A National Strategy For Palliative Care

Desired dementia care towards end of life: Development and experiences of implementing a new approach to improve person-centred dementia care

AIMS

To describe the co-creation of the 'Desired Dementia Care Towards End of Life' (DEDICATED) approach to improve person-centred palliative care for individuals with dementia and to describe the experiences of healthcare professionals during the approach's implementation.

METHODS

A needs assessment, comprising both qualitative and quantitative studies, informed palliative care needs of healthcare professionals, family caregivers and individuals with dementia. The approach was co-created with healthcare and education professionals, guided by the findings. Then, healthcare professionals were trained to implement the approach in their organizations. From April to June 2022, semi-structured interviews with actively engaged professionals were analysed using Conventional Content Analysis.

RESULTS

The needs assessment yielded six key themes: (1) raising palliative care awareness, (2) familiarization with a person with dementia, (3) communication about future care preferences, (4) managing pain and responsive behaviour, (5) enhancing interprofessional collaboration in advance care planning and (6) improving interprofessional collaboration during transitions to nursing homes. Interviews with 17 healthcare professionals revealed that active involvement in co-creating or providing feedback facilitated implementation. Overall, the DEDICATED approach was perceived as a valuable toolkit for optimizing palliative care for people with dementia and their loved ones.

CONCLUSION

Co-creating the DEDICATED approach with healthcare professionals facilitated implementation in daily practice. The approach was considered helpful in enhancing person-centred palliative dementia care.

IMPACT STATEMENT

This study underscores the importance of active involvement of healthcare professionals in the research and development of new interventions or tools for palliative care, which can influence the successful implementation, dissemination and sustained usage of the developed tools.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The developed approach can improve person-centred palliative care for individuals with dementia, ultimately improving their quality of life and that of their loved ones.

REPORTING METHOD

This study used the Consolidated Criteria for Reporting Qualitative Research.

PATIENT OF PUBLIC CONTRIBUTION

No patient or public contribution.

US Medicare Hospice and Palliative Medicine Physician Workforce and Service Delivery in 2008-2020

CONTEXT

Despite clinical benefits of early palliative care, little is known about Medicare physician workforce specialized in Hospice and Palliative Medicine (HPM) and their service delivery settings.

OBJECTIVES

To examine changes in Medicare HPM physician workforce and their service delivery settings in 2008-2020.

METHODS

Using the Medicare Data on Provider Practice and Specialty from 2008 to 2020, we identified 2375 unique Medicare Fee-For-Service (FFS) physicians (15,565 physician-year observations) with self-reported specialty in "Palliative Care and Hospice". We examined changes in the annual number of HPM physicians, average number of Medicare services overall and by care setting, total number of Medicare FFS beneficiaries, and total Medicare allowed charges billed by the physician.

RESULTS

The number of Medicare HPM physicians increased 2.32 times from 771 in 2008 to 1790 in 2020. The percent of HPM physicians practicing in metropolitan areas increased from 90% to 96% in 2008-2020. Faster growth was also observed in female physicians (52.4% to 60.1%). Between 2008 and 2020, we observed decreased average annual Medicare FFS beneficiaries (170 to 123), number of FFS services (467 to 335), and Medicare allowed charges billed by the physician ($47,230 to $37,323). The share of palliative care delivered in inpatient settings increased from 47% to 68% in 2008-2020; whereas the share of services delivered in outpatient settings decreased from 37% to 19%.

CONCLUSION

Despite growth in Medicare HPM physician workforce, access is disproportionately concentrated in metropolitan and inpatient settings. This may limit receipt of early outpatient specialized palliative care, especially in nonmetropolitan areas.

Clinician Perspectives on Virtual Specialty Palliative Care for Patients With Advanced Illnesses

Background: Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness. Objectives: We sought to understand referring clinician perspectives on barriers and facilitators to utilizing virtual tools to increase upstream access to palliative care. Design: Participants in this multisite qualitative study included practicing clinicians who commonly place palliative care referrals across multiple specialties, including hematology/oncology, family medicine, cardiology, and geriatrics. All interviews were transcribed and subsequently coded and analyzed by trained research coordinators using Atlas.ti software. Settings/Subjects: This study included 23 clinicians (21 physicians, 2 nonphysicians) across 5 specialties, 4 practice settings, and 7 states in the United States. Results: Respondents felt that community-based specialty palliative services including symptom management, advance care planning, physical therapy, and mental health counseling would benefit their patients. However, they had mixed feelings about automated referrals, with some clinicians feeling hesitant about not being alerted to such referrals. Many respondents were supportive of virtual palliative care, particularly for those who may have difficulty accessing physician offices, but most respondents felt that such care should only be provided after an initial in-person consultation where clinicians can meet face-to-face with patients. Conclusion: Clinicians believe that automated referrals and virtual palliative care could increase access to the benefits of specialty palliative care. However, virtual palliative care models should give attention to iterative communication with primary clinicians and the perceived need for an initial in-person visit.

Looking Beyond Mortality Prediction: Primary Care Physician Views of Patients' Palliative Care Needs Predicted by a Machine Learning Tool

OBJECTIVES

 To assess primary care physicians' (PCPs) perception of the need for serious illness conversations (SIC) or other palliative care interventions in patients flagged by a machine learning tool for high 1-year mortality risk.

METHODS

 We surveyed PCPs from four Brigham and Women's Hospital primary care practice sites. Multiple mortality prediction algorithms were ensembled to assess adult patients of these PCPs who were either enrolled in the hospital's integrated care management program or had one of several chronic conditions. The patients were classified as high or low risk of 1-year mortality. A blinded survey had PCPs evaluate these patients for palliative care needs. We measured PCP and machine learning tool agreement regarding patients' need for an SIC/elevated risk of mortality.

RESULTS

 Of 66 PCPs, 20 (30.3%) participated in the survey. Out of 312 patients evaluated, 60.6% were female, with a mean (standard deviation [SD]) age of 69.3 (17.5) years, and a mean (SD) Charlson Comorbidity Index of 2.80 (2.89). The machine learning tool identified 162 (51.9%) patients as high risk. Excluding deceased or unfamiliar patients, PCPs felt that an SIC was appropriate for 179 patients; the machine learning tool flagged 123 of these patients as high risk (68.7% concordance). For 105 patients whom PCPs deemed SIC unnecessary, the tool classified 83 as low risk (79.1% concordance). There was substantial agreement between PCPs and the tool (Gwet's agreement coefficient of 0.640).

CONCLUSIONS

 A machine learning mortality prediction tool offers promise as a clinical decision aid, helping clinicians pinpoint patients needing palliative care interventions.

Misconception between palliative care and euthanasia among Thai general practitioners: a cross-sectional study

BACKGROUND

Palliative care lower medical expenses and enhances quality of life, but misconception with euthanasia delays timely care and makes inappropriate patient management.

OBJECTIVE

To examine the magnitude of misconceptions between palliative care and euthanasia among Thai general practitioners, explore the association with knowledge, attitudes, and practical experience, and assess the association between misconception and confidence in practicing and referring patients to palliative care centers.

METHODS

All 144 general practitioners who were going to start residency training at Maharaj Nakorn Chiang Mai Hospital in 2021 participated in this observational cross-sectional study. A chi-square test was utilized to examine the relationship between misconception and knowledge, attitude, practical experience, confidence to practice, and confidence to refer patients. Multivariable logistic regression was carried out while controlling for age, sex, knowledge, attitude, and experience to examine the relationship between misconception and confidence to practice and refer patients for palliative care. Statistical significance was defined at p < 0.05.

