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Miyashita M, Evans CJ, Yi D, Gomes B, Gao W. Symptom burden, service use and care dissatisfaction among older adults with cancer, cardiovascular disease, respiratory disease, dementia and neurological disease during the last 3 months before death: A pooled analysis of mortality follow-back surveys. Palliat Med 2024:2692163241246049. [PMID: 38679837 DOI: 10.1177/02692163241246049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
BACKGROUND Variation in the provision of care and outcomes in the last months of life by cancer and non-cancer conditions is poorly understood. AIMS (1) To describe patient conditions, symptom burden, practical problems, service use and dissatisfaction with end-of-life care for older adults based on the cause of death. (2) To explore factors related to these variables focussing on the causes of death. DESIGN Secondary analysis of pooled data using cross-sectional mortality follow-back surveys from three studies: QUALYCARE; OPTCare Elderly; and International Access, Right, and Empowerment 1. SETTING/PARTICIPANTS Data reported by bereaved relatives of people aged ⩾75 years who died of cancer, cardiovascular disease, respiratory disease, dementia or neurological disease. RESULTS The pooled dataset contained 885 responses. Overall, service use and circumstances surrounding death differed significantly across causes of death. Bereaved relatives reported symptom severity from moderate to overwhelming in over 30% of cases for all causes of death. Across all causes of death, 28%-38% of bereaved relatives reported some level of dissatisfaction with care. Patients with cardiovascular disease and dementia experienced lower symptom burden and dissatisfaction than those with cancer. The absence of a reliable key health professional was consistently associated with higher symptom burden (p = 0.002), practical problems (p = 0.001) and dissatisfaction with care (p = 0.001). CONCLUSIONS We showed different trajectories towards death depending on cause. Improving symptom burden and satisfaction in patients at the end-of-life is challenging, and the presence of a reliable key health professional may be helpful.
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Affiliation(s)
- Mitsunori Miyashita
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
- Department of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan, Japan
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Deokee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Barbara Gomes
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
- School of Public Health, Jiangxi Medical College, Nanchang University, Nanchang, China
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Evans CJ, van den Berg MEL, Lewis LK. Physiotherapy for people with dementia: a Call to Action for the development of clinical guidelines. Physiotherapy 2024; 122:27-29. [PMID: 38241940 DOI: 10.1016/j.physio.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/10/2023] [Indexed: 01/21/2024]
Affiliation(s)
- C J Evans
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, PO Box 2100, Sturt Rd, Bedford Park, SA 5042, Australia.
| | - M E L van den Berg
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, PO Box 2100, Sturt Rd, Bedford Park, SA 5042, Australia
| | - L K Lewis
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, PO Box 2100, Sturt Rd, Bedford Park, SA 5042, Australia
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Mitchell S, Turner N, Fryer K, Beng J, Ogden ME, Watson M, Gardiner C, Bayly J, Sleeman KE, Evans CJ. A framework for more equitable, diverse, and inclusive Patient and Public Involvement for palliative care research. Res Involv Engagem 2024; 10:19. [PMID: 38331966 PMCID: PMC10851547 DOI: 10.1186/s40900-023-00525-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/30/2023] [Indexed: 02/10/2024]
Abstract
BACKGROUND There are marked inequalities in palliative care provision. Research is needed to understand how such inequalities can be addressed, so that everyone living with advanced illness can receive the care they need, when they need it. Research into inequalities in palliative care should be guided by Patient and Public Involvement (PPI) that includes people from diverse backgrounds, who are less likely to receive specialist services. Multi-disciplinary research partnerships, bringing together primary care (the main providers of palliative care to diverse communities) and specialist palliative care, have the potential to work together in new ways to do research to address inequalities and improve palliative care in practice. This report describes a research partnership between primary care and palliative care that aimed to: (1) create opportunities for more inclusive PPI in palliative care research, (2) co-design new resources to support more equitable, diverse and inclusive PPI for palliative care, (3) propose a new framework for inclusive PPI in palliative care research. METHODS PPI members were recruited via primary care and palliative care research networks from three diverse areas of the UK. A pragmatic, collaborative approach was taken to achieve the partnership aims. Online workshops were carried out to understand barriers to inclusive PPI in palliative care and to co-design resources. Evaluation included a "you said, we did" impact log and a short survey. The approach was informed by good practice principles from previous PPI, and existing theory relating to equity, equality, diversity, and inclusion. RESULTS In total, 16 PPI members were recruited. Most were White British (n = 10), other ethnicities were Asian (n = 4), Black African (n = 1) and British mixed race (n = 1). The research team co-ordinated communication and activities, leading to honest conversations about barriers to inclusive PPI. Resources were co-designed, including a role description for an Equity, Equality, Diversity and Inclusion Champion, a "jargon buster", an animation and an online recipe book ( http://www.re-equipp.co.uk/ ) to inform future PPI. Learning from the partnership has been collated into a new framework to inform more inclusive PPI for future palliative care research. CONCLUSION Collaboration and reciprocal learning across a multi-disciplinary primary care and palliative care research partnership led to the development of new approaches and resources. Research team commitment, shared vision, adequate resource, careful planning, relationship building and evaluation should underpin approaches to increase equality, diversity and inclusivity in future PPI for palliative care research.
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Affiliation(s)
- Sarah Mitchell
- Division of Primary Care, Palliative Care and Public Health, Leeds Institute of Health Sciences, University of Leeds, Clarendon Road, Leeds, UK.
| | - Nicola Turner
- School of Health Sciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Kate Fryer
- Academic Unit of Primary Medical Care, University of Sheffield, Herries Road, Sheffield, UK
| | - Jude Beng
- Academic Unit of Primary Medical Care, University of Sheffield, Herries Road, Sheffield, UK
| | - Margaret E Ogden
- Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London, Cicely Saunders Institute of Palliative Care, London, UK
| | - Melanie Watson
- Health Sciences School, University of Sheffield, 3a Clarkehouse Rd, Sheffield, UK
| | - Clare Gardiner
- Health Sciences School, University of Sheffield, 3a Clarkehouse Rd, Sheffield, UK
| | - Joanne Bayly
- Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London, Cicely Saunders Institute of Palliative Care, London, UK
- St Barnabas Hospices, Worthing, UK
| | - Katherine E Sleeman
- Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London, Cicely Saunders Institute of Palliative Care, London, UK
| | - Catherine J Evans
- Policy and Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Kings College London, Cicely Saunders Institute of Palliative Care, London, UK
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Aworinde J, Evans CJ, Gillam J, Ramsenthaler C, Davies N, Ellis‐Smith C. Co-design of the EMBED-Care Framework as an intervention to enhance shared decision-making for people affected by dementia and practitioners, comprising holistic assessment, linked with clinical decision support tools: A qualitative study. Health Expect 2024; 27:e13987. [PMID: 38343168 PMCID: PMC10859658 DOI: 10.1111/hex.13987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 01/17/2024] [Accepted: 01/27/2024] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION Shared decision-making intends to align care provision with individuals' preferences. However, the involvement of people living with dementia in decision-making about their care varies. We aimed to co-design the EMBED-Care Framework, to enhance shared decision-making between people affected by dementia and practitioners. METHODS A theory and evidence driven co-design study was conducted, using iterative workshops, informed by a theoretical model of shared decision-making and the EMBED-Care Framework (the intervention) for person-centred holistic palliative dementia care. The intervention incorporates a holistic outcome measure for assessment and review, linked with clinical decision-support tools to support shared decision-making. We drew on the Medical Research Council (MRC) guidance for developing and evaluating complex interventions. Participants included people with dementia of any type, current or bereaved family carers and practitioners. We recruited via established dementia groups and research and clinical networks. Data were analysed using reflexive thematic analysis to explore how and when the intervention could enhance communication and shared decision-making, and the requirements for use, presented as a logic model. RESULTS Five co-design workshops were undertaken with participants comprising people affected by dementia (n = 18) and practitioners (n = 36). Three themes were generated, comprising: (1) 'knowing the person and personalisation of care', involving the person with dementia and/or family carer identifying the needs of the person using a holistic assessment. (2) 'engaging and considering the perspectives of all involved in decision-making' required listening to the person and the family to understand their priorities, and to manage multiple preferences. (3) 'Training and support activities' to use the Framework through use of animated videos to convey information, such as to understand the outcome measure used to assess symptoms. CONCLUSIONS The intervention developed sought to enhance shared decision-making with individuals affected by dementia and practitioners, through increased shared knowledge of individual priorities and choices for care and treatment. The workshops generated understanding to manage disagreements in determining priorities. Practitioners require face-to-face training on the intervention, and on communication to manage sensitive conversations about symptoms, care and treatment with individuals and their family. The findings informed the construction of a logic model to illustrate how the intervention is intended to work.
