Frequency, Timing, and Predictors of Palliative Care Consultation in Patients with Advanced Cancer at a Tertiary Cancer Center: Secondary Analysis of Routinely Collected Health Data

INTRODUCTION

Early integration of palliative care (PC) with oncological care is associated with improved outcomes in patients with advanced cancer. Limited information exists on the frequency, timing, and predictors of PC consultation in patients receiving oncological care. The Cross Cancer Institute (CCI) is the sole tertiary cancer center serving the northern half of the Canadian province of Alberta, located in the city of Edmonton. The objectives of this study were to estimate the proportion of patients with advanced cancer at the CCI who received consultation by the CCI PC program and the comprehensive integrated PC program in Edmonton, and to determine the timing and predictors of consultation.

MATERIALS AND METHODS

In this secondary analysis of routinely collected health data, adult patients who died between April 2013 and March 2014, and had advanced disease while under the care of a CCI oncologist, were eligible. Data from the Alberta Cancer Registry, electronic medical records, and Edmonton PC program database were linked.

RESULTS

Of 2,253 eligible patients, 810 (36%) received CCI PC consultation. Median time between consultation and death was 2 months (range, 1.1-5.4). In multivariable logistic regression analysis, age, residence, income, cancer type, and interval from advanced cancer diagnosis to death influenced odds of receiving consultation. Among 1,439 patients residing in Edmonton, 1,121 (78%) were referred to the Edmonton PC program.

CONCLUSION

A minority of patients with advanced cancer received PC consultation at the tertiary cancer center, occurring late in the disease trajectory. Frequency and timing of PC consultation varied significantly, according to multiple factors.

IMPLICATIONS FOR PRACTICE

Clinical and demographic factors are associated with variations in frequency and timing of palliative care consultation at a cancer center and may, in some cases, reflect barriers to access that warrant attention.

Continuous Palliative Sedation for Existential Distress? A Survey of Canadian Palliative Care Physicians' Views

BACKGROUND

Palliative sedation can be used for refractory symptoms during end-of-life care. However, continuous palliative sedation (CPS) for existential distress remains controversial due to difficulty determining when this distress is refractory.

OBJECTIVES

The aim was to determine the opinions and practices of Canadian palliative care physicians regarding CPS for existential distress.

METHODS

A survey focusing on experience and views regarding CPS for existential distress was sent to 322 members of the Canadian Society of Palliative Care Physicians.

RESULTS

Eighty-one surveys returned (accessible target, 314), resulting in a response rate of 26%. One third (31%) of the respondents reported providing CPS for existential distress. On a 5-point Likert-type scale, 40% of participants disagreed, while 43% agreed that CPS could be used for existential distress alone.

CONCLUSION

Differing opinions exist regarding this complex and potentially controversial issue, necessitating the education of health-care professionals and increased awareness within the general public.

Attitude and support to inform clinical predictions of survival in patients with advanced cancer

39

Background: Tumour factors (eg primary site, size) helpful in prognostication in early stage cancer may be less important than patient factors, such as Karnofsky performance status (KPS), later in the disease trajectory. We evaluated the utilization of the parameters attitude (ATT) and psychosocial support (PSS) in predicting remaining lifespan by two experienced multidisciplinary teams (MDT). Methods: After clinical assessment of consecutive patients, a quantitative clinical prediction of survival (CPS) was made prospectively, independently and anonymously by each health care provider (HCP). HCP recorded up to 4 factors (free-text) influencing their CPS. The Palliative Radiation Oncology (06/2010-12/2014) and Palliative Care (06/2012-01/2014) teams participated. Demographics, disease information, and date of death were abstracted. Summary statistics (means, standard deviations, and proportions) were calculated. Estimates for actual survival (AS) were obtained. Wilcoxon tests compared continuous variables and chi-square tests were used for categorical variables. Results: 2,582 predictions were made by 11 disciplines for 881 unique patients over 1,054 clinic visits. Median age was 66 years, 58.6% were male and 37.3% had lung cancer. KPS, when recorded, was ≥ 70 at 46.3% of visits. Cognitive status was below expected for 174/460 visits. Mean AS was 177 ± 190 days and mean CPS was 258 ± 300 days. The median number of factors cited was 4 (range 0-4), with disease extent most common. ATT and PSS as perceived by the HCP influenced 6.7% and 5.8% of CPS respectively, varying across disciplines (p < 0.0001). Overall, mean CPS was significantly longer when ATT (337d vs 252d; p < 0.0001) or PSS (310d vs 254d; p < 0.004) was quoted. CPS estimates by Nursing and Students were longer when ATT was mentioned (both p < 0.004). Students’ CPS were longer when PSS was described (p = 0.048). Mean AS was also longer when ATT (259d vs 178d; p < 0.0001) or PSS (224d vs 181d; p = 0.03) were cited overall, as well as within the Nursing, Student and Pharmacist groups (all p < 0.05). Conclusions: Attitude and available psychosocial support as evaluated by MDT appeared to correlate with both clinical prediction of survival and actual survival in this cohort.