RESULTS

About 41% of general physicians had misconceptions regarding palliative care and euthanasia. High knowledge was associated with a lower level of misconception (p = 0.01). The absence of misconceptions was weakly associated with a higher level of confidence in practicing palliative care, with an adjusted odds ratio of 1.51 (95% confidence interval 0.73 to 3.10, p = 0.07).

CONCLUSION

High misconception rates between palliative care and euthanasia among young Thai physicians might impact their confidence in delivering palliative care. Training initiatives for medical students and practitioners can mitigate misconceptions, fostering better palliative care utilization in Thailand.

Trends in Specialty Palliative Care Service Utilization and In-Hospital Outcomes for Patients With Amyotrophic Lateral Sclerosis

Background: Hospitalized people with amyotrophic lateral sclerosis (ALS) may benefit from specialty palliative care services (sPCS). Objective: To describe access to in-hospital sPCS for people with ALS (pALS). Methods: We compared years 2010-2011 to 2018-2019, and conducted trend analyses of sPCS from 2010 to 2019 stratified by race. Results: Of 103,193 pALS admitted during the study period, 13,885 (13.4%) received sPCS. Rates of sPCS increased over time (2010-2011: 8.9% vs. 2018-2019: 16.6%; p < 0.01). From 2010 to 2019, there was an increase in sPCS (p-trend<0.01) for all studied racial groups. Conclusions: Access to palliative care has increased over time for pALS admitted to hospitals in the United States.

Nurse-Led, Telephone-Based Primary Palliative Care Intervention for Patients With Lung Cancer: Domains of Quality Care

Palliative care is traditionally delivered by specialty-trained palliative care teams. Because of a national workforce shortage of palliative care specialists, there is an urgent need to explore alternative models of palliative care delivery to meet the needs of patients living with serious illness. As part of a multisite randomized controlled trial, 2 registered nurses without previous palliative care experience were trained to deliver a primary palliative care intervention to patients with newly diagnosed lung cancer. The intervention focused on assessing and managing symptoms, psychosocial needs, education, and initiating goals-of-care discussions. The primary outcome, improved symptom burden and quality of life, was not statistically significant. Despite this finding, nurses addressed 5 of the 8 National Consensus Project Guidelines domains of quality palliative care: structure and processes of care; physical, psychological, and social aspects of care; and ethical and legal aspects. Patients' engagement in goals-of-care discussions, a measure of high-quality palliative care, increased. Clinical recommendations offered by the nurses to the patients' clinicians were addressed and accepted on a timely basis. Most patients rated satisfaction with the intervention as "very or extremely" satisfied. These findings may inform future nurse-led palliative care interventions on the specific quality domains of palliative care.

Kidney Transplant Clinicians' Perceptions of Palliative Care for Patients With Failing Allografts in the US: A Mixed Methods Study

RATIONALE & OBJECTIVE

Kidney transplant patients with failing allografts have a physical and psychological symptom burden as well as high morbidity and mortality. Palliative care is underutilized in this vulnerable population. We described kidney transplant clinicians' perceptions of palliative care to delineate their perceived barriers to and facilitators of providing palliative care to this population.

STUDY DESIGN

National explanatory sequential mixed methods study including an online survey and semistructured interviews.

SETTING & PARTICIPANTS

Kidney transplant clinicians in the United States surveyed and interviewed from October 2021 to March 2022.

ANALYTICAL APPROACH

Descriptive summary of survey responses, thematic analysis of qualitative interviews, and mixed methods integration of data.

RESULTS

A total of 149 clinicians completed the survey, and 19 completed the subsequent interviews. Over 90% of respondents agreed that palliative care can be helpful for patients with a failing kidney allograft. However, 46% of respondents disagreed that all patients with failing allografts benefit from palliative care, and two-thirds thought that patients would not want serious illness conversations. More than 90% of clinicians expressed concern that transplant patients and caregivers would feel scared or anxious if offered palliative care. The interviews identified three main themes: (1) transplant clinicians' unique sense of personal and professional responsibility was a barrier to palliative care engagement, (2) clinicians' uncertainty regarding the timing of palliative care collaboration would lead to delayed referral, and (3) clinicians felt challenged by factors related to patients' cultural backgrounds and identities, such as language differences. Many comments reflected an unfamiliarity with the broad scope of palliative care beyond end-of-life care.

LIMITATIONS

Potential selection bias.

CONCLUSIONS

Our study suggests that multiple barriers related to patients, clinicians, health systems, and health policies may pose challenges to the delivery of palliative care for patients with failing kidney transplants. This study illustrates the urgent need for ongoing efforts to optimize palliative care delivery models dedicated to kidney transplant patients, their families, and the clinicians who serve them.

PLAIN-LANGUAGE SUMMARY

Kidney transplant patients experience physical and psychological suffering in the context of their illnesses that may be amenable to palliative care. However, palliative care is often underutilized in this population. In this mixed-methods study, we surveyed 149 clinicians across the United States, and 19 of them completed semistructured interviews. Our study results demonstrate that several patient, clinician, system, and policy factors need to be addressed to improve palliative care delivery to this vulnerable population.

Trend Analysis of Palliative Care Utilization in Patients with Chronic Obstructive Pulmonary Disease During Hospitalization from 2007 to 2018 in Taiwan

Purpose

Palliative care utilization among hospitalized patients with advanced chronic obstructive pulmonary disease (COPD) in Taiwan remains low despite its costs making it eligible for reimbursement since 2009. Few studies have examined the trends of palliative care utilization. We analyzed the annual rate, associated factors, and timing of the inpatient palliative care utilization by hospitalized patients with COPD.

Patients and Methods

We conducted a cross-sectional observational study between 1 January 2007 and 31 December 2018. Population-based claims data were extracted from Taiwan's National Health Insurance Research Database to identify patients aged ≧40 years with COPD five years before the first instance of inpatient palliative care utilization.

Results

There were 24,502 patients with COPD receiving inpatient palliative care. Our results indicated that older age, concomitant chronic conditions-especially cancer-and severity of comorbidities were associated with a higher rate of palliative care utilization by hospitalized patients with chronic obstructive pulmonary disease. In our study, the proportion of hospitalized patients with COPD receiving inpatient palliative care and having a Charlson comorbidity index score of 1-2 was lower than that of patients with cancer and a Charlson comorbidity index score ≧3 during the 12-year study-observation period. In addition, approximately 50% of hospitalized patients with COPD received palliative care within 18 months after their initial admission for COPD during the study period. However, individuals with a CCI score of 1-2 exhibited a slower entry into palliative care, with nearly 50% initiating it within the first two years.

Conclusion

Inpatient palliative care utilization by hospitalized patients with advanced COPD remains low due to various causes. Our findings highlight that palliative care may be considered by professional care providers as routine care and as a way to manage problematic symptoms during hospitalization.

Features that hindered the capacity development of a national prostate cancer service

Introduction

In Scotland, prostate cancer services have struggled to meet demand, and urological cancer services have missed Scottish Government waiting time targets to a greater extent than other cancer services. This study provides understanding of the capacity development needs of a national prostate cancer service including why the service had been unable to adapt to meet demand and how capacity could be developed.

Methods

Delphi technique was applied to a purposive sample of prostate cancer clinicians working across Scotland between 2015 and 2017. Interviews were conducted with healthcare professionals involved in delivery of care to people with prostate cancer including General Practitioners, followed by questionnaires which were distributed to Specialist Nurses, Oncologists and Urologists involved in delivering specialist prostate cancer services within NHS Scotland. Findings are reported from interviews analysed using a directed approach to content analysis, followed by three rounds of iterative online questionnaires analysed using descriptive statistics.