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Affiliation(s)
- Jesutofunmi Aworinde
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Catherine J. Evans
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
- Sussex Community NHS Foundation TrustBrightonUK
| | - Juliet Gillam
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
| | - Christina Ramsenthaler
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
- Department of Health SciencesZurich University of Applied Sciences (ZHAW)WinterthurSwitzerland
- Hull York Medical School, Wolfson Palliative Care Research CentreUniversity of HullHullEngland
| | - Nathan Davies
- Research Department of Primary Care and Population HealthCentre for Aging Population Studies, University College LondonLondonUK
| | - Clare Ellis‐Smith
- Cicely Saunders Institute of Palliative Care, Policy and RehabilitationKing's College LondonLondonUK
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Greenish D, Evans CJ, Khine CK, Rodrigues JCL. The thymus: what's normal and what's not? Problem-solving with MRI. Clin Radiol 2023; 78:885-894. [PMID: 37709611 DOI: 10.1016/j.crad.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 09/16/2023]
Abstract
Anterior mediastinal masses can be difficult to characterise on computed tomography (CT) due to the wide spectrum of normal appearances of thymic tissue as well as the challenge of differentiating between benign and malignant pathologies. Additionally, attenuation of cystic mediastinal lesions can be misinterpreted on CT due to varying attenuation values. Anecdotally, non-vascular magnetic resonance imaging (MRI) of the thorax is underutilised across radiology departments in the UK, but has been shown to improve diagnostic certainty and reduce unnecessary surgical intervention. T2-weighted MRI is useful in confirming the cystic nature of lesions, whereas chemical shift techniques can be utilised to document the presence of macroscopic and intra-cellular fat and thus help distinguish between benign and malignant pathologies. In this review article, we present a practical approach to using MRI for the characterisation of anterior mediastinal lesions based on our clinical experience in a UK district general hospital.
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Affiliation(s)
- D Greenish
- Department of Radiology, Royal United Hospital, Combe Park, Bath BA13NG, UK
| | - C J Evans
- Department of Radiology, Royal United Hospital, Combe Park, Bath BA13NG, UK
| | - C K Khine
- Department of Radiology, Royal United Hospital, Combe Park, Bath BA13NG, UK
| | - J C L Rodrigues
- Department of Radiology, Royal United Hospital, Combe Park, Bath BA13NG, UK; Department of Health, University of Bath, Bath, UK.
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Williamson LE, Sleeman KE, Evans CJ. Exploring access to community care and emergency department use among people with dementia: A qualitative interview study with people with dementia, and current and bereaved caregivers. Int J Geriatr Psychiatry 2023; 38:e5966. [PMID: 37485729 DOI: 10.1002/gps.5966] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 06/27/2023] [Indexed: 07/25/2023]
Abstract
OBJECTIVES Emergency department (ED) attendance is common among people with dementia and associated with poor health outcomes. Literature suggests a link between access to community care and the ED, but we know little about the mechanisms behind this link. This study aimed to explore experiences of accessing community and emergency care among people affected by dementia. METHODS Informed by critical realism, semi-structured online and telephone interviews were conducted with people with dementia and family caregivers, with and without experience of using the ED. Participants were recruited from across the United Kingdom using purposive sampling with maximum variation. A mostly experiential reflexive thematic analysis approach was used, applying the candidacy model of access to deepen interpretation. RESULTS Two dyad and 33 individual interviews were conducted with 10 people with dementia, 11 current caregivers and 16 bereaved caregivers (men = 11, 70-89 years = 18, white ethnicity = 32). Three themes are reported: (1) Navigating a 'push system', (2) ED as the 'last resort', and (3) Taking dementia 'seriously'. Themes describe a discrepancy between the configuration of services and the needs of people affected by dementia, who resort to the ED in the absence of accessible alternatives. Underlying this discrepancy is a lack of systemic prioritisation of dementia and wider societal stigma. CONCLUSION Although a last resort, ED attendance is frequently the path of least resistance for people with dementia who encounter multiple barriers for timely, responsive access to community health and social care. Greater systemic prioritisation of dementia as a life-limiting condition may help to reduce reliance on the ED through essential development of post-diagnostic care, from diagnosis to the end of life.
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Affiliation(s)
- Lesley E Williamson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, London, UK
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, London, UK
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
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O'Hara L, Evans CJ, Bowers B. Family carers' administration of injectable medications at the end of life: a service evaluation of a novel intervention. Br J Community Nurs 2023; 28:284-292. [PMID: 37261983 DOI: 10.12968/bjcn.2023.28.6.284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Timely and safe administration of injectable medications for patients at home is vital in optimally managing distressing symptoms in the final days of life. This article discusses a service evaluation of family carers' (including close friends) administrating subcutaneous end-of-life medications. The procedure was not intended to become normal care, rather the exception when appropriate and needed, with 24/7 skilled support from community nursing and palliative care services. A service evaluation of the procedure was undertaken in rural and urban areas in the South East of England. The procedure ran over 6 months and used detailed processes with recruitment criteria to mitigate risk of harm. In total, 11 patients participated with their family carers, including five carers with experience in healthcare roles. Of the 11 family carers, 10 were able to administer injections safely with structured training and support in place. Patients received timely symptom relief and their family carers were able to support loved ones by administering injectable medications rapidly without waiting for a nurse to arrive. This was particularly welcomed in more rural areas where waiting times were greater due to the large geographical area covered and limited staff availability during out-of-hours periods. The findings informed a carefully monitored wider rollout and ongoing evaluation in adult community nursing services in the NHS Trust.
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Affiliation(s)
- Lisa O'Hara
- Nurse Consultant, Palliative and End of Life Care (PEoLC), Sussex Community NHS Foundation Trust
| | - Catherine J Evans
- Professor of Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London; Honorary Nurse Consultant, Sussex Community NHS Foundation Trust
| | - Ben Bowers
- Wellcome Post-Doctoral Research Fellow, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge; Community Nursing Research Consultant, Queen's Nursing Institute, London; Honorary Nurse Consultant in Palliative Care, Cambridgeshire and Peterborough NHS Foundation Trust
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Bradshaw A, Ostler S, Goodman C, Batkovskyte I, Ellis-Smith C, Tunnard I, Bone AE, Barclay S, Vernon M, Higginson IJ, Evans CJ, Sleeman KE. Provision of palliative and end-of-life care in UK care homes during the COVID-19 pandemic: A mixed methods observational study with implications for policy. Front Public Health 2023; 11:1058736. [PMID: 36998280 PMCID: PMC10043445 DOI: 10.3389/fpubh.2023.1058736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/17/2023] Open
Abstract
Introduction Little consideration has been given to how the provision of palliative and end-of-life care in care homes was affected by COVID-19. The aims of this study were to: (i) investigate the response of UK care homes in meeting the rapidly increasing need for palliative and end-of-life care during the COVID-19 pandemic and (ii) propose policy recommendations for strengthening the provision of palliative and end-of-life care within care homes. Materials and methods A mixed methods observational study was conducted, which incorporated (i) an online cross-sectional survey of UK care homes and (ii) qualitative interviews with care home practitioners. Participants for the survey were recruited between April and September 2021. Survey participants indicating availability to participate in an interview were recruited using a purposive sampling approach between June and October 2021. Data were integrated through analytic triangulation in which we sought areas of convergence, divergence, and complementarity. Results There were 107 responses to the survey and 27 interviews. We found that (i) relationship-centered care is crucial to high-quality palliative and end-of-life care within care homes, but this was disrupted during the pandemic. (ii) Care homes' ability to maintain high-quality relationship-centered care required key "pillars" being in place: integration with external healthcare systems, digital inclusion, and a supported workforce. Inequities within the care home sector meant that in some services these pillars were compromised, and relationship-centered care suffered. (iii) The provision of relationship-centered care was undermined by care home staff feeling that their efforts and expertise in delivering palliative and end-of-life care often went unrecognized/undervalued. Conclusion Relationship-centered care is a key component of high-quality palliative and end-of-life care in care homes, but this was disrupted during the COVID-19 pandemic. We identify key policy priorities to equip care homes with the resources, capacity, and expertise needed to deliver palliative and end-of-life care: (i) integration within health and social care systems, (ii) digital inclusivity, (iii) workforce development, (iv) support for care home managers, and (v) addressing (dis)parities of esteem. These policy recommendations inform, extend, and align with policies and initiatives within the UK and internationally.
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Affiliation(s)
- Andy Bradshaw
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Sophia Ostler
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Claire Goodman
- Center for Research in Public Health and Community Care (CRIPACC), University of Hertfordshire, Hatfield, United Kingdom
| | - Izabele Batkovskyte
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Clare Ellis-Smith
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - India Tunnard
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Anna E. Bone
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Martin Vernon
- Tameside and Glossop Integrated Care NHS Foundation Trust, Ashton-under-Lyne, United Kingdom
| | - Irene J. Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
| | - Catherine J. Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
- Sussex Community NHS Foundation Trust, Brighton, United Kingdom
| | - Katherine E. Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, United Kingdom
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Kawashima A, Evans CJ. Needs-based triggers for timely referral to palliative care for older adults severely affected by noncancer conditions: a systematic review and narrative synthesis. BMC Palliat Care 2023; 22:20. [PMID: 36890522 PMCID: PMC9996955 DOI: 10.1186/s12904-023-01131-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 02/01/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Older people with noncancer conditions are less likely to be referred to palliative care services due to the inherent uncertain disease trajectory and a lack of standardised referral criteria. For older adults with noncancer conditions where prognostic estimation is unpredictable, needs-based criteria are likely more suitable. Eligibility criteria for participation in clinical trials on palliative care could inform a needs-based criteria. This review aimed to identify and synthesise eligibility criteria for trials in palliative care to construct a needs-based set of triggers for timely referral to palliative care for older adults severely affected by noncancer conditions. METHODS A systematic narrative review of published trials of palliative care service level interventions for older adults with noncancer conditions. Electronic databases Medline, Embase, CINAHL, PsycINFO, CENTRAL, and ClinicalTrials.gov. were searched from inception to June 2022. We included all types of randomised controlled trials. We selected trials that reported eligibility criteria for palliative care involvement for older adults with noncancer conditions, where > 50% of the population was aged ≥ 65 years. The methodological quality of the included studies was assessed using a revised Cochrane risk-of-bias tool for randomized trials. Descriptive analysis and narrative synthesis provided descriptions of the patterns and appraised the applicability of included trial eligibility criteria to identify patients likely to benefit from receiving palliative care. RESULTS 27 randomised controlled trials met eligibility out of 9,584 papers. We identified six major domains of trial eligibility criteria in three categories, needs-based, time-based and medical history-based criteria. Needs-based criteria were composed of symptoms, functional status, and quality of life criteria. The major trial eligibility criteria were diagnostic criteria (n = 26, 96%), followed by medical history-based criteria (n = 15, 56%), and physical and psychological symptom criteria (n = 14, 52%). CONCLUSION For older adults severely affected by noncancer conditions, decisions about providing palliative care should be based on the present needs related to symptoms, functional status, and quality of life. Further research is needed to examine how the needs-based triggers can be operationalized as referral criteria in clinical settings and develop international consensus on referral criteria for older adults with noncancer conditions.
