A by trend higher proportion of NCAs died within one day after admission to palliative home care (12 vs. 5 %; p < .05) and a smaller proportion was re-admitted to hospital during home care (6 vs. 20 %; p < .001). NCAs died predominantly in nursing homes (50 vs. 20 %; p < .001).

Conclusions

Although the proportion of NCAs was relatively high in this study, the access to PC services seems to takes place late in the disease trajectory, as demonstrated by the lower survival rate for NCAs. Nevertheless, the results show, that NCAs PC needs are as complex and intense as in CAs.

Drug treatment at the end of life: an epidemiologic study in nursing homes

OBJECTIVE

To examine drug treatment in nursing home patients at the end of life, and identify predictors of palliative drug therapy.

DESIGN

A historical cohort study.

SETTING

Three urban nursing homes in Norway.

SUBJECTS

All patients admitted from January 2008 and deceased before February 2013.

MAIN OUTCOME MEASURES

Drug prescriptions, diagnoses, and demographic data were collected from electronic patient records. Palliative end-of-life drug treatment was defined on the basis of indication, drug, and formulation.

RESULTS

524 patients were included, median (range) age at death 86 (19-104) years, 59% women. On the day of death, 99.4% of the study population had active prescriptions; 74.2% had palliative drugs either alone (26.9%) or concomitantly with curative/preventive drugs (47.3%). Palliative drugs were associated with nursing home, length of stay > 16 months (AOR 2.10, 95% CI 1.12-3.94), age (1.03, 1.005-1.05), and a diagnosis of cancer (2.12, 1.19-3.76). Most initiations of palliative drugs and withdrawals of curative/preventive drugs took place on the day of death.

CONCLUSION

Palliative drug therapy and drug therapy changes are common for nursing home patients on the last day of life. Improvements in end-of-life care in nursing homes imply addressing prognostication and earlier response to palliative needs.

Experience of advanced chronic obstructive pulmonary disease: metasynthesis of qualitative research

CONTEXT

Chronic obstructive pulmonary disease (COPD) is a life-limiting illness. Despite best available treatments, individuals continue to experience symptom burden and have high health care utilization.

OBJECTIVES

To increase understanding of the experience and ongoing needs of individuals living with COPD.

METHODS

Medline, PsycINFO, CINAHL, and Sociological Abstracts were searched for articles published between January 1990 and June 2013. Metasynthesis of qualitative data followed the principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Metasyntheses are increasingly used to gain understandings of complex research questions through synthesizing data from individual qualitative studies. Descriptive and analytical themes were developed through thematic synthesis and expert panel discussion of extracted primary quotes, not the primary data themselves.

RESULTS

Twenty-two studies were included. Four hundred twenty-two free codes were condensed into seven descriptive themes: better understanding of condition, breathlessness, fatigue, frailty, anxiety, social isolation, and loss of hope and maintaining meaning. These seven themes were condensed further into three analytical themes that described the experience and ongoing needs of individuals with COPD: the need for better understanding of condition, sustained symptom burden, and the unrelenting psychological impact of living with COPD.

CONCLUSION

Combining discrete qualitative studies provided a useful perspective of the experience of living with COPD over the past two decades. Further studies into the ongoing needs of individuals with COPD are unlikely to add to this well-established picture. Future research should focus on solutions through the development of interventions that address patients' ongoing needs.

Characteristics of a pediatric hospice palliative care program over 15 years

OBJECTIVES

Pediatric palliative care has seen the adoption of several service provision models, yet there is minimal literature describing them. Canuck Place Children's Hospice (CPCH) is North America's first freestanding pediatric hospice. This study describes the characteristics of and services delivered to all children on the CPCH program from 1996 to 2010.

METHODS

A retrospective review of all patient medical records CPCH was conducted. Analyses examined trends and correlations between 40 selected data points: linear regression modeling was used to assess trends over time; t tests were used to examine significant associations between independent means; and the Kaplan-Meier method was used to measure survival probabilities.

RESULTS

The study cohort included 649 children. The majority of diagnoses belonged to cancers (30%), and diseases of the neuromuscular (20%), and central nervous systems (18%). The majority of deaths occurred among the cancer (45%), central nervous system (15%), and metabolic disease groups (14%). By study end date, 24% of children were still alive, 61% died, and 15% transitioned to adult services (more than half of whom were cognitively competent). On average, 1024 days were spent on the CPCH program (median = 301). The majority of inpatient hospice discharges were for respite (82%); only 7% were for end-of-life care. Location of death was shared between CPCH (61%), hospital (22%), and home (16%).

CONCLUSIONS

Diagnostic groups largely determine the nature and magnitude of services used, and our involvement with pediatric life-threatening conditions is increasing. Reviews of pediatric palliative programs can help evaluate the services needed by the population served.

Caring at the end of life: do cancer caregivers differ from other caregivers?