High-risk indicators for family involvement in social work in health care: a review of the literature

Shifts in health concerns, fiscal restraints, technological advances, and demands for accountability have created severe tensions within health care settings. New demands point to the need for a redefinition of services. High-risk screening appears to be a clear method of delineating service need. A review of the empirical literature highlights individual, family, and illness variables that alone and together may improve identification of patients and families in need of social work services. The development of screening mechanisms may be a useful vehicle for improved psychosocial care and for the planning of social work services.

Physical and genetic mapping of cloned ribosomal DNA from Toxoplasma gondii: primary and secondary structure of the 5S gene

The ribosomal DNA (rDNA encoding rRNA) of the obligately intracellular protozoan parasite, Toxoplasma gondii, was identified, cloned, physically mapped, its copy number determined, and the 5S gene sequenced. Using total RNA as a probe, a collection of recombinant lambda phages containing copies of rDNA were isolated from a lambda 2001 tachyzoite genomic library. Northern gel hybridization confirmed specific homology of the 7.5-kb rDNA unit, subcloned into pTZ18R, to T. gondii rRNA. The mapped rDNA found in pTOX1 contained small ribosomal subunit (SS; 18S)- and large ribosomal subunit (LS; 26S)-encoding genes localized using intragenic heterologous probes from the conserved sequences of the SS (18S) and LS (28S) Xenopus laevis genes. the physical mapping data, together with partial digestion experiments and Southern gel hybridization, confirmed a 7.5-kb rDNA unit arranged in a simple head-to-tail fashion that is tandemly repeated. We estimated the rDNA repeat copy number in T. gondii to be 110 copies per haploid tachyzoite genome. Parts of the SS gene and the complete 5S gene were sequenced. The 5S gene was found to be within the rDNA locus, a rare occurrence found only in some fungi and protozoa. Secondary-structure analysis revealed an organization remarkably similar to the 5S RNA of eukaryotes.

Enhanced Ia expression by alveolar macrophages following intratracheal administration of bleomycin to rats

Bleomycin is an important anticancer drug that causes severe, and sometimes life-threatening, pulmonary toxicity. Initially, there is an acute inflammation followed by an irreversible pulmonary fibrosis. Our studies have focussed on the effects of the acute pulmonary inflammation on the state of alveolar macrophage activation. To study this, we administered a single dose of 3.6 mg bleomycin/kg body weight intratracheally to rats and obtained alveolar macrophages at selected times thereafter. Ia expression was determined by fluorescent microscopy of cells labelled with a fluorochrome-tagged antibody against rat Ia molecules. We report that: 1.) alveolar macrophages have elevated Ia expression shortly after receiving intratracheally administered bleomycin; 2.) Ia expression is not limited to a specific subpopulation of alveolar macrophages; 3.) Ia expression is transient in nature returning to control levels 7-14 days after bleomycin administration; and, 4.) the degree of upregulation of Ia expression is directly related to the dose of bleomycin administered.

Calibration method for small animal indirect calorimeters

A simple mini-butane burner or "artificial rat," for calibration of small animal indirect calorimeters (modified Benedict and Haldane systems), was developed. Substitution of this burner for a live animal at regular intervals in an experimental protocol provides a means by which whole system function can be verified without disturbing respirometer conditions. Heat production, degree of total combustion of butane, proportion of unburned butane, and the CO2 production (VCO2)-to-O2 consumption (VO2) ratio were determined in animal and burner experiments by direct measurement or were derived from mass equations. Burner security was also discussed. VCO2/VO2 obtained in calibration experiments using the Benedict system remained constant and was not significantly different from the expected value for total combustion of butane. Observation of a stabilization phase in the Haldane burner experiments illustrated the utility of calibration over the duration of a normal animal experiment. This miniburner gave highly reproducible results and simulated the daily VO2, VCO2, and heat production of an adult rat.

Development of gene probes and evolutionary relationships of the PSE-4 bla gene to plasmid-mediated beta-lactamases of gram-negative bacteria

Six types of plasmid-mediated carbenicillinases can be distinguished on the basis of their substrate profiles, molecular mass isoelectric values and immunological properties. As yet, no structural classification has been attempted for these enzymes at the molecular level. We have isolated the PSE-4 structural gene responsible for carbenicillinase production in Pseudomonas aeruginosa strain Dalgleish and studied its expression in E. coli. A detailed physical map of the cloned fragment and the construction of deletion mutants permitted the precise localization of the PSE-4 structural gene. Various restriction endonuclease fragments known to be flanking or internal to the PSE-4 bla gene were used as DNA probes and tested for homologous sequences in other beta-lactamase genes. A collection of three restriction fragment probes internal or delimiting the PSE-4 structural gene were hybridized with purified plasmid DNA coding for 18 other beta-lactamases. Under high stringency conditions, only the PSE-1, CARB-3 and CARB-4 genes cross-hybridized with PSE-4; while one of the probes tested hybridized solely with CARB-3. Further analysis indicated that the PSE-1, PSE-4, CARB-3 and CARB-4 bla genes are related and could presumably have evolved from a common progenitor.