Results

Reform is needed to meet demand within prostate cancer services in Scotland. Barriers to capacity development included: lack of shared understanding of quality of care between policy makers and healthcare professionals; lack of leadership of service developments nationally and regionally; and difficulties in drawing on other capacities to support the service. Cohesive working and a need for efficient training for nurse specialists were needed to develop capacity. Consensus was reached for development of national working groups to set standards for quality care (100% agreement) and further development of existing regional working groups (100% agreement) to implement this care (91% agreement), which should include input from primary and community care practitioners (100% agreement) to meet demand.

Discussion

This work provides important understanding of barriers and facilitators to service development across a national service, including highlighting the importance of a shared vision for quality care between policy makers and healthcare professionals. Mechanisms to support service change are identified.

Medicaid Expansion Associated With Increase In Palliative Care For People With Advanced-Stage Cancers

Clinical guidelines have endorsed early palliative care for patients with advanced malignancies, but receipt remains low in the US. This study examined the association between Medicaid expansion under the Affordable Care Act and receipt of palliative care among patients newly diagnosed with advanced-stage cancers. Using the National Cancer Database, we found that the percentage of eligible patients who received palliative care as part of first-course treatment increased from 17.0 percent preexpansion to 18.9 percent postexpansion in Medicaid expansion states and from 15.7 percent to 16.7 percent, respectively, in nonexpansion states, resulting in a net increase of 1.3 percentage points in expansion states in adjusted analyses. Increases in receipt of palliative care associated with Medicaid expansion were largest for patients with advanced pancreatic, colorectal, lung, and oral cavity and pharynx cancers and non-Hodgkin lymphoma. Our findings suggest that increasing Medicaid coverage facilitates access to guideline-based palliative care for advanced cancer, and they provide additional evidence of benefit in cancer care from states' expansion of income eligibility for Medicaid.

Hospice and Palliative Care for Undergraduate Nursing Education: Results from a Delphi Study

There is an urgent need to strengthen the nursing workforce through hospice and palliative care education to support patients living with serious illness. The aim of this study was to identify skills/topics in hospice and palliative care for undergraduate nursing education. We conducted a two-round online Delphi Survey of hospice and palliative care leaders and clinicians in New York State between June and August 2022. Participants were asked to list and rate the importance of clinical skills and topics in hospice and palliative care for undergraduate nursing education. Twenty-eight participants completed Round One and 21 participants completed Round Two. Topics ranked as extremely important were goals of care, patient/family education, communication skills, advance directives, medication management, pain management, and symptom management. Our findings highlight the importance of including the perspective of healthcare systems leaders and clinicians in discussions about training of future nurses to meet the needs of patients with serious illness and their families.

Palliative medicine integration in the USA: cancer centre executives' attitudes

OBJECTIVES

To compare cancer centre (CC) executives' attitudes towards palliative care between National Cancer Institute-designated CCs (NCI-CCs) and non-NCI-designated CCs (non-NCI-CCs) in 2018 and to examine the changes in attitudes and beliefs between 2009 and 2018.

METHODS

CC chief executives at all NCI-CCs and a random sample of non-NCI-CCs were surveyed from April to August 2018. Twelve questions examined the executives' attitudes towards palliative care integration, perceived barriers and self-assessments. The primary outcome was agreement on the statement 'a stronger integration of palliative care services into oncology practice will benefit patients at my institution.' Survey findings from 2018 were compared with data from 2009 to examine changes in attitudes.

RESULTS

52 of 77 (68%) NCI-CCs and 88 of 126 (70%) non-NCI-CCs responded to the survey. A vast majority of executives at NCI-CCs and non-NCI-CCs endorsed palliative care integration (89.7% vs 90.0%; p>0.999). NCI-CCs were more likely to endorse increasing funding for palliative care (52.5% vs 23.1%; p=0.01) and hiring physician specialists (70.0% vs 37.5%; p=0.004) than non-NCI-CCs. The top three perceived barriers among NCI-CCs and non-NCI-CCs were limited institutional budgets (57.9% vs 59.0%; p=0.92), poor reimbursements (55.3% vs 43.6%; p=0.31), and lack of adequately trained palliative care physicians and nurses (52.6% vs 43.6%; p=0.43). Both NCI-CCs and non-NCI-CCs favourably rated their palliative care services (89.7% vs 71.8%; p=0.04) with no major changes since 2009.

CONCLUSION

CC executives endorse integration of palliative care, with greater willingness to invest in palliative care among NCI-CCs. Resource limitation continues to be a major barrier.

A Retrospective Study Analyzing a Palliative Care-Hospital Medicine Collaboration to Improve Quality of Care of Patients With Advanced Illness

BACKGROUND

Palliative care seeks to improve outcomes for patients with advanced illness (AI). Advocacy exists for making it part of mainstream care for hospitalized patients with AI.

AIM

To determine if a partnership between hospital-medicine and specialized palliative care would increase identification of AI patients with palliative care needs requiring palliative consultation. Secondary outcomes: Decreasing 30-day readmission, length of stay (LOS) and pain scores, increasing documentation reflecting goals and advanced care planning.

DESIGN

Retrospective chart review of patients with AI admitted to a hospitalist-resident run unit divided into Care Models, "A" and "B," and analyzed over two ten-month periods, "1" and "2." Triggers for palliative needs were provided for "A." During biweekly rounding, needs were assessed and generalist vs. specialist level palliative care concepts were used for consultation.

SETTING

Quaternary-level teaching center in the New York Metropolitan area.

PATIENTS

3,395 AI patients were analyzed, 1,707 from "1," and 1,688 from "2."

RESULTS

Comparing care models and time frames, palliative care consultation increased in "A" (P-value = .0013, P-value = .0005). When investigating "A" in "1" to "2," CMI was higher. Comparing "B" between "1" and "2," found older age and lower LACE. When adjusting for confounders (LACE and CMI), our models did not show a difference. Data on discharge disposition was significant for subacute rehab but not for mortality. There were no differences between care models and time-periods for secondary outcomes.

CONCLUSION

Our study demonstrated the demand for palliative care services integrated into hospital medicine and highlighted areas of focus for future studies.

Predictors of Documented Goals-of-Care Discussion for Hospitalized Patients With Chronic Illness

CONTEXT

Goals-of-care discussions are important for patient-centered care among hospitalized patients with serious illness. However, there are little data on the occurrence, predictors, and timing of these discussions.

OBJECTIVES

To examine the occurrence, predictors, and timing of electronic health record (EHR)-documented goals-of-care discussions for hospitalized patients.

METHODS

This retrospective cohort study used natural language processing (NLP) to examine EHR-documented goals-of-care discussions for adults with chronic life-limiting illness or age ≥80 hospitalized 2015-2019. The primary outcome was NLP-identified documentation of a goals-of-care discussion during the index hospitalization. We used multivariable logistic regression to evaluate associations with baseline characteristics.

RESULTS

Of 16,262 consecutive, eligible patients without missing data, 5,918 (36.4%) had a documented goals-of-care discussion during hospitalization; approximately 57% of these discussions occurred within 24 hours of admission. In multivariable analysis, documented goals-of-care discussions were more common for women (OR=1.26, 95%CI 1.18-1.36), older patients (OR=1.04 per year, 95%CI 1.03-1.04), and patients with more comorbidities (OR=1.11 per Deyo-Charlson point, 95%CI 1.10-1.13), cancer (OR=1.88, 95%CI 1.72-2.06), dementia (OR=2.60, 95%CI 2.29-2.94), higher acute illness severity (OR=1.12 per National Early Warning Score point, 95%CI 1.11-1.14), or prior advance care planning documents (OR=1.18, 95%CI 1.08-1.30). Documentation of these discussions was less common for racially or ethnically minoritized patients (OR=0.823, 95%CI 0.75-0.90).