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Affiliation(s)
- Arisa Kawashima
- Department of Nursing for Advanced Practice, Division of Integrated Health Sciences, Nagoya University Graduate School of Medicine, Nagoya, Japan.,King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Faculty of Nursing, Midwifery and Palliative Care, London, UK. .,Sussex Community NHS Foundation Trust, Brighton, UK.
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Williamson LE, Leniz J, Chukwusa E, Evans CJ, Sleeman KE. A population-based retrospective cohort study of end-of-life emergency department visits by people with dementia: multilevel modelling of individual- and service-level factors using linked data. Age Ageing 2023; 52:afac332. [PMID: 36861183 PMCID: PMC9978317 DOI: 10.1093/ageing/afac332] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/12/2022] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND emergency department (ED) visits have inherent risks for people with dementia yet increase towards the end-of-life. Although some individual-level determinants of ED visits have been identified, little is known about service-level determinants. OBJECTIVE to examine individual- and service-level factors associated with ED visits by people with dementia in the last year of life. METHODS retrospective cohort study using hospital administrative and mortality data at the individual-level, linked to health and social care service data at the area-level across England. The primary outcome was number of ED visits in the last year of life. Subjects were decedents with dementia recorded on the death certificate, with at least one hospital contact in the last 3 years of life. RESULTS of 74,486 decedents (60.5% women; mean age 87.1 years (standard deviation: 7.1)), 82.6% had at least one ED visit in their last year of life. Factors associated with more ED visits included: South Asian ethnicity (incidence rate ratio (IRR) 1.07, 95% confidence interval (CI) 1.02-1.13), chronic respiratory disease as the underlying cause of death (IRR 1.17, 95% CI 1.14-1.20) and urban residence (IRR 1.06, 95% CI 1.04-1.08). Higher socioeconomic position (IRR 0.92, 95% CI 0.90-0.94) and areas with higher numbers of nursing home beds (IRR 0.85, 95% CI 0.78-0.93)-but not residential home beds-were associated with fewer ED visits at the end-of-life. CONCLUSIONS the value of nursing home care in supporting people dying with dementia to stay in their preferred place of care must be recognised, and investment in nursing home bed capacity prioritised.
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Affiliation(s)
| | - Javiera Leniz
- Departamento de Salud Pública, Escuela de Medicina, Pontificia Universidad Católica de, Santiago, Chile
| | - Emeka Chukwusa
- King’s College London, Cicely Saunders Institute, London SE5 9PJ, UK
| | - Catherine J Evans
- King’s College London, Cicely Saunders Institute, London SE5 9PJ, UK
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton BN2 3EW, UK
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Firth AM, Lin CP, Yi DH, Goodrich J, Gaczkowska I, Waite F, Harding R, Murtagh FE, Evans CJ. How is community based 'out-of-hours' care provided to patients with advanced illness near the end of life: A systematic review of care provision. Palliat Med 2023; 37:310-328. [PMID: 36924146 PMCID: PMC10126468 DOI: 10.1177/02692163231154760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
BACKGROUND Deaths in the community are increasing. However, community palliative care out-of-hours is variable. We lack detailed understanding of how care is provided out-of-hours and the associated outcomes. AIM To review systematically the components, outcomes and economic evaluation of community-based 'out-of-hours' care for patients near the end of life and their families. DESIGN Mixed method systematic narrative review. Narrative synthesis, development and application of a typology to categorise out-of-hours provision. Qualitative data were synthesised thematically and integrated at the level of interpretation and reporting. DATA SOURCES Systematic review searching; MEDLINE, EMBASE, PsycINFO, CINAHL from January 1990 to 1st August 2022. RESULTS About 64 publications from 54 studies were synthesised (from 9259 retrieved). Two main themes were identified: (1) importance of being known to a service and (2) high-quality coordination of care. A typology of out-of-hours service provision was constructed using three overarching dimensions (service times, focus of team delivering the care and type of care delivered) resulting in 15 categories of care. Only nine papers were randomised control trials or controlled cohorts reporting outcomes. Evidence on effectiveness was apparent for providing 24/7 specialist palliative care with both hands-on clinical care and advisory care. Only nine publications reported economic evaluation. CONCLUSIONS The typological framework allows models of out-of-hours care to be systematically defined and compared. We highlight the models of out-of-hours care which are linked with improvement of patient outcomes. There is a need for effectiveness and cost effectiveness studies which define and categorise out-of-hours care to allow thorough evaluation of services.
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Affiliation(s)
- Alice M Firth
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Cheng-Pei Lin
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Institute of Community Health Care, College of Nursing, National Yang Ming Chiao Tung University, Taipei
| | - Deok Hee Yi
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Joanna Goodrich
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Inez Gaczkowska
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Frances Waite
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Richard Harding
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Fliss Em Murtagh
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,University of Hull, Wolfson Palliative Care Research Centre, Hull, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
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Brighton LJ, Nolan CM, Barker RE, Patel S, Walsh JA, Polgar O, Kon SSC, Gao W, Evans CJ, Maddocks M, Man WDC. Frailty and Mortality Risk in COPD: A Cohort Study Comparing the Fried Frailty Phenotype and Short Physical Performance Battery. Int J Chron Obstruct Pulmon Dis 2023; 18:57-67. [PMID: 36711228 PMCID: PMC9880562 DOI: 10.2147/copd.s375142] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 08/22/2022] [Indexed: 01/20/2023] Open
Abstract
Background Identifying frailty in people with chronic obstructive pulmonary disease (COPD) is deemed important, yet comparative characteristics of the most commonly used frailty measures in COPD are unknown. This study aimed to compare how the Fried Frailty Phenotype (FFP) and Short Physical Performance Battery (SPPB) characterise frailty in people with stable COPD, including prevalence of and overlap in identification of frailty, disease and health characteristics of those identified as living with frailty, and predictive value in relation to survival time. Methods Cohort study of people with stable COPD attending outpatient clinics. Agreement between frailty classifications was described using Cohen's Kappa. Disease and health characteristics of frail versus not frail participants were compared using t-, Mann-Whitney U and Chi-Square tests. Predictive value for mortality was examined with multivariable Cox regression. Results Of 714 participants, 421 (59%) were male, mean age 69.9 years (SD 9.7), mean survival time 2270 days (95% CI 2185-2355). Similar proportions were identified as frail using the FFP (26.2%) and SPPB (23.7%) measures; classifications as frail or not frail matched in 572 (80.1%) cases, showing moderate agreement (Kappa = 0.469, SE = 0.038, p < 0.001). Discrepancies seemed driven by FFP exhaustion and weight loss criteria and the SPPB balance component. People with frailty by either measure had worse exercise capacity, health-related quality of life, breathlessness, depression and dependence in activities of daily living. In multivariable analysis controlling for the Age Dyspnoea Obstruction index, sex, BMI, comorbidities and exercise capacity, both the FFP and SPPB had predictive value in relation to mortality (FFP aHR = 1.31 [95% CI 1.03-1.66]; SPPB aHR = 1.29 [95% CI 0.99-1.68]). Conclusion In stable COPD, both the FFP and SPPB identify similar proportions of people living with/without frailty, the majority with matching classifications. Both measures can identify individuals with multidimensional health challenges and increased mortality risk and provide additional information alongside established prognostic variables.
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Affiliation(s)
- Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Claire M Nolan
- Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK.,Division of Physiotherapy, College of Health, Medicine and Life Sciences, Brunel University London, London, UK
| | - Ruth E Barker
- Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Insight Innovation, Wessex Academic Health Science Network, Southampton, UK
| | - Suhani Patel
- Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Jessica A Walsh
- Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Oliver Polgar
- Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Samantha S C Kon
- Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Department of Respiratory Medicine, The Hillingdon Hospital NHS Trust, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,Brighton General Hospital, Sussex Community NHS Foundation Trust, Brighton, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - William D C Man
- Harefield Respiratory Research Group, Royal Brompton and Harefield Hospitals, Guy's and St Thomas NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College, London, UK.,Harefield Pulmonary Rehabilitation Unit, Guy's and St Thomas NHS Foundation Trust, London, UK.,Faculty of Life Sciences & Medicine, King's College London, London, UK
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13
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Leniz J, Evans CJ, Yi D, Bone AE, Higginson IJ, Sleeman KE. Formal and Informal Costs of Care for People With Dementia Who Experience a Transition to Hospital at the End of Life: A Secondary Data Analysis. J Am Med Dir Assoc 2022; 23:2015-2022.e5. [PMID: 35820492 DOI: 10.1016/j.jamda.2022.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/26/2022] [Accepted: 06/12/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To explore formal and informal care costs in the last 3 months of life for people with dementia, and to evaluate the association between transitions to hospital and usual place of care with costs. DESIGN Cross-sectional study using pooled data from 3 mortality follow-back surveys. SETTING AND PARTICIPANTS People who died with dementia. METHODS The Client Service Receipt Inventory survey was used to derive formal (health, social) and informal care costs in the last 3 months of life. Generalized linear models were used to explore the association between transitions to hospital and usual place of care with formal and informal care costs. RESULTS A total of 146 people who died with dementia were included. The mean age was 88.1 years (SD 6.0), and 98 (67.1%) were female. The usual place of care was care home for 85 (58.2%). Sixty-five individuals (44.5%) died in a care home, and 85 (58.2%) experienced a transition to hospital in the last 3 months. The mean total costs of care in the last 3 months of life were £31,224.7 (SD 23,536.6). People with a transition to hospital had higher total costs (£33,239.2, 95% CI 28,301.8-39,037.8) than people without transition (£21,522.0, 95% CI 17,784.0-26,045.8), mainly explained by hospital costs. People whose usual place of care was care homes had lower total costs (£23,801.3, 95% CI 20,172.0-28,083.6) compared to home (£34,331.4, 95% CI 27,824.7-42,359.5), mainly explained by lower informal care costs. CONCLUSIONS AND IMPLICATIONS Total care costs are high among people dying with dementia, and informal care costs represent an important component of end-of-life care costs. Transitions to hospital have a large impact on total costs; preventing these transitions might reduce costs from the health care perspective, but not from patients' and families' perspectives. Access to care homes could help reduce transitions to hospital as well as reduce formal and informal care costs.