OBJECTIVE

Cancer is one of the most common health conditions in receipt of informal caregiving. This study compares key characteristics of caregivers who cared for someone with cancer until death with caregivers of people with other life-limiting illnesses and their care recipients irrespective of health service utilisation.

METHOD

Data were analysed from annual state-wide South Australian Health Omnibus Surveys (2000-2007) involving 14,624 respondents, regarding end of life care. Descriptive and comparative data are presented.

RESULTS

Almost a third of respondents (32%; participation rate 72%) had someone close to them die from an 'expected' death in the preceding 5 years. One in 10 (10%) respondents reported providing hands-on care predominantly for someone with cancer. Compared with non-cancer caregivers, cancer caregivers cared for someone who was significantly younger (mean age 66 (95% CI 64 to 67) years vs 74 (95% CI 72 to 77) years; one-way analysis of variance p<0.0001) and were more likely to report having a hospice/palliative care service involved in the care of the deceased (65% (95% CI 63 to 67) compared with 39% (95% CI 37 to 42). In the Australian context, this may mean contact with inpatient, outpatient and community-based services.There were no differences between the needs which caregivers perceived to be unmet or the perceptions that no additional supports were required between the two groups.

CONCLUSIONS

Informal caregivers perform a critical social and economic role in care provision. Cancer caregivers are a proportionally larger cohort than non-cancer caregivers. With the increasing incidence of cancer, the sustainability of a voluntary cancer caregiving workforce will be reliant upon minimising the burden of care.

Trends in end-of-life decision making in patients with and without cancer

PURPOSE

Because of cancer's high symptom burden and specific disease course, patients with cancer are more likely than other patients to face end-of-life decisions that have possible or certain life-shortening effects (ELDs). This study examines the incidence of ELDs in patients with cancer compared with patients without cancer and the trends in ELD incidence from 1998-2007.

PATIENTS AND METHODS

A nationwide death certificate study in Flanders, Belgium, was conducted in 2007, analogous to one completed in 1998. Physicians who had signed selected death certificates (n = 6,927) were sent a questionnaire.

RESULTS

The response rate was 58.4%. Nonsudden deaths were studied. Intensified symptom alleviation occurred more in patients with cancer than in those without (53.8% v 31.7%; P < .001) as did euthanasia (6.8% v 0.9%; P < .001). There was no difference between groups in nontreatment decisions and life-ending acts without patient's explicit request. Patients with cancer were less involved in the end-of-life decision-making process than patients without cancer (69.7% v 83.5%; P = .001). From 1998 to 2007, ELD incidence has increased in patients with cancer (+6.7%) and even more in patients without cancer (+14.9%) because of an increase in intensified symptom alleviation. In patients with cancer, euthanasia rates increased strongly and life-ending acts without the patient's explicit request decreased.

CONCLUSION

The higher ELD incidence in patients with cancer compared with those without is probably related to differences in disease trajectories and access to end-of-life care. During the period from 1998 to 2007, when euthanasia was legalized and palliative care intensified, overall ELDs increased, including those as a result of symptom alleviation and euthanasia, with a decrease in life-ending acts without explicit request.

Interventions to support a palliative care approach in patients with chronic obstructive pulmonary disease: an integrative review

BACKGROUND

End-stage chronic obstructive pulmonary disease (COPD) is a debilitating, life-limiting condition. A palliative approach is appropriate for individuals with end-stage COPD, yet currently few interventions embrace this holistic, multidisciplinary and inclusive perspective.

OBJECTIVE

To describe interventions to support a palliative care approach in patients with end-stage COPD.

DESIGN

Integrative review. DATA SOURCES AND REVIEW METHOD: Peer reviewed articles meeting the search criteria were accessed from Medline, PsychINFO, CINAHL and Google Scholar databases as well as Caresearch online resource. The domains of quality palliative care developed by Steinhauser were used as the conceptual framework to synthesise information.

RESULTS

This review has shown that a range of palliative interventions are used to address the needs of individuals with end-stage COPD. Although evidence exists for discrete elements of palliative management in this patient group, there is limited evidence for health service coordination and models that integrate the multiple domains of palliative care with active management.

CONCLUSION

Further investigation is required to address the complex personal, provider and system elements associated with managing end-stage COPD. A comprehensive and collaborative approach is required to address the complex and varied needs of individuals with end-stage COPD and their families.

Unmet needs of severely affected multiple sclerosis patients: the health professionals' view

BACKGROUND

Research has only started recently to specifically concentrate on the group of patients severely affected by multiple sclerosis (MS).

AIM

The aim of this study was to assess the perception on patients' unmet needs by healthcare professionals.

METHODS

Focus groups and expert interviews were recorded, transcribed verbatim and analysed by qualitative content analysis.