CONCLUSION

Among hospitalized patients with serious illness, documented goals-of-care discussions identified by NLP were more common among patients with older age and increased burden of acute or chronic illness, and less common among racially or ethnically minoritized patients. This suggests important disparities in goals-of-care discussions.

Telehealth Palliative Care in Nursing Homes: A Scoping Review

OBJECTIVES

Many adults older than 65 spend time in a nursing home (NH) at the end of life where specialist palliative care is limited. However, telehealth may improve access to palliative care services. A review of the literature was conducted to synthesize the evidence for telehealth palliative care in NHs to provide recommendations for practice, research, and policy.

DESIGN

Joanna Briggs Institute guidance for scoping reviews, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews frameworks were used to guide this literature review.

SETTINGS AND PARTICIPANTS

Reviewed articles focused on residents in NHs with telehealth palliative care interventionists operating remotely. Participants included NH residents, care partner(s), and NH staff/clinicians.

METHODS

We searched Medline (Ovid), Embase (Elsevier), Cochrane Library (WileyOnline), Scopus (Elsevier), CINHAL (EBSCOhost), Trip PRO, and Dissertations & Theses Global (ProQuest) in June 2021, with an update in January 2022. We included observational and qualitative studies, clinical trials, quality improvement projects, and case and clinical reports that self-identified as telehealth palliative care for NH residents.

RESULTS

The review yielded 11 eligible articles published in the United States and internationally from 2008 to 2020. Articles described live video as the preferred telehealth delivery modality with goals of care and physical aspects of care being most commonly addressed. Findings in the articles focused on 5 patient and family-centered outcomes: symptom management, quality of life, advance care planning, health care use, and evaluation of care. Consistent benefits of telehealth palliative care included increased documentation of goals of care and decrease in acute care use. Disadvantages included technological difficulties and increased NH financial burden.

CONCLUSIONS AND IMPLICATIONS

Although limited in scope and quality, the current evidence for telehealth palliative care interventions shows promise for improving quality and outcomes of serious illness care in NHs. Future empirical studies should focus on intervention effectiveness, implementation outcomes (eg, managing technology), stakeholders' experience, and costs.

A Systematic Review of Interprofessional Palliative Care Education Programs

CONTEXT

Interprofessional education (IPE) involving palliative and end-of-life content benefits learners by addressing interprofessional and palliative care (PC) competency needs.

OBJECTIVES

A synthesis of educational approaches promoting interprofessional PC in academic and clinical settings would address research gaps and promote effective teaching.

METHODS

A systematic review of interprofessional PC educational studies was conducted to summarize current approaches in PC IPE and to appraise teaching and research methods. Characteristics of excellence in interprofessional PC education established by Donesky et al. served as a framework for evaluating studies in this systematic review.

RESULTS

A total of 39 articles met inclusion criteria for this review. Learners from medicine and nursing were the most included professions. University programs represented most studies, and evaluation methods demonstrated achievement of mostly self-reported outcomes like learner attitude and self-efficacy. While the effect of interprofessional collaboration on patient outcomes is well-documented, the effect of IPE on PC delivery is not. Although content spanned all interprofessional and PC domains, few studies addressed cultural aspects and fewer addressed well-being for the care provider.

CONCLUSION

In light of the current healthcare landscape, there is an imminent need to address culture and provider well-being more directly through interprofessional PC education. Education and research must also move beyond university programs into health systems to support the professional development of clinicians for systems integration, sustainability, and impact on patient outcomes. Future evaluation of interprofessional PC education would be strengthened by multisite studies, randomized controlled trials, and repeated measures looking at outcomes over time.

Mitigating Moral Injury for Palliative Care Clinicians

Palliative care clinicians (PCCs) in the United States face the combination of increasing burnout and a growing need for their services based on demographic changes and an increasing burden of serious illness. In addition to efforts to increase the number of PCCs and to train other clinicians in "primary palliative skills," we must address the burnout in the field to address the growing gap between need for this care and capacity to provide it. To address burnout in PCCs, we must develop solutions with the unique contributors to burnout in this field in mind. PCCs are particularly susceptible to moral distress and moral injury faced by all clinicians, and these states are inextricably linked to burnout. We propose three solutions to address moral distress and moral injury in PCCs to reduce burnout. These solutions are grounded in the dilemmas particular to palliative care and in best evidence: first, to create space for PCCs to confront moral challenges head-on; second, to integrate ethics consultations into care of some patients cared for by PCCs; and third, to reassess care models for PCCs. These approaches can mitigate burnout and thus address the growing gap in our ability to provide high-quality palliative care for those patients in need.

Top Ten Tips Palliative Care Clinicians Should Know About Leveraging the Electronic Health Record for Data Collection and Quality Improvement

As palliative care (PC) programs rapidly grow and expand across settings, the need to measure, improve, and standardize high-quality PC has also grown. The electronic health record (EHR) is a key component of these efforts as a central hub of care delivery and a repository of patient and system data. Deliberate efforts to leverage the EHR for PC quality improvement (QI) can help PC programs and health systems improve care for patients with serious illnesses. This article, written by clinicians with experience in QI, informatics, and clinical program development, provides practical tips and guidance on EHR strategies and tools for QI and quality measurement.

Implementation and Effectiveness of a Learning Collaborative to Improve Palliative Care for Seriously Ill Hemodialysis Patients

BACKGROUND AND OBJECTIVES

Limited implementation of palliative care practices in hemodialysis may contribute to end-of-life care that is intensive and not patient centered. We determined whether a learning collaborative for hemodialysis center providers improved delivery of palliative care best practices.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Ten US hemodialysis centers participated in a pre-post study targeting seriously ill patients between April 2019 and September 2020. Three practices were prioritized: screening for serious illness, goals of care discussions, and use of a palliative dialysis care pathway. The collaborative educational bundle consisted of learning sessions, communication skills training, and implementation support. The primary outcome was change in the probability of complete advance care planning documentation among seriously ill patients. Health care utilization was a secondary outcome, and implementation outcomes of acceptability, adoption, feasibility, and penetration were assessed using mixed methods.

RESULTS

One center dropped out due to the coronavirus disease 2019 pandemic. Among the remaining nine centers, 20% (273 of 1395) of patients were identified as seriously ill preimplementation, and 16% (203 of 1254) were identified as seriously ill postimplementation. From the preimplementation to postimplementation period, the adjusted probability of complete advance care planning documentation among seriously ill patients increased by 34.5 percentage points (95% confidence interval, 4.4 to 68.5). There was no difference in mortality or in utilization of palliative hemodialysis, hospice referral, or hemodialysis discontinuation. Screening for serious illness was widely adopted, and goals of care discussions were adopted with incomplete integration. There was limited adoption of a palliative dialysis care pathway.

CONCLUSIONS

A learning collaborative for hemodialysis centers spanning the coronavirus disease 2019 pandemic was associated with adoption of serious illness screening and goals of care discussions as well as improved documentation of advance care planning for seriously ill patients.

CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER

Pathways Project: Kidney Supportive Care, NCT04125537.

Inclusion of essential components of the World Health Organization palliative care development model in national palliative care plans: A documentary analysis in 31 countries

CONTEXT

The World Health Organization has proposed a new model for the development of palliative care. Whether the current national palliative care plans of Member States are aligned or need to be reformed to meet the new model is unknown.

METHODS

We conducted a documentary analysis of national palliative care plans based on an analytic framework structured with the elements recommended by the World Health Organization: (a) building a plan, (b) plan components, and (c) plan implementation. We conducted a categorical analysis of national plans by subgroups according to income and development level of palliative care.