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Affiliation(s)
- Javiera Leniz
- King's College London, Cicely Saunders Institute of Palliative Care, Polity and Rehabilitation, London, United Kingdom.
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Polity and Rehabilitation, London, United Kingdom
| | - Deokhee Yi
- King's College London, Cicely Saunders Institute of Palliative Care, Polity and Rehabilitation, London, United Kingdom
| | - Anna E Bone
- King's College London, Cicely Saunders Institute of Palliative Care, Polity and Rehabilitation, London, United Kingdom
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Polity and Rehabilitation, London, United Kingdom
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Polity and Rehabilitation, London, United Kingdom
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Goodrich J, Tutt L, Firth AM, Evans CJ, Murtagh FE, Harding R. The most important components of out-of-hours community care for patients at the end of life: A Delphi study of healthcare professionals' and patient and family carers' perspectives. Palliat Med 2022; 36:1296-1304. [PMID: 35766525 PMCID: PMC9446430 DOI: 10.1177/02692163221106284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Community services for palliative patients outside normal working hours are variable and the best evidence-based models of care have not been determined. AIM To establish expert consensus on the most important components of out-of-hours community palliative care services. DESIGN Delphi study. The first round listed 68 components generated from systematic literature reviewing, focus groups with healthcare professionals and input from the project's patient and public involvement advisory group. The components deemed 'essential' by over 70% of participants in the first round were refined and carried forward to a second round, asking participants to rank each on a five-point Likert scale (5 highest to 1 lowest). The consensus threshold was median of 4 to 5 and interquartile range of ⩽1. PARTICIPANTS Community specialist palliative care health professionals, generalist community health professionals and patients and family carers with experience of receiving care out-of-hours at home. RESULTS Fifty-four participants completed round 1, and 44 round 2. Forty-five components met the threshold as most important for providing out-of-hours care, with highest consensus for: prescription, delivery and administration of medicines; district and community nurse visits; and shared electronic patient records and advance care plans. CONCLUSIONS The Delphi method identified the most important components to provide community palliative care for patients out-of-hours, which are often provided by non-specialist palliative care professionals. The importance placed on the integration and co-ordination with specialist palliative care through shared electronic records and advance care plans demonstrates the reassurance for patients and families of being known to out-of-hours services.
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Affiliation(s)
- Joanna Goodrich
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Lydia Tutt
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Alice M Firth
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Catherine J Evans
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
| | - Fliss Em Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Richard Harding
- Florence Nightingale Faculty of Nursing Midwifery a Palliative Care, Cicely Saunders Institute, King's College London, London, UK
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15
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Koffman J, Penfold C, Cottrell L, Farsides B, Evans CJ, Burman R, Nicholas R, Ashford S, Silber E. “I wanna live and not think about the future” what place for advance care planning for people living with severe multiple sclerosis and their families? A qualitative study. PLoS One 2022; 17:e0265861. [PMID: 35617268 PMCID: PMC9135191 DOI: 10.1371/journal.pone.0265861] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Little is known about how people with multiple sclerosis (MS) and their families comprehend advance care planning (ACP) and its relevance in their lives.
Aim
To explore under what situations, with whom, how, and why do people with MS and their families engage in ACP.
Methods
We conducted a qualitative study comprising interviews with people living with MS and their families followed by an ethical discussion group with five health professionals representing specialties working with people affected by MS and their families. Twenty-seven people with MS and 17 family members were interviewed between June 2019 and March 2020. Interviews and the ethical discussion group were audio-recorded and transcribed verbatim. Data were analysed using the framework approach.
Results
Participants’ narratives focused on three major themes: (i) planning for an uncertain future; (ii) perceived obstacles to engaging in ACP that included uncertainty concerning MS disease progression, negative previous experiences of ACP discussions and prioritising symptom management over future planning; (iii) Preferences for engagement in ACP included a trusting relationship with a health professional and that information then be shared across services. Health professionals’ accounts from the ethical discussion group departed from viewing ACP as a formal document to that of an ongoing process of seeking preferences and values. They voiced similar concerns to people with MS about uncertainty and when to initiate ACP-related discussions. Some shared concerns of their lack of confidence when having these discussions.
Conclusion
These findings support the need for a whole system strategic approach where information about the potential benefits of ACP in all its forms can be shared with people with MS. Moreover, they highlight the need for health professionals to be skilled and trained in engaging in ACP discussions and where information is contemporaneously and seamlessly shared across services.
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Affiliation(s)
- Jonathan Koffman
- Hull York Medical School, Wolfson Palliative Care Research Centre, Hull, United Kingdom
- King’s College London, Cicely Saunders Institute, London, United Kingdom
- * E-mail:
| | - Clarissa Penfold
- Hull York Medical School, Wolfson Palliative Care Research Centre, Hull, United Kingdom
| | | | - Bobbie Farsides
- Brighton and Sussex Medical School, Brighton, United Kingdom
| | - Catherine J. Evans
- King’s College London, Cicely Saunders Institute, London, United Kingdom
| | - Rachel Burman
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
| | - Richard Nicholas
- United Kingdom Multiple Sclerosis Tissue Bank, Burlington Danes, Imperial College London, London, United Kingdom
| | - Stephen Ashford
- King’s College London, Cicely Saunders Institute, London, United Kingdom
- Regional Hyper-Acute Rehabilitation Unit, Northwick Park Hospital, North West University, Harrow, United Kingdom
| | - Eli Silber
- King’s College Hospital NHS Foundation Trust, London, United Kingdom
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16
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Aworinde J, Ellis‐Smith C, Gillam J, Roche M, Coombes L, Yorganci E, Evans CJ. How do person‐centered outcome measures enable shared decision‐making for people with dementia and family carers?—A systematic review. A&D Transl Res & Clin Interv 2022; 8:e12304. [PMID: 35676942 PMCID: PMC9169867 DOI: 10.1002/trc2.12304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 04/15/2022] [Accepted: 04/20/2022] [Indexed: 11/18/2022]
Abstract
Objectives To identify published evidence on person‐centered outcome measures (PCOMs) used in dementia care and to explore how PCOMs facilitate shared decision‐making and improve outcomes of care. To build a logic model based on the findings, depicting linkages with PCOM impact mechanisms and care outcomes. Design Mixed‐methods systematic review. We searched PsycINFO, MEDLINE, CINAHL, and ASSIA from databases and included studies reporting experiences and/or impact of PCOM use among people with dementia, family carers, and/or practitioners. Groen Van de Ven's model of collaborative deliberation informed the elements of shared decision‐making in dementia care in the abstraction, analysis, and interpretation of data. Data were narratively synthesized to develop the logic model. Setting Studies were conducted in long‐term care, mixed settings, emergency department, general primary care, and geriatric clinics. Participants A total of 1064 participants were included in the review. Results Ten studies were included. PCOMs can facilitate shared decision‐making through “knowing the person,” “identifying problems, priorities for care and treatment and goal setting,” “evaluating decisions”, and “implementation considerations for PCOM use.” Weak evidence on the impact of PCOMs to improve communication between individuals and practitioners, physical function, and activities of daily living. Conclusions PCOMs can enable shared decision‐making and impact outcomes through facilitating collaborative working between the person's network of family and practitioners to identify and manage symptoms and concerns. The constructed logic model demonstrates the key mechanisms to discuss priorities for care and treatment, and to evaluate decisions and outcomes. A future area of research is training for family carers to use PCOMs with practitioners.