RESULTS

Unmet needs were identified in four main categories ('support from family/friends'; 'healthcare services'; 'managing everyday life'; 'maintaining biographical continuity'). Whereas physicians assessed most unmet needs in the category 'healthcare services', nurses and social workers focussed on unmet needs in the categories 'support from family/friends' and 'maintaining biographical continuity'. Although the study focused on unmet needs of patients, professionals also voiced their unmet needs when caring for these patients. The group of professionals identified more subcategories than patients and included unmet needs of relatives.

CONCLUSION

Adding professionals' perspective to that of patients is essential to gain a holistic view on patients' unmet needs and to further optimize their care. The perspective of palliative care might contribute to meet unmet needs of severely affected MS patients.

The preferred priorities for care document in motor neurone disease: views of bereaved relatives and carers

Increasing emphasis is being placed on the need for advanced care planning (ACP) at the end of life. The Preferred Priorities for Care (PPC) document is a patient-held record promoted by the End of Life Care Strategy as an ACP tool to promote discussion and communication amongst patients, family and health care providers. However, little research exists into evaluating its effectiveness or exploring patient and carer views, particularly in non-malignant disease. Because the majority of patients with Motor Neurone Disease (MND) lose verbal communication, early discussion of patients' wishes and preferences, a central aspect of ACP, is vital. This study examined MND patients' bereaved relatives' experiences of using the PPC document and their perceptions about its impact on end-of-life care using qualitative methods. Key findings adding to existing literature were that the PPC document was felt to have little impact on end-of-life care amongst this patient group and that there was a perceived lack of awareness of the document amongst health care professionals (HCPs), in particular hospital staff. This was felt to limit the effectiveness of the document. This has obvious implications for practice, looking at awareness amongst HCPs and ways to improve this situation, particularly in light of the current pressures to meet patient preferences at the end of life.

[Palliative medicine and advanced incurable illness]

Advanced incurable and life-threatening diseases of internal organs such as chronic obstructive pulmonary disease (COPD), heart failure, and terminal kidney failure are associated with considerable burden for the patients caused by pronounced symptoms (e.g., dyspnea, anxiety, depression) and unmet psychosocial needs. Nevertheless, in Germany addressing palliative medicine in the context of these disorders and co-treatment of these patients by cross-sector partnership with specialized palliative care physicians are not very developed. Against the background of an international perspective and current guidelines, general aspects of palliative care needs (symptom control, communication, advance care planning, etc.) are discussed together with the resultant implications for potential cooperation between internal medicine and palliative care as well as special aspects of the individual diseases (e.g., prognosis or implications of certain treatment options such as "automatic implantable cardioverter-defibrillator", AICD). Timely involvement of the specific expertise of palliative care medicine can ensure that the workload of the primary providers (and their teams) is reduced and better cross-sector management (hospital and home) of the severely ill patients and their families is achieved.

An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses

BACKGROUND

Breathlessness is a debilitating and distressing symptom in a wide variety of diseases and still a difficult symptom to manage. An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation.

METHODS

Systematic reviews were identified via electronic databases between July 2007 and September 2009. Reviews were included within the study if they reported research on adult participants using either a measure of breathlessness or some other measure of respiratory symptoms.

RESULTS

In total 219 systematic reviews were identified and 153 included within the final review, of these 59 addressed non-pharmacological interventions and 94 addressed pharmacological interventions. The reviews covered in excess of 2000 trials. The majority of systematic reviews were conducted on interventions for asthma and COPD, and mainly focussed upon a small number of pharmacological interventions such as corticosteroids and bronchodilators, including beta-agonists. In contrast, other conditions involving breathlessness have received little or no attention and studies continue to focus upon pharmacological approaches. Moreover, although there are a number of non-pharmacological studies that have shown some promise, particularly for COPD, their conclusions are limited by a lack of good quality evidence from RCTs, small sample sizes and limited replication.

CONCLUSIONS

More research should focus in the future on the management of breathlessness in respiratory diseases other than asthma and COPD. In addition, pharmacological treatments do not completely manage breathlessness and have an added burden of side effects. It is therefore important to focus more research on promising non-pharmacological interventions.

How to provide care for patients suffering from terminal non-oncological diseases: barriers to a palliative care approach

Despite the seemingly evident pertinence of palliative care for patients suffering from non-oncological long-term life-threatening diseases, everyday clinical practice is far from that assumption. This study aims to explore palliative care service provision for these patients in Spain. Patients, family caregivers and healthcare professionals were interviewed, individually or in a group, aiming at identifying barriers in the provision of care and strategies to overcome them. Ritchie and Spencer's framework was used for data analysis. The barriers identified were as follows: lack of clarity about prognosis, the hegemony of the curative approach, avoiding words and the desire to cheat death. Provision of palliative care services for these patients should be guided by the characteristic trajectory of each type of disease. Even if healthcare systems were capable of providing specialized palliative care services to this large group of patients, other barriers should not be overlooked. It would then seem appropriate to provide therapeutic and palliative care simultaneously, thus facilitating adaptation processes for both patients and relatives.