FINDINGS

We identified 112 countries with a palliative care plan, of which 31 were included in the analysis. Of these 31 plans, only 8 had the six components proposed by the World Health Organization, 29 reported an implementation strategy, 23 were aligned with the country's national public health plan, and 15 allocated financial resources for plan implementation. All the national plans assessed included the component provision of palliative care in integrated health services; 93%, education and training; 83%, research; 80%, empowered people and communities; 54%, health policies related to palliative care, and 48% use of essential medicines.

CONCLUSIONS

National palliative care plans include the two new development components, but few are fully aligned with the 2021 World Health Organization's model.

Adapting a palliative care-focused cancer self- and family management intervention for use in Israel

BACKGROUND

In Israel, there is a need to improve quality of life and health outcomes among patients and families facing cancer. Increasing awareness of, literacy about, and availability of palliative care may further this goal.

AIMS

This study aimed to adapt a palliative care-focused cancer self- and family management intervention developed in the US for use in Israel.

METHODS

The Managing Cancer Care (MCC) psycho-educational intervention is comprised of Managing Cancer Care: A Personal Guide (MCC-PT^©) for patients and Managing Cancer Care: A Caregiver's Guide (MCC-CG^©) for family caregivers. Following translation into Hebrew, an expert panel of Israeli nurses edited the MCC tool for cultural relevance. The authors then conducted qualitative interviews with patients with breast cancer and their family caregivers to obtain feedback. Data were analysed using qualitative content analysis.

FINDINGS

Following recommendations from Israeli experts in oncology and/or palliative care (n=3), the authors revised intervention content specific to the US healthcare system and culture. Patients' (n=13) and family caregivers' (n=10) reported MCC as attractive (70%, 80%), topically relevant (80%, 70%), and culturally appropriate, but felt that palliative care resources should be more Israel-specific.

CONCLUSION

The MCC tool is acceptable to potential users, warranting further pilot-testing.

The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness

CONTEXT

Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness.

OBJECTIVE

To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness.

METHODS

Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea).

RESULTS

Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness.

DISCUSSION

The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.

Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital

INTRODUCTION

Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age.

METHODS AND ANALYSIS

The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included.

ETHICS AND DISSEMINATION

The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT04857060; ClinicalTrials.gov.

Development of a national quality framework for palliative care in a mixed generalist and specialist care model: A whole-sector approach and a modified Delphi technique

In a predominantly biomedical healthcare model focused on cure, providing optimal, person-centred palliative care is challenging. The general public, patients, and healthcare professionals are often unaware of palliative care’s benefits. Poor interdisciplinary teamwork and limited communication combined with a lack of early identification of patients with palliative care needs contribute to sub-optimal palliative care provision. We aimed to develop a national quality framework to improve availability and access to high-quality palliative care in a mixed generalist-specialist palliative care model. We hypothesised that a whole-sector approach and a modified Delphi technique would be suitable to reach this aim. Analogous to the international AGREE guideline criteria and employing a whole-sector approach, an expert panel comprising mandated representatives for patients and their families, various healthcare associations, and health insurers answered the main question: ‘What are the elements defining high-quality palliative care in the Netherlands?’. For constructing the quality framework, a bottleneck analysis of palliative care provision and a literature review were conducted. Six core documents were used in a modified Delphi technique to build the framework with the expert panel, while stakeholder organisations were involved and informed in round-table discussions. In the entire process, preparing and building relationships took one year and surveying, convening, discussing content, consulting peers, and obtaining final consent from all stakeholders took 18 months. A quality framework, including a glossary of terms, endorsed by organisations representing patients and their families, general practitioners, elderly care physicians, medical specialists, nurses, social workers, psychologists, spiritual caregivers, and health insurers was developed and annexed with a summary for patients and families. We successfully developed a national consensus-based patient-centred quality framework for high-quality palliative care in a mixed generalist-specialist palliative care model. A whole-sector approach and a modified Delphi technique are feasible structures to achieve this aim. The process we reported may guide other countries in their initiatives to enhance palliative care.

Home-Based Palliative Care Organizations Struggle to Survive and Thrive in a Competitive Market

BACKGROUND

New opportunities to expand home-based palliative care (HBPC) highlight the need for novel data that explores how HBPC providers currently navigate this nascent business.

OBJECTIVES

To investigate how HBPC providers and their organizations sustain their operations in a rapidly evolving market.

STUDY DESIGN

This was an exploratory, qualitative study.

SETTING

We conducted focus groups with staff of nine HBPC organizations that held provider contracts with a large California insurance provider.

MEASUREMENT

A research team member experienced in qualitative methods conducted semi-structured focus group interviews with HBPC agency staff who were knowledgeable about their agency's patient recruitment and enrollment processes. Interview sessions of roughly an hour long were audio-recorded and transcribed verbatim. We used thematic analysis procedures to identify codes and themes.

RESULTS

We identified seven themes: market competition, market diversity, HBPC reimbursement, service standardization, hiring practices, marketing, strategic enrollment processes, and outcomes monitoring. The participants called for more standardization in their field. In discussing key business operations-hiring, marketing, patient enrollment, outcomes monitoring-they demonstrated inventiveness and willingness to innovate in order to succeed in a complex healthcare sector.

CONCLUSION

Our study expands on the literature by providing a glimpse of the challenges encountered by HBPC providers and their organizations and the myriad strategies they undertake to navigate a health-service area that lacks standardized practice and payment guidelines. Our findings suggest that HBPC agencies will continue to struggle in the absence of standardization in practice, payment, and quality oversight.

"If You Built It, They Could Come": Opportunities to Expand Access to Palliative Care

There are growing calls to broaden palliative care access to more populations, diseases, and care settings and to earlier in the disease process; yet, supply of specialty palliative care is not likely to keep pace with demand. This article discusses possible solutions by which to bridge the gap between limited palliative care supply and demand. The proposed solutions include: (1) specialist workforce development; (2) alternate models of care; (3) triaging systems; and (4) telemedicine. Education/training, research, and policy mechanisms could operationalize these solutions. With the solutions in hand, the field may be able to increase the reach, sustainability, and equity of palliative care, thereby improving access and enabling a multitude of positive patient, family, and health care system outcomes.

Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model

Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.

A Pilot Randomized Trial of an Interactive Web-based Tool to Support Surrogate Decision Makers in the Intensive Care Unit

Rationale: Breakdowns in clinician-family communication in intensive care units (ICUs) are common, yet there are no easily scaled interventions to prevent this problem.Objectives: To assess the feasibility, usability, acceptability, and perceived effectiveness of a communication intervention that pairs proactive family meetings with an interactive, web-based tool to help surrogates prepare for clinician-family meetings.Methods: We conducted a two-arm, single-blind, patient-level randomized trial comparing the Family Support Tool with enhanced usual care in two ICUs in a tertiary-care hospital. Eligible participants included surrogates of incapacitated patients judged by their physicians to have ≥40% risk of death or severe long-term functional impairment. The intervention group received unlimited tool access, with prompts to complete specific content upon enrollment and before two scheduled family meetings. Before family meetings, research staff shared with clinicians a one-page summary of surrogates' main questions, prognostic expectations, beliefs about the patient's values, and attitudes about goals of care. The comparator group received usual care enhanced with scheduled family meetings. Feasibility outcomes included the proportion of participants who accessed the tool before the first family meeting, mean number of logins, and average tool engagement time. We assessed tool usability with the System Usability Scale, assessed tool acceptability and perceived effectiveness with internally developed questionnaires, and assessed quality of communication and shared decision-making using the Quality of Communication questionnaire.Results: Of 182 screened patients, 77 were eligible. We enrolled 52 (67.5%) patients and their primary surrogate. Ninety-six percent of intervention surrogates (24/25) accessed the tool before the first family meeting (mean engagement time, 62 min ± 27.7) and logged in 4.2 times (±2.1) on average throughout the hospitalization. Surrogates reported that the tool was highly usable (mean, 82.4/100), acceptable (mean, 4.5/5 ± 0.9), and effective (mean, 4.4/5 ± 0.2). Compared with the control group, surrogates who used the tool reported higher overall quality of communication (mean, 8.9/10 ± 1.6 vs. 8.0/10 ± 2.4) and higher quality in shared decision-making (mean, 8.7/10 ± 1.5 vs. 8.0/10 ± 2.4), but the difference did not reach statistical significance.Conclusions: It is feasible to deploy an interactive web-based tool to support communication and shared decision-making for surrogates in ICUs. Surrogates and clinicians rated the tool as highly usable, acceptable, and effective.