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Affiliation(s)
- Jesutofunmi Aworinde
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation King's College London London UK
| | - Clare Ellis‐Smith
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation King's College London London UK
| | - Juliet Gillam
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation King's College London London UK
| | - Moïse Roche
- Division of Psychiatry University College London London UK
| | - Lucy Coombes
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation King's College London London UK
- The Royal Marsden NHS Foundation Trust Sutton UK
| | - Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation King's College London London UK
| | - Catherine J. Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation King's College London London UK
- Sussex Community NHS Foundation Trust Brighton UK
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17
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Bayly J, Bone AE, Ellis-Smith C, Tunnard I, Yaqub S, Yi D, Nkhoma KB, Cook A, Combes S, Bajwah S, Harding R, Nicholson C, Normand C, Ahuja S, Turrillas P, Kizawa Y, Morita T, Nishiyama N, Tsuneto S, Ong P, Higginson IJ, Evans CJ, Maddocks M. Common elements of service delivery models that optimise quality of life and health service use among older people with advanced progressive conditions: a tertiary systematic review. BMJ Open 2021; 11:e048417. [PMID: 34853100 PMCID: PMC8638152 DOI: 10.1136/bmjopen-2020-048417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Health and social care services worldwide need to support ageing populations to live well with advanced progressive conditions while adapting to functional decline and finitude. We aimed to identify and map common elements of effective geriatric and palliative care services and consider their scalability and generalisability to high, middle and low-income countries. METHODS Tertiary systematic review (Cochrane Database of Systematic Reviews, CINAHL, Embase, January 2000-October 2019) of studies in geriatric or palliative care that demonstrated improved quality of life and/or health service use outcomes among older people with advanced progressive conditions. Using frameworks for health system analysis, service elements were identified. We used a staged, iterative process to develop a 'common components' logic model and consulted experts in geriatric or palliative care from high, middle and low-income countries on its scalability. RESULTS 78 studies (59 geriatric and 19 palliative) spanning all WHO regions were included. Data were available from 17 739 participants. Nearly half the studies recruited patients with heart failure (n=36) and one-third recruited patients with mixed diagnoses (n=26). Common service elements (≥80% of studies) included collaborative working, ongoing assessment, active patient participation, patient/family education and patient self-management. Effective services incorporated patient engagement, patient goal-driven care and the centrality of patient needs. Stakeholders (n=20) emphasised that wider implementation of such services would require access to skilled, multidisciplinary teams with sufficient resource to meet patients' needs. Identified barriers to scalability included the political and societal will to invest in and prioritise palliative and geriatric care for older people, alongside geographical and socioeconomic factors. CONCLUSION Our logic model combines elements of effective services to achieve optimal quality of life and health service use among older people with advanced progressive conditions. The model transcends current best practice in geriatric and palliative care and applies across the care continuum, from prevention of functional decline to end-of-life care. PROSPERO REGISTRATION NUMBER CRD42020150252.
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Affiliation(s)
- Joanne Bayly
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- St Barnabas Hospice, Worthing, UK
| | - Anna E Bone
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Clare Ellis-Smith
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - India Tunnard
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Shuja Yaqub
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Kennedy B Nkhoma
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, London, UK
| | - Amelia Cook
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Sarah Combes
- Florence Nightingale Faculty of Nursing Midwifery and Palliative Care, King's College London, London, UK
- St Christopher's Hospice, London, UK
- University of Surrey Faculty of Health and Medical Sciences, Guildford, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Richard Harding
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Caroline Nicholson
- St Christopher's Hospice, London, UK
- University of Surrey Faculty of Health and Medical Sciences, Guildford, UK
| | - Charles Normand
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Centre for Health Policy and Management, The University of Dublin Trinity College, Dublin, Ireland
| | - Shalini Ahuja
- Health Service and Population Research Department, King's College London Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Pamela Turrillas
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | | | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara Hospital, Hamamatsu, Japan
| | - Nanako Nishiyama
- Graduate School of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Department of Palliative Medicine, Kyoto University Hospital, Kyoto, Japan
| | - Paul Ong
- WHO Centre for Health Development (WKC), Kobe, Japan
| | - Irene J Higginson
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Sussex Community NHS Foundation Trust, Brighton, UK
| | - Matthew Maddocks
- Cicely Saunders Institute for Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Evans CJ, Bone AE, Yi D, Morgan M, Maddocks M, Wright J, Lindsay F, Higginson IJ. Response to Zhou (2021) "Comment on Evans et al. (2021) 'Community-based short-term integrated palliative and supportive care reduces symptom distress for older people with chronic noncancer conditions compared with usual care'". Int J Nurs Stud 2021; 125:104119. [PMID: 34782149 DOI: 10.1016/j.ijnurstu.2021.104119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/20/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation; Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Elm Grove, Brighton BN2 3EW, United Kingdom.
| | - Anna E Bone
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation
| | - Deokhee Yi
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation
| | - Myfanwy Morgan
- Institute of Pharmaceutical Science, King's College London, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, United Kingdom
| | - Matthew Maddocks
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation
| | - Juliet Wright
- University of Sussex, Brighton and Sussex Medical School, Falmer, Brighton BN1 9RH, United Kingdom
| | - Fiona Lindsay
- Martlets Hospice, Wayfield Avenue, Hove BN3 7LW, United Kingdom
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation
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Ellis-Smith C, Tunnard I, Dawkins M, Gao W, Higginson IJ, Evans CJ. Managing clinical uncertainty in older people towards the end of life: a systematic review of person-centred tools. BMC Palliat Care 2021; 20:168. [PMID: 34674695 PMCID: PMC8532380 DOI: 10.1186/s12904-021-00845-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 08/07/2021] [Indexed: 12/01/2022] Open
Abstract
Background Older people with multi-morbidities commonly experience an uncertain illness trajectory. Clinical uncertainty is challenging to manage, with risk of poor outcomes. Person-centred care is essential to align care and treatment with patient priorities and wishes. Use of evidence-based tools may support person-centred management of clinical uncertainty. We aimed to develop a logic model of person-centred evidence-based tools to manage clinical uncertainty in older people. Methods A systematic mixed-methods review with a results-based convergent synthesis design: a process-based iterative logic model was used, starting with a conceptual framework of clinical uncertainty in older people towards the end of life. This underpinned the methods. Medline, PsycINFO, CINAHL and ASSIA were searched from 2000 to December 2019, using a combination of terms: “uncertainty” AND “palliative care” AND “assessment” OR “care planning”. Studies were included if they developed or evaluated a person-centred tool to manage clinical uncertainty in people aged ≥65 years approaching the end of life and quality appraised using QualSyst. Quantitative and qualitative data were narratively synthesised and thematically analysed respectively and integrated into the logic model. Results Of the 17,095 articles identified, 44 were included, involving 63 tools. There was strong evidence that tools used in clinical care could improve identification of patient priorities and needs (n = 14 studies); that tools support partnership working between patients and practitioners (n = 8) and that tools support integrated care within and across teams and with patients and families (n = 14), improving patient outcomes such as quality of death and dying and satisfaction with care. Communication of clinical uncertainty to patients and families had the least evidence and is challenging to do well. Conclusion The identified logic model moves current knowledge from conceptualising clinical uncertainty to applying evidence-based tools to optimise person-centred management and improve patient outcomes. Key causal pathways are identification of individual priorities and needs, individual care and treatment and integrated care. Communication of clinical uncertainty to patients is challenging and requires training and skill and the use of tools to support practice. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00845-9.
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Affiliation(s)
- Clare Ellis-Smith
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.
| | - India Tunnard
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Marsha Dawkins
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Guys & St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Wei Gao
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,King's College Hospital NHS Foundation Trust, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, UK
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20
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Tunnard I, Yi D, Ellis-Smith C, Dawkins M, Higginson IJ, Evans CJ. Preferences and priorities to manage clinical uncertainty for older people with frailty and multimorbidity: a discrete choice experiment and stakeholder consultations. BMC Geriatr 2021; 21:553. [PMID: 34649510 PMCID: PMC8515697 DOI: 10.1186/s12877-021-02480-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 09/14/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical uncertainty is inherent for people with frailty and multimorbidity. Depleted physiological reserves increase vulnerability to a decline in health and adverse outcomes from a stressor event. Evidence-based tools can improve care processes and outcomes, but little is known about priorities to deliver care for older people with frailty and multimorbidity. This study aimed to explore the preferences and priorities for patients, family carers and healthcare practitioners to enhance care processes of comprehensive assessment, communication and continuity of care in managing clinical uncertainty using evidence-based tools. METHODS A parallel mixed method observational study in four inpatient intermediate care units (community hospitals) for patients in transition between hospital and home. We used a discrete choice experiment (DCE) to examine patient and family preferences and priorities on the attributes of enhanced services; and stakeholder consultations with practitioners to discuss and generate recommendations on using tools to augment care processes. Data analysis used logit modelling in the DCE, and framework analysis for consultation data. RESULTS Thirty-three patients participated in the DCE (mean age 84 years, SD 7.76). Patients preferred a service where family were contacted on admission and discharge (β 0.36, 95% CI 0.10 to 0.61), care received closer to home (β - 0.04, 95% CI - 0.06 to - 0.02) and the GP is fully informed about care (β 0.29, 95% CI 0.05-0.52). Four stakeholder consultations (n = 48 participants) generated 20 recommendations centred around three main themes: tailoring care processes to manage multiple care needs for an ageing population with frailty and multimorbidity; the importance of ongoing communication with patient and family; and clear and concise evidence-based tools to enhance communication between clinical teams and continuity of care on discharge. CONCLUSION Family engagement is vital to manage clinical uncertainty. Both patients and practitioners prioritise engaging the family to support person-centred care and continuity of care within and across care settings. Patients wished to maximise family involvement by enabling their support with a preference for care close to home. Evidence-based tools used across disciplines and services can provide a shared succinct language to facilitate communication and continuity of care at points of transition in care settings.
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Affiliation(s)
- India Tunnard
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ England
| | - Deokhee Yi
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ England
| | - Clare Ellis-Smith
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ England
| | - Marsha Dawkins
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ England
| | - Irene J. Higginson
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ England
| | - Catherine J. Evans
- King’s College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ England
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW England
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21
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Cooper M, Pollard A, Pandey A, Bremner S, Macken L, Evans CJ, Austin M, Parnell N, Steer S, Thomson S, Hashim A, Mason L, Verma S. Palliative Long-Term Abdominal Drains Versus Large Volume Paracentesis in Refractory Ascites Due to Cirrhosis (REDUCe Study): Qualitative Outcomes. J Pain Symptom Manage 2021; 62:312-325.e2. [PMID: 33348031 DOI: 10.1016/j.jpainsymman.2020.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 12/06/2020] [Accepted: 12/08/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Palliative care remains suboptimal in end-stage liver disease (ESLD). OBJECTIVES We report qualitative outcomes from the REDUCe study. We aimed to explore and contrast experiences/perceptions/care pathways of patients with refractory ascites due to ESLD randomized to either palliative long-term abdominal drains (LTADs) (allow home drainage) vs. large volume paracentesis (LVP) (hospital drainage). METHODS Concurrent embedded qualitative study in a 12-week feasibility randomized controlled trial. Telephone interviews were conducted, data being recorded, transcribed verbatim, and analyzed using applied thematic analysis, considered in terms of a pathway approach toward accessing health care. Quantitative outcomes were collected (integrated palliative outcome scale, short-form liver disease quality of life, EQ-5D-5 L, Zarit Burden Interview-12). RESULTS Fourteen patients (six allocated LTAD and eight LVP) and eight nurses participated in the qualitative study. The patient journey in the LVP group could be hindered by challenges along the entire care pathway, from recognizing the need for drainage to a lengthy wait in hospital for drainage and/or to be discharged. These issues also impacted upon caregivers. In contrast, LTADs appeared to transform this care pathway at all levels across the patient's journey by removing the need for hospital drainage. Additional benefits included personalized care, improved symptom control of ascites, being at home, and regular support from community nurses. Nurses also viewed the LTAD favorably, though expressed the need for additional support should this become standard of care. CONCLUSION Patients and nurses expressed acceptability of palliative LTAD in ESLD and preference for this approach in enabling care at home. Proceeding to a definitive trial is feasible. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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Affiliation(s)
- Max Cooper
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Alex Pollard
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Aparajita Pandey
- Research & Development Department, Sussex Partnership NHS Foundation Trust, Brighton, UK
| | | | - Lucia Macken
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK; Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Catherine J Evans
- Kings College, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, London, UK; Sussex Community NHS Foundation Trust, Brighton, UK
| | - Mark Austin
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Nick Parnell
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Shani Steer
- Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Sam Thomson
- Department of Gastroenterology and Hepatology, Western Sussex NHS Foundation Trust, Worthing, UK
| | - Ahmed Hashim
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK; Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Louise Mason
- Department of Palliative Medicine, Brighton and Sussex University Hospitals Trust, Brighton, UK
| | - Sumita Verma
- Department of Clinical and Experimental Medicine, Brighton and Sussex Medical School, Brighton, UK; Department of Gastroenterology and Hepatology, Brighton and Sussex University Hospitals Trust, Brighton, UK.
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22
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Sleeman KE, Timms A, Gillam J, Anderson JE, Harding R, Sampson EL, Evans CJ. Priorities and opportunities for palliative and end of life care in United Kingdom health policies: a national documentary analysis. BMC Palliat Care 2021; 20:108. [PMID: 34261478 PMCID: PMC8279030 DOI: 10.1186/s12904-021-00802-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/13/2021] [Indexed: 12/25/2022] Open
Abstract
Background Access to high-quality palliative care is inadequate for most people living and dying with serious illness. Policies aimed at optimising delivery of palliative and end of life care are an important mechanism to improve quality of care for the dying. The extent to which palliative care is included in national health policies is unknown. We aimed to identify priorities and opportunities for palliative and end of life care in national health policies in the UK. Methods Documentary analysis consisting of 1) summative content analysis to describe the extent to which palliative and end of life care is referred to and/or prioritised in national health and social care policies, and 2) thematic analysis to explore health policy priorities that are opportunities to widen access to palliative and end of life care for people with serious illness. Relevant national policy documents were identified through web searches of key government and other organisations, and through expert consultation. Documents included were UK-wide or devolved (i.e. England, Scotland, Northern Ireland, Wales), health and social care government strategies published from 2010 onwards. Results Fifteen policy documents were included in the final analysis. Twelve referred to palliative or end of life care, but details about what should improve, or mechanisms to achieve this, were sparse. Policy priorities that are opportunities to widen palliative and end of life care access comprised three inter-related themes: (1) integrated care – conceptualised as reorganisation of services as a way to enable improvement; (2) personalised care – conceptualised as allowing people to shape and manage their own care; and (3) support for unpaid carers – conceptualised as enabling unpaid carers to live a more independent lifestyle and balance caring with their own needs. Conclusions Although information on palliative and end of life care in UK health and social care policies was sparse, improving palliative care may provide an evidence-based approach to achieve the stated policy priorities of integrated care, personalised care, and support for unpaid carers. Aligning existing evidence of the benefits of palliative care with the three priorities identified may be an effective mechanism to both strengthen policy and improve care for people who are dying. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00802-6.
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Affiliation(s)
- Katherine E Sleeman
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK.
| | - Anna Timms
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Juliet Gillam
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, James Clerk Maxwell Building, 57 Waterloo Road, London, SE1 8WA, UK
| | - Janet E Anderson
- School of Health Sciences, City, University of London, Northampton Square, London, EC1V 0HB, UK
| | - Richard Harding
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Catherine J Evans
- Faculty of Nursing, Midwifery and Palliative Care, King's College London, Cicely Saunders Institute, Bessemer Road, London, SE5 9PJ, UK.,Sussex Community NHS Foundation Trust, Brighton, UK
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23
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Williamson LE, Evans CJ, Cripps RL, Leniz J, Yorganci E, Sleeman KE. Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review. J Am Med Dir Assoc 2021; 22:2046-2055.e35. [PMID: 34273269 DOI: 10.1016/j.jamda.2021.06.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/10/2021] [Accepted: 06/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life. DESIGN Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271). SETTING AND PARTICIPANTS Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life. MEASUREMENTS The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources. RESULTS After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance. CONCLUSIONS AND IMPLICATIONS The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.
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Affiliation(s)
- Lesley E Williamson
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom.
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom; Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, United Kingdom
| | - Rachel L Cripps
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Javiera Leniz
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Emel Yorganci
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute, Brixton, London, United Kingdom
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24
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Evans CJ, Bone AE, Yi D, Gao W, Morgan M, Taherzadeh S, Maddocks M, Wright J, Lindsay F, Bruni C, Harding R, Sleeman KE, Gomes B, Higginson IJ. Community-based short-term integrated palliative and supportive care reduces symptom distress for older people with chronic noncancer conditions compared with usual care: A randomised controlled single-blind mixed method trial. Int J Nurs Stud 2021; 120:103978. [PMID: 34146843 DOI: 10.1016/j.ijnurstu.2021.103978] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/18/2021] [Accepted: 05/01/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Globally, a rising number of people live into advanced age and die with multimorbidity and frailty. Palliative care is advocated as a person-centred approach to reduce health-related suffering and promote quality of life. However, no evidence-based interventions exist to deliver community-based palliative care for this population. AIM To evaluate the impact of the short-term integrated palliative and supportive care intervention for older people living with chronic noncancer conditions and frailty on clinical and economic outcomes and perceptions of care. DESIGN Single-blind trial with random block assignment to usual care or the intervention and usual care. The intervention comprised integrated person-centred palliative care delivered by multidisciplinary palliative care teams working with general practitioners and community nurses. Main outcome was change in five key palliative care symptoms from baseline to 12-weeks. Data analysis used intention to treat and complete cases to examine the mean difference in change scores and effect size between the trial arms. Economic evaluation used cost-effectiveness planes and qualitative interviews explored perceptions of the intervention. SETTING/PARTICIPANTS Four National Health Service general practices in England with recruitment of patients aged ≥75 years, with moderate to severe frailty, chronic noncancer condition(s) and ≥2 symptoms or concerns, and family caregivers when available. RESULTS 50 patients were randomly assigned to receive usual care (n = 26, mean age 86.0 years) or the intervention and usual care (n = 24, mean age 85.3 years), and 26 caregivers (control n = 16, mean age 77.0 years; intervention n = 10, mean age 77.3 years). Participants lived at home (n = 48) or care home (n = 2). Complete case analysis (n = 48) on the main outcome showed reduced symptom distress between the intervention compared with usual care (mean difference -1.20, 95% confidence interval -2.37 to -0.027) and medium effect size (omega squared = 0.071). Symptom distress reduced with decreased costs from the intervention compared with usual care, demonstrating cost-effectiveness. Patient (n = 19) and caregiver (n = 9) interviews generated themes about the intervention of 'Little things make a big difference' with optimal management of symptoms and 'Care beyond medicines' of psychosocial support to accommodate decline and maintain independence. CONCLUSIONS This palliative and supportive care intervention is an effective and cost-effective approach to reduce symptom distress for older people severely affected by chronic noncancer conditions. It is a clinically effective way to integrate specialist palliative care with primary and community care for older people with chronic conditions. Further research is indicated to examine its implementation more widely for people at home and in care homes. TRIAL REGISTRATION Controlled-Trials.com ISRCTN 45837097 Tweetable abstract: Specialist palliative care integrated with district nurses and GPs is cost-effective to reduce symptom distress for older people severely affected by chronic conditions.