The Essential Role of Occupational Therapy to Address Functional Needs of Individuals Living with Advanced Chronic Cancers

OBJECTIVE

Medical progress in cancer care has led to increased life expectancy outcomes across all stages of cancer, including in advanced cancers. People now living with advanced chronic cancers have unique, ongoing functional and quality-of-life needs. This article explores the functional considerations of individuals living with advanced chronic cancers in terms of managing chronic palliative care needs, assessing and intervening for functional issues, and consistently using occupational therapy in shared service provision together with medical and nursing teams. The unique and changing functional needs of these individuals may be effectively addressed through consideration of chronic palliative approaches to care; earlier access to occupational therapy services to facilitate continued engagement in everyday activities; and shared service provision with nursing to address both medical wellness and functional status.

DATA SOURCES

These include key databases (Pubmed, CINAHL), international guidelines, and professional guidance documents.

CONCLUSION

Individuals living with advanced chronic cancer have ongoing and fluctuating functional needs that should be addressed in palliative care service provision. The inclusion of occupational therapy as part of inter- and multidisciplinary teams can facilitate maximization of function for individuals living with advanced chronic cancer.

IMPLICATIONS FOR NURSING PRACTICE

Timely early referrals to occupational therapy can address functional issues as they arise, and can prepare individuals for future functional considerations.

Preparing Advanced Practice Registered Nursing Students to Provide Primary Palliative Care

BACKGROUND

Advanced practice registered nursing students need primary palliative care education to care for the growing number of patients with serious illness and their families and to fill the serious resource gaps in specialty palliative care.

PROBLEM

There has been a lack of primary palliative care education in most graduate nursing programs and little direction as to competencies and essential content.

APPROACH

In an effort to support faculty to teach palliative care content, the End-of-Life Nursing Education Consortium (ELNEC) has created an online curriculum that meets the new American Association of Colleges of Nursing Graduate-Competencies and Recommendations for Educating Nursing Students in primary palliative care for master's degree and doctor of nursing practice students.

OUTCOMES

During the first 9 months of its release, more than 170 nursing programs have accessed the ELNEC Graduate curriculum, and there have been more than 200 student completions.

CONCLUSION

Primary palliative care education is essential for all advanced practice nursing students. The new ELNEC Graduate curriculum offers the opportunity to provide quality education remotely.

Association of ACO Shared Savings Success and Serious Illness Spending

EXECUTIVE SUMMARY

Accountable care organizations (ACOs) need confidence in their return on investment to implement changes in care delivery that prioritize seriously ill and high-cost Medicare beneficiaries. The objective of this study was to characterize spending on seriously ill beneficiaries in ACOs with Medicare Shared Savings Program (MSSP) contracts and the association of spending with ACO shared savings. The population included Medicare fee-for-service beneficiaries identified with serious illness (N = 2,109,573) using the Medicare Master Beneficiary Summary File for 100% of ACO-attributed beneficiaries linked to MSSP beneficiary files (2014-2016). Lower spending for seriously ill Medicare beneficiaries and risk-bearing contracts in ACOs were associated with achieving ACO shared savings in the MSSP. For most ACOs, the seriously ill contribute approximately half of the spending and constitute 8%-13% of the attributed population. Patient and geographic (county) factors explained $2,329 of the observed difference in per beneficiary per year spending on seriously ill beneficiaries between high- and low-spending ACOs. The remaining $12,536 may indicate variation as a result of potentially modifiable factors. Consequently, if 10% of attributed beneficiaries were seriously ill, an ACO that moved from the worst to the best quartile of per capita serious illness spending could realize a reduction of $1,200 per beneficiary per year for the ACO population overall. Though the prevalence and case mix of seriously ill populations vary across ACOs, this association suggests that care provided for seriously ill patients is an important consideration for ACOs to achieve MSSP shared savings.

Examining Barriers and Facilitators to Palliative Care Access in Rural Areas: A Scoping Review

BACKGROUND

Despite the growth of palliative care (PC), access to PC remains challenging for rural Americans living with chronic diseases. Given the demand and benefits of PC, a comprehensive view of PC access would inform policymakers in developing PC services in rural areas.

OBJECTIVE

This scoping review aimed to understand the barriers and facilitators to PC access in rural areas from the voices of service users and service providers during the past decade.

METHODS

A scoping literature review was conducted from 2010 to 2020 using MEDLINE, CINAHL, and PsychINFO databases. Results: Twenty-eight studies met inclusion criteria. Barriers to PC access in rural areas mostly arose in structural issues: (1) the inadequate knowledge and awareness of PC among both service users and providers and (2) the poorly structured PC system. Other barriers included communication gaps/challenges between providers and patients/families and cultural barriers. The facilitators mainly originated in patients/families' connectedness with local providers and with other social networks such as friends.

CONCLUSIONS

These findings highlight the need for funding support to increase provider competency, service availability and accessibility, and the public knowledge and awareness of PC in rural areas. A holistic and tailored PC model that standardizes care delivery, referral and coordination, including family caregiver support programs, can improve care access. Future practice and research are warranted to implement and evaluate innovative approaches, such as a coordinated community-based approach, to the successful integration of PC in rural communities.

Frequency of providing a palliative approach to care in family practice: a chart review and perceptions of healthcare practitioners in Canada

Background

Most patients nearing the end of life can benefit from a palliative approach in primary care. We currently do not know how to measure a palliative approach in family practice. The objective of this study was to describe the provision of a palliative approach and evaluate clinicians’ perceptions of the results.

Methods

We conducted a descriptive study of deceased patients in an interprofessional team family practice. We integrated conceptual models of a palliative approach to create a chart review tool to capture a palliative approach in the last year of life and assessed a global rating of whether a palliative approach was provided. Clinicians completed a questionnaire before learning the results and after, on perceptions of how often they believed a palliative approach was provided by the team.

Results

Among 79 patients (mean age at death 73 years, 54% female) cancer and cardiac diseases were the top conditions responsible for death. One-quarter of patients were assessed as having received a palliative approach. 53% of decedents had a documented discussion about goals of care, 41% had nurse involvement, and 15.2% had a discussion about caregiver well-being. These indicators had the greatest discrimination between a palliative approach or not. Agreement that elements of a palliative approach were provided decreased significantly on the clinician questionnaire from before to after viewing the results.

Conclusions

This study identified measurable indicators of a palliative approach in family practice, that can be used as the basis for quality improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01400-4.

Geriatrics and palliative medicine leadership is needed now more than ever: What are the training gaps?

BACKGROUND

Geriatrics and palliative medicine specialists are uniquely trained to provide expert coordinated care for older adults and seriously ill and complex patients. Health system leadership geared towards this patient population is critically important as society ages. Currently, there is no standardized approach to teaching core leadership skills. To assess the leadership training needs of geriatrics and palliative medicine fellowship graduates, we conducted a needs assessment to identify (1) early career leadership trajectories and challenges and (2) knowledge and skills deemed essential for effective leadership.

METHODS

Individuals identified as leaders in geriatrics and/or palliative medicine completed an electronic survey and a semi-structured qualitative interview. These leaders were divided into two categories: Icahn School of Medicine at Mount Sinai (ISMMS) trained leaders or non-ISMMS trained leaders. The semi-structured interviews were recorded, transcribed, and reviewed using thematic analysis.

RESULTS

Within 1 year of fellowship graduation, 50% of ISMMS trained leaders had leadership positions; within 6 years, 100% had a leadership role. Based on qualitative interviews, both ISMMS trained leaders and non-ISMMS trained leaders perceived leadership training gaps in two domains: (1) knowledge and (2) skills. Knowledge and skill gap themes included communication and management, mentorship and negotiation, program development, knowledge, and apprenticeship.

CONCLUSION

Geriatrics and palliative medicine physicians obtained leadership roles quickly after fellowship. Both ISMMS trained leaders and non-ISMMS trained leaders often felt unprepared, learned "on the job," and sought out additional leadership training. Early leadership training is needed to prepare fellowship graduates for the pressing demands of accelerated leadership.

Place of Death for Persons With and Without Cognitive Impairment in the United States

BACKGROUND/OBJECTIVES

There is increasing recognition that place of death is an important component of quality of end-of-life care (EOLC) and quality of death. This study examined where older persons with and without cognitive impairment die in the United States, what factors contribute to place of death, and whether place of death influences satisfaction with EOLC.

DESIGN

Cross-sectional secondary data analysis.

SETTING

In-person interviews with community-dwelling proxy respondents.

PARTICIPANTS

Data were collected from 1,500 proxies for deceased participants in the National Health and Aging Trends Study (NHATS), a nationally-representative sample of community-dwelling Medicare beneficiaries aged 65 and older.

MEASUREMENTS

Study variables were obtained from the NHATS "last month of life" interview data. Survey weights were applied to all analyses.

RESULTS

Persons with cognitive impairment (CI) most often died at home, while cognitively healthy persons (CHP) were equally likely to die at home or in a hospital. Persons with CI who utilized the Medicare Hospice Benefit were 14.5 times more likely to die at home than in a hospital, and 3.4 times more likely to die at home than a nursing home. CHP who use this benefit were over six times more likely to die at home than in a hospital, and more than twice as likely to die at home than a nursing home. Place of death for CHP was also associated with age and race. Proxies of persons with CI who died at home rated EOLC as more favorable, while proxies of CHP rated in-home and hospital care equally.

CONCLUSION

Findings add to the scant literature identifying factors associated with place of death for older adults with and without CI and results suggest that place of death is a quality of care indicator for these populations. These findings may inform EOLC planning and policy-making and facilitate greater well-being at end-of-life.

Taking care of dying patients through an 'interprofessional ecosystem': a grounded theory study on the experience of an interprofessional team in palliative care

BACKGROUND

The interprofessional approach is part of the philosophy in palliative care, and its benefits are already documented. However, there are no evidence regarding the process through which the interprofessional team faces the process of the patient's end-of-life and how this experience might be of value for the team's development itself. The aim of this study was to analyse and understand the psychosocial processes that occurs when an interprofessional team accompanies patients and their families to death in palliative care, with the ultimate aim to develop a substantive theory to describe this phenomenon.

METHODS

A Grounded Theory method, as theorized by Strauss and Corbin, was adopted for this study. Data were collected through semi-structured interviews and then independently analysed using constant comparison analysis. Fourteen healthcare professionals - belonging to different disciplines (doctor, nurse coordinator, nurse, nurse assistant, psychologist) - were interviewed in a Northern Italy palliative care facility.

FINDINGS

The core category of this study was identified to be the process of accompaniment of the dying patient as an interprofessional ecosystem. Moreover, the results showed four main factors determining the development of the core psychosocial process: from professionals' 'Hidden Amazement' to 'Onerous Happiness' where 'Weaving of Professional Resources' and 'Work Meaning' are the underlying conditions to catalyse the process itself.

CONCLUSION

Interprofessional care appears an essential value, which becomes the source of the team's strength when facing end-of-life experiences. Health policies and organisations should take the importance of the characteristics of the work environment more carefully. The meaning that professionals attribute to their work and to the team itself, indeed, it may have impact on the overall quality of care and contribute to sustain work engagement, even in stressful situations like end-of-life care.

Avoided Hospitalization Criteria: Validating the Impact of a Community-Based Palliative Care Program

Objective: This report describes the experiences of a community-based palliative care (CBPC) program's efforts to understand the patterns of hospital utilization, specifically utilization reduction experienced by admitted patients. Efforts to quantify and describe an avoided hospitalization and opportunities to use these data to strengthen partnerships with local insurance payers to assure sustainability of the CBPC will be discussed. Background: Patients with serious chronic illness experience emergency room care and hospitalizations with increasing frequency as their health deteriorates. CBPC programs are well positioned to decrease hospital utilization by early involvement and improved care management. Methods: Arizona Palliative Home Care (AZPHC) program is a free standing CBPC in Maricopa County, Arizona, serving 3300 patients annually. An interdisciplinary team was formed within the CBPC to facilitate the identification of avoided hospital events and communicate these data to community partners in an effective and consistent manner. The processes developed by this team are described. Results: AZPHC has enhanced its hospitalization avoidance strategies by communicating the rate of hospitalization avoidance events in a consistent and strategic manner. Providing instances of avoided hospitalizations with accompanying patient narratives to payers has enabled AZPHC to demonstrate the impact the CBPC has on improving quality of care and reducing overall costs. Discussion: CBPC programs require payment for sustainability; therefore, partnerships with local insurance payers are essential. Presenting data that validate the impact of a program from a clinical and financial perspective will advance the growth of payer-CBPC provider relationships and secure a future for funded CBPC programs.

Models of outpatient neuropalliative care for patients with amyotrophic lateral sclerosis

Objective

To describe some current models of outpatient neuropalliative care (NPC) available to patients with amyotrophic lateral sclerosis at different institutions within the United States.

Methods

Six NPC physicians were asked to contribute written descriptions about the PC available in their ALS clinics. Descriptions were then compiled and assessed for similarities and differences.

Results

All clinics are multidisciplinary, with regular appointments every 3 months and similar appointment times for new visits (60–120 minutes) and follow-up visits (20–45 minutes). Four clinics have an NPC specialist embedded within the ALS clinic, 1 institution has a separate clinic for NPC, and 1 institution has both. The NPC physician at 5 institutions is a neurologist with formal palliative care training and at 1 institution is an internist with formal palliative care training. NPC is part of routine care for all patients at 2 institutions, and the primary reasons for consultation are goals of care (GOC) and severe symptom management.

Conclusion

NPC is provided to patients with ALS heterogeneously throughout the United States with some variation in services and delivery, but all clinics are addressing similar core needs. Given the poor prognosis and high PC needs, those with ALS are the ideal patients to receive NPC. Future studies are necessary given the paucity of data available to determine best practices and to better define meaningful outcomes.

A Methodologic Approach to Conducting a Statewide Community Needs Assessment of Pediatric Palliative Care and Hospice Resources

CONTEXT

Prior studies have indicated that pediatric palliative care (PPC) resources vary across states and within regions in a state. Evaluating the current status of PPC and pediatric hospice care through a community needs assessment (CNA) can help address the gaps that exist to improve and increase access to PPC for children in need.

OBJECTIVES

Using the state of Georgia as an example, the process, methods, lessons learned, and limitations in conducting a statewide PPC CNA are described.

METHODS

A mixed-method descriptive design with multiple stages incorporating different methodological approaches was used. These included literature review, community profile, survey and interview questionnaire development, windshield survey, identifying and interviewing key informants, and quantitative survey of the state's hospice organizations. Key themes (providing PPC, PPC environment, collaboration, and future of PPC) and subthemes emerged, which were then triangulated across all existing data collection techniques to provide recommendations of varying feasibility and importance.