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Affiliation(s)
- Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England; Martlets Hospice, Wayfield Avenue, Hove BN3 7LW, England; Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, England.
| | - Anna E Bone
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
| | - Deokhee Yi
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
| | - Wei Gao
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
| | - Myfanwy Morgan
- Institute of Pharmaceutical Science, King's College London, Franklin-Wilkins Building, Stamford Street, London SE1 9NH, England.
| | - Shamim Taherzadeh
- Northbourne Medical Centre, 193A Upper Shoreham Road, Shoreham-by-Sea, BN43 6BT, England.
| | - Matthew Maddocks
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
| | - Juliet Wright
- University of Sussex, Brighton and Sussex Medical School, Falmer, Brighton, BN1 9RH, England.
| | - Fiona Lindsay
- Martlets Hospice, Wayfield Avenue, Hove BN3 7LW, England; Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, England.
| | - Carla Bruni
- Sussex Community National Health Service Foundation Trust, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, England.
| | - Richard Harding
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
| | - Barbara Gomes
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabiliation, Bessemer Road, London, SE 9PJ, England.
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Oluyase AO, Higginson IJ, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FEM, Bajwah S. Hospital-based specialist palliative care compared with usual care for adults with advanced illness and their caregivers: a systematic review. Health Serv Deliv Res 2021. [DOI: 10.3310/hsdr09120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Most deaths still take place in hospital; cost-effective commissioning of end-of-life resources is a priority. This review provides clarity on the effectiveness of hospital-based specialist palliative care.
Objectives
The objectives were to assess the effectiveness and cost-effectiveness of hospital-based specialist palliative care.
Population
Adult patients with advanced illnesses and their unpaid caregivers.
Intervention
Hospital-based specialist palliative care.
Comparators
Inpatient or outpatient hospital care without specialist palliative care input at the point of entry to the study, or community care or hospice care provided outside the hospital setting (usual care).
Primary outcomes
Patient health-related quality of life and symptom burden.
Data sources
Six databases (The Cochrane Library, MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO and CareSearch), clinical trial registers, reference lists and systematic reviews were searched to August 2019.
Review methods
Two independent reviewers screened, data extracted and assessed methodological quality. Meta-analysis was carried out using RevMan (The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark), with separate synthesis of qualitative data.
Results
Forty-two randomised controlled trials involving 7779 participants (6678 patients and 1101 unpaid caregivers) were included. Diagnoses of participants were as follows: cancer, 21 studies; non-cancer, 14 studies; and mixed cancer and non-cancer, seven studies. Hospital-based specialist palliative care was offered in the following models: ward based (one study), inpatient consult (10 studies), outpatient (six studies), hospital at home or hospital outreach (five studies) and multiple settings that included hospital (20 studies). Meta-analyses demonstrated significant improvement favouring hospital-based specialist palliative care over usual care in patient health-related quality of life (10 studies, standardised mean difference 0.26, 95% confidence interval 0.15 to 0.37; I
2 = 3%) and patient satisfaction with care (two studies, standardised mean difference 0.36, 95% confidence interval 0.14 to 0.57; I
2 = 0%), a significant reduction in patient symptom burden (six studies, standardised mean difference –0.26, 95% confidence interval –0.41 to –0.12; I
2 = 0%) and patient depression (eight studies, standardised mean difference –0.22, 95% confidence interval –0.34 to –0.10; I
2 = 0%), and a significant increase in the chances of patients dying in their preferred place (measured by number of patients with home death) (seven studies, odds ratio 1.63, 95% confidence interval 1.23 to 2.16; I
2 = 0%). There were non-significant improvements in pain (four studies, standardised mean difference –0.16, 95% confidence interval –0.33 to 0.01; I
2 = 0%) and patient anxiety (five studies, mean difference –0.63, 95% confidence interval –2.22 to 0.96; I
2 = 76%). Hospital-based specialist palliative care showed no evidence of causing serious harm. The evidence on mortality/survival and cost-effectiveness was inconclusive. Qualitative studies (10 studies, 322 participants) suggested that hospital-based specialist palliative care was beneficial as it ensured personalised and holistic care for patients and their families, while also fostering open communication, shared decision-making and respectful and compassionate care.
Limitation
In almost half of the included randomised controlled trials, there was palliative care involvement in the control group.
Conclusions
Hospital-based specialist palliative care may offer benefits for person-centred outcomes including health-related quality of life, symptom burden, patient depression and satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death) with little evidence of harm.
Future work
More studies are needed of populations with non-malignant diseases, different models of hospital-based specialist palliative care, and cost-effectiveness.
Study registration
This study is registered as PROSPERO CRD42017083205.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 12. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Massimo Costantini
- Palliative Care Unit, Azienda Unità Sanitaria Locale – Istituto di Ricovero e Cura a Carattere Scientifico (USL-IRCCS), Reggio Emilia, Italy
| | - Fliss EM Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London, London, UK
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Brighton LJ, Evans CJ, Farquhar M, Bristowe K, Kata A, Higman J, Ogden M, Nolan C, Yi D, Gao W, Koulopoulou M, Hasan S, Steves CJ, Man WDC, Maddocks M. Integrating Comprehensive Geriatric Assessment for people with COPD and frailty starting pulmonary rehabilitation: the Breathe Plus feasibility trial protocol. ERJ Open Res 2021; 7:00717-2020. [PMID: 33816606 PMCID: PMC8005693 DOI: 10.1183/23120541.00717-2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/21/2020] [Indexed: 12/13/2022] Open
Abstract
One in five people with COPD also lives with frailty. People living with both COPD and frailty are at increased risk of poorer health and outcomes, and face challenges to completing pulmonary rehabilitation. Integrated approaches that are adapted to the additional context of frailty are required. The aim of the present study is to determine the feasibility of conducting a randomised controlled trial of an integrated Comprehensive Geriatric Assessment for people with COPD and frailty starting pulmonary rehabilitation. This is a multicentre, mixed-methods, assessor-blinded, randomised, parallel group, controlled feasibility trial (“Breathe Plus”; ISRCTN13051922). We aim to recruit 60 people aged ≥50 with both COPD and frailty referred for pulmonary rehabilitation. Participants will be randomised 1:1 to receive usual pulmonary rehabilitation, or pulmonary rehabilitation with an additional Comprehensive Geriatric Assessment. Outcomes (physical, psycho-social and service use) will be measured at baseline, 90 days and 180 days. We will also collect service and trial process data, and conduct qualitative interviews with a sub-group of participants and staff. We will undertake descriptive analysis of quantitative feasibility outcomes (recruitment, retention, missing data, blinding, contamination, fidelity), and framework analysis of qualitative feasibility outcomes (intervention acceptability and theory, outcome acceptability). Recommendations on progression to a full trial will comprise integration of quantitative and qualitative data, with input from relevant stakeholders. This study has been approved by a UK Research Ethics Committee (ref.: 19/LO/1402). This protocol describes the first study testing the feasibility of integrating a Comprehensive Geriatric Assessment alongside pulmonary rehabilitation, and testing this intervention within a mixed-methods randomised controlled trial. This protocol describes the first study testing the feasibility of integrating a Comprehensive Geriatric Assessment alongside pulmonary rehabilitation for people with both COPD and frailty, and the appropriate trial methods to test its effectivenesshttps://bit.ly/39lZ7f1
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Affiliation(s)
- Lisa Jane Brighton
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Morag Farquhar
- University of East Anglia, School of Health Sciences, Norwich, UK
| | - Katherine Bristowe
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | | | - Jade Higman
- King's College London, Clinical Trials Unit, London, UK
| | - Margaret Ogden
- King's College London, Cicely Saunders Institute Public Involvement Group, London, UK
| | - Claire Nolan
- Guy's and St Thomas NHS Foundation Trust, Harefield Respiratory Research Group, London, UK.,Imperial College, National Heart and Lung Institute, London, UK
| | - Deokhee Yi
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Wei Gao
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Maria Koulopoulou
- King's College Hospital NHS Foundation Trust, Pulmonary Rehabilitation, London, UK
| | - Sharmeen Hasan
- King's College Hospital NHS Foundation Trust, Dept of Clinical Gerontology, London, UK
| | - Claire J Steves
- King's College London, Dept of Twin Research and Genetic Epidemiology, London, UK.,Guys and St. Thomas' NHS Foundation Trust, Dept of Ageing and Health, London, UK
| | - William D-C Man
- Guy's and St Thomas NHS Foundation Trust, Harefield Respiratory Research Group, London, UK.,Imperial College, National Heart and Lung Institute, London, UK.,Guy's and St Thomas NHS Foundation Trust, Harefield Pulmonary Rehabilitation Unit, London, UK
| | - Matthew Maddocks
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
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Evans CJ, Potts L, Dalrymple U, Pring A, Verne J, Higginson IJ, Gao W. Characteristics and mortality rates among patients requiring intermediate care: a national cohort study using linked databases. BMC Med 2021; 19:48. [PMID: 33579284 PMCID: PMC7880511 DOI: 10.1186/s12916-021-01912-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/14/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Adults increasingly live and die with chronic progressive conditions into advanced age. Many live with multimorbidity and an uncertain illness trajectory with points of marked decline, loss of function and increased risk of end of life. Intermediate care units support mainly older adults in transition between hospital and home to regain function and anticipate and plan for end of life. This study examined the patient characteristics and the factors associated with mortality over 1 year post-admission to an intermediate care unit to inform priorities for care. METHODS A national cohort study of adults admitted to intermediate care units in England using linked individual-level Hospital Episode Statistics and death registration data. The main outcome was mortality within 1 year from admission. The cohort was examined as two groups with significant differences in mortality between main diagnosis of a non-cancer condition and cancer. Data analysis used Kaplan-Meier curves to explore mortality differences between the groups and a time-dependant Cox proportional hazards model to determine mortality risk factors. RESULTS The cohort comprised 76,704 adults with median age 81 years (IQR 70-88) admitted to 220 intermediate care units over 1 year in 2016. Overall, 28.0% died within 1 year post-admission. Mortality varied by the main diagnosis of cancer (total n = 3680, 70.8% died) and non-cancer condition (total n = 73,024, 25.8% died). Illness-related factors had the highest adjusted hazard ratios [aHRs]. At 0-28 days post-admission, risks were highest for non-cancer respiratory conditions (pneumonia (aHR 6.17 [95%CI 4.90-7.76]), chronic obstructive pulmonary disease (aHR 5.01 [95% CI 3.78-6.62]), dementia (aHR 5.07 [95% CI 3.80-6.77]) and liver disease (aHR 9.75 [95% CI 6.50-14.6]) compared with musculoskeletal disorders. In cancer, lung cancer showed largest risk (aHR 1.20 [95%CI 1.04-1.39]) compared with cancer 'other'. Risks increased with high multimorbidity for non-cancer (aHR 2.57 [95% CI 2.36-2.79]) and cancer (aHR 2.59 [95% CI 2.13-3.15]) (reference: lowest). CONCLUSIONS One in four patients died within 1 year. Indicators for palliative care assessment are respiratory conditions, dementia, liver disease, cancer and rising multimorbidity. The traditional emphasis on rehabilitation and recovery in intermediate care units has changed with an ageing population and the need for greater integration of palliative care.