RESULTS

Described in a subsequent article (Johnson K.A. et al.).

CONCLUSION

This approach can be used by other state organizations, coalitions, governments, or national organizations looking to perform a CNA of palliative care, hospice resources, or could be applied to other geographical settings or types of care.

Exploring a New Model of End-of-Life Care for Older People That Operates in the Space Between the Life World and the Healthcare System: A Qualitative Case Study

BACKGROUND

Innovative service models to facilitate end-of-life care for older people may be required to enable and bolster networks of care. The aim of this study was to understand how and why a new charitably funded service model of end-of-life care impacts upon the lives of older people.

METHODS

A multiple exploratory qualitative case study research strategy. Cases were 3 sites providing a new end-oflife service model for older people. The services were provided in community settings, primarily providing support in peoples own homes. Study participants included the older people receiving the end-of-life care service, their informal carers, staff providing care within the service and other stakeholders. Data collection included individual interviews with older people and informal carers at 2 time points, focus group interviews with staff and local stakeholders, nonparticipant observation of meetings, and a final cross-case deliberative panel discussion workshop. Framework analysis facilitated analysis within and across cases.

RESULTS

Twenty-three service users and 5 informal carers participated in individual interviews across the cases. Two focus groups were held with an additional 12 participants, and 19 people attended the deliberative panel workshop. Important elements contributing to the experience and impacts of the service included organisation, where services felt they were 'outsiders,' the focus of the services and their flexible approach; and the impacts particularly in enriching relationships and improving mental health.

CONCLUSION

These end-of-life care service models operated in a space between the healthcare system and the person's life world. This meant there could be ambiguity around their services, where they occupied a liminal, but important, space. These services are potentially important to older people, but should not be overly constrained or they may lose the very flexibility that enables them to have impact.

Original Research: Understanding Nursing Home Staff Attitudes Toward Death and Dying: A Survey

BACKGROUND

Nearly 70% of nursing home residents are eligible for palliative care, yet few receive formal palliative care outside of hospice. Little is known about nursing home staff attitudes, knowledge, skills, and behaviors related to palliative care.

METHODS

We administered a modified survey measuring attitudes toward death to 146 nursing home staff members, including both clinical and nonclinical staff, from 14 nursing homes.

RESULTS

Nursing home staff generally reported feeling comfortable caring for the dying, but half believed the end of life is a time of great suffering. Pain control (63%), loneliness (52%), and depression (48%) were the most important issues identified with regard to these patients, and there was ambivalence about the use of strong pain medications and the utility of feeding tubes at the end of life. Top priorities identified for improving palliative care included greater family involvement (43%), education and training in pain control (50%) and in management of other symptoms (37%), and use of a palliative care team (35%) at their facility.

CONCLUSIONS

Findings show there is a need for more palliative care training and education, which should be built on current staff knowledge, skills, and attitudes toward palliative care.

Quality of Palliative and End-Of-Life Care in Hong Kong: Perspectives of Healthcare Providers

Background: In response to population aging, there is a need for health systems to focus on care for chronic disease, specifically palliative care, while focusing on people-centered care. The objective of this study is to explore the healthcare system enablers and barriers to the provision of quality palliative and end-of-life care from the perspective of healthcare professionals. Materials and Methods: Using purposive sampling, fifteen focus group interviews and nine individual interviews involving 72 healthcare providers were conducted. Primary qualitative data were collected between May 2016 and July 2017. All recorded discussions were transcribed verbatim and analyzed. A thematic framework was developed. Results: The provision of quality palliative and end-of-life care is influenced by the interaction and integration of nine sub-themes under four identified themes: (1) political context; (2) organization setting; (3) support to patients, caregivers, and family members, and (4) healthcare workers and the public. Conclusions: Integration of palliative and end-of-life care is an important pillar of healthcare service to improve quality of life by addressing patients’ values, wishes and preference, and assist their family to handle challenges at the end stage of life. Further improvements to the service framework would be required, specifically in the political framework, multidisciplinary approach, and readiness and competence in healthcare workers and community. These were highlighted in our study as key components in service provision to ensure that patients can receive continuous and integrated care between hospitals and the community as well as dignified care at the end stage of life.

Lack of Awareness and Common Misconceptions About Palliative Care Among Adults: Insights from a National Survey

BACKGROUND

Despite recent growth in palliative care programs palliative care remains underutilized. Studies suggest that patients and providers commonly associate palliative care with end of life, often leading to misconceptions and late referrals.

OBJECTIVE

To characterize self-reported palliative care knowledge and misconceptions about palliative care among US adults and demographic, health, and social role factors associated with knowledge and misconceptions.

DESIGN

We conducted secondary data analysis of nationally representative, self-reported data from the 2018 Health Information National Trends Survey (HINTS) 5, Cycle 2. We examined associations between knowledge and misconceptions about palliative care together with demographics, health care access, health status, and social roles.

PARTICIPANTS

3504 US adults. 2594 included in the first analysis after omitting missing cases; 683 who reported knowing about palliative care were included in the second analysis.

MAIN MEASURES

Palliative care knowledge was self-reported in response to: "How would you describe your level of knowledge about palliative care?" Level of misconceptions was based on a series of factual and attitudinal statements about palliative care.

KEY RESULTS

Among US adults, 28.8% report knowing about palliative care, but only 12.6% report knowing what palliative care is and hold no misconceptions. Those most likely to report knowing about palliative care are female, college-educated, higher income, have a primary health care provider, or are a caregiver. Among those who report knowing about palliative care, misconceptions were common: 44.4% automatically think of death, 38.0% equate palliative care with hospice, 17.8% believe you must stop other treatments, and 15.9% see palliative care as giving up.

CONCLUSIONS

US adults who have some knowledge of palliative care are most likely to confuse it with hospice but are less likely to see it as requiring forgoing treatment or as giving up. Primary care clinicians should be encouraged to communicate about palliative care with patients.

Supportive Care for Superutilizers of a Managed Care Organization

Background: Ohana Health Plan, Inc., (OHP) is one of the first managed care organizations offering supportive care services targeted to superutilizers. Bristol Hospice Hawaii, LLC, partnered with OHP to provide interdisciplinary supportive care services to home-bound OHP members. Objectives: The purpose of this study was to measure symptom relief, satisfaction, resource utilization, and cost savings associated with supportive care. Design: Prospective study. Setting: Over 12 months, 27 superutilizer members residing in the community were referred by OHP, 21 members were enrolled into supportive care. Measurements: Data were collected upon admission and repeatedly thereafter using the Edmonton Symptom Assessment Scale (ESAS) and the Missoula-Vitas Quality of Life Index (MVQOLI). The Family Satisfaction with Advanced Cancer Care (FAMCARE) Scale was administered at discharge. Emergency department (ED) visits and hospital utilization were tracked. Results: Median age was 63 years; more than half had cardiac diagnoses. Majority of members were Hawaiian and other Pacific Islander. Median length of stay in supportive care was 90 days. Five (23%) members enrolled in hospice following supportive care. Symptom improvement occurred in pain (p < 0.0001), anxiety (p = 0.0052), and shortness of breath (p = 0.0447). This model has shown a 79.5% reduction of ED visits per thousand members and a 75% reduction of hospitalizations per thousand. Overall net savings was 36%. Discussions and documentation of end-of-life wishes increased from 23% to 85%. Conclusion: Supportive care is highly effective in reducing costs associated with superutilizers. Our experience demonstrates the effectiveness of supportive care approaches in this population through improved care and lower health care costs overall.