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Affiliation(s)
- Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, England. .,Sussex Community NHS Foundation Trust HQ, Brighton General Hospital, Elm Grove, Brighton, BN2 3EW, England.
| | - Laura Potts
- Public Health England, 2 Rivergate, Redcliffe, Bristol, BS1 6EH, England
| | - Ursula Dalrymple
- Public Health England, 2 Rivergate, Redcliffe, Bristol, BS1 6EH, England
| | - Andrew Pring
- Public Health England, 2 Rivergate, Redcliffe, Bristol, BS1 6EH, England
| | - Julia Verne
- Public Health England, 2 Rivergate, Redcliffe, Bristol, BS1 6EH, England
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, England
| | - Wei Gao
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, Bessemer Road, London, SE5 9PJ, England
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Finucane AM, Bone AE, Etkind S, Carr D, Meade R, Munoz-Arroyo R, Moine S, Iyayi-Igbinovia A, Evans CJ, Higginson IJ, Murray SA. How many people will need palliative care in Scotland by 2040? A mixed-method study of projected palliative care need and recommendations for service delivery. BMJ Open 2021; 11:e041317. [PMID: 33536318 PMCID: PMC7868264 DOI: 10.1136/bmjopen-2020-041317] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To estimate future palliative care need and complexity of need in Scotland, and to identify priorities for future service delivery. DESIGN We estimated the prevalence of palliative care need by analysing the proportion of deaths from defined chronic progressive illnesses. We described linear projections up to 2040 using national death registry data and official mortality forecasts. An expert consultation and subsequent online consensus survey generated recommendations on meeting future palliative care need. SETTING Scotland, population of 5.4 million. PARTICIPANTS All decedents in Scotland over 11 years (2007 to 2017). The consultation had 34 participants; 24 completed the consensus survey. PRIMARY AND SECONDARY OUTCOMES Estimates of past and future palliative care need in Scotland from 2007 up to 2040. Multimorbidity was operationalised as two or more registered causes of death from different disease groups (cancer, organ failure, dementia, other). Consultation and survey data were analysed descriptively. RESULTS We project that by 2040, the number of people requiring palliative care will increase by at least 14%; and by 20% if we factor in multimorbidity. The number of people dying from multiple diseases associated with different disease groups is projected to increase from 27% of all deaths in 2017 to 43% by 2040. To address increased need and complexity, experts prioritised sustained investment in a national digital platform, roll-out of integrated electronic health and social care records; and approaches that remain person-centred. CONCLUSIONS By 2040 more people in Scotland are projected to die with palliative care needs, and the complexity of need will increase markedly. Service delivery models must adapt to serve growing demand and complexity associated with dying from multiple diseases from different disease groups. We need sustained investment in secure, accessible, integrated and person-centred health and social care digital systems, to improve care coordination and optimise palliative care for people across care settings.
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Affiliation(s)
- Anne M Finucane
- Research, Marie Curie Hospice Edinburgh, Edinburgh, UK
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Anna E Bone
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Simon Etkind
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | | | - Richard Meade
- Policy and Public Affairs, Marie Curie, Edinburgh, UK
| | | | - Sébastien Moine
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
- Health Education, Université Paris, Paris, UK
| | | | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Scott A Murray
- Primary Palliative Care Research Group, Usher Institute, University of Edinburgh, Edinburgh, UK
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Johnson H, Ogden M, Brighton LJ, Etkind SN, Oluyase AO, Chukwusa E, Yu P, de Wolf-Linder S, Smith P, Bailey S, Koffman J, Evans CJ. Patient and public involvement in palliative care research: What works, and why? A qualitative evaluation. Palliat Med 2021; 35:151-160. [PMID: 32912087 PMCID: PMC7797607 DOI: 10.1177/0269216320956819] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Public involvement is increasingly considered a prerequisite for high-quality research. However, involvement in palliative care is impeded by limited evidence on the best approaches for populations affected by life-limiting illness. AIM To evaluate a strategy for public involvement in palliative care and rehabilitation research, to identify successful approaches and areas for improvement. DESIGN Co-produced qualitative evaluation using focus groups and interviews. Thematic analysis undertaken by research team comprising public contributors and researchers. SETTING/PARTICIPANTS Researchers and public members from a palliative care and rehabilitation research institute, UK. RESULTS Seven public members and 19 researchers participated. Building and maintaining relationships, taking a flexible approach and finding the 'right' people were important for successful public involvement. Relationship building created a safe environment for discussing sensitive topics, although public members felt greater consideration of emotional support was needed. Flexibility supported involvement alongside unpredictable circumstances of chronic and life-limiting illness, and was facilitated by responsive communication, and opportunities for in-person and virtual involvement at a project- and institution-level. However, more opportunities for two-way feedback throughout projects was suggested. Finding the 'right' people was crucial given the diverse population served by palliative care, and participants suggested more care needed to be taken to identify public members with experience relevant to specific projects. CONCLUSION Within palliative care research, it is important for involvement to focus on building and maintaining relationships, working flexibly, and identifying those with relevant experience. Taking a strategic approach and developing adequate infrastructure and networks can facilitate public involvement within this field.
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Affiliation(s)
- Halle Johnson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Margaret Ogden
- Patient and Public Contributor, Cicely Saunders Institute, King's College London, London, UK
| | - Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Simon Noah Etkind
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Emeka Chukwusa
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Peihan Yu
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Susanne de Wolf-Linder
- Institute of Nursing, School of Health Professions, Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Pam Smith
- Patient and Public Contributor, Cicely Saunders Institute, King's College London, London, UK
| | - Sylvia Bailey
- Patient and Public Contributor, Cicely Saunders Institute, King's College London, London, UK
| | - Jonathan Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
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Bajwah S, Oluyase AO, Yi D, Gao W, Evans CJ, Grande G, Todd C, Costantini M, Murtagh FE, Higginson IJ. The effectiveness and cost-effectiveness of hospital-based specialist palliative care for adults with advanced illness and their caregivers. Cochrane Database Syst Rev 2020; 9:CD012780. [PMID: 32996586 PMCID: PMC8428758 DOI: 10.1002/14651858.cd012780.pub2] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Serious illness is often characterised by physical/psychological problems, family support needs, and high healthcare resource use. Hospital-based specialist palliative care (HSPC) has developed to assist in better meeting the needs of patients and their families and potentially reducing hospital care expenditure. There is a need for clarity on the effectiveness and optimal models of HSPC, given that most people still die in hospital and also to allocate scarce resources judiciously. OBJECTIVES To assess the effectiveness and cost-effectiveness of HSPC compared to usual care for adults with advanced illness (hereafter patients) and their unpaid caregivers/families. SEARCH METHODS We searched CENTRAL, CDSR, DARE and HTA database via the Cochrane Library; MEDLINE; Embase; CINAHL; PsycINFO; CareSearch; National Health Service Economic Evaluation Database (NHS EED) and two trial registers to August 2019, together with checking of reference lists and relevant systematic reviews, citation searching and contact with experts to identify additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating the impact of HSPC on outcomes for patients or their unpaid caregivers/families, or both. HSPC was defined as specialist palliative care delivered by a palliative care team that is based in a hospital providing holistic care, co-ordination by a multidisciplinary team, and collaboration between HSPC providers and generalists. HSPC was provided to patients while they were admitted as inpatients to acute care hospitals, outpatients or patients receiving care from hospital outreach teams at home. The comparator was usual care, defined as inpatient or outpatient hospital care without specialist palliative care input at the point of entry into the study, community care or hospice care provided outside of the hospital setting. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. We assessed risk of bias and extracted data. To account for use of different scales across studies, we calculated standardised mean differences (SMDs) with 95% confidence intervals (CIs) for continuous data. We used an inverse variance random-effects model. For binary data, we calculated odds ratio (ORs) with 95% CIs. We assessed the evidence using GRADE and created a 'Summary of findings' table. Our primary outcomes were patient health-related quality of life (HRQoL) and symptom burden (a collection of two or more symptoms). Key secondary outcomes were pain, depression, satisfaction with care, achieving preferred place of death, mortality/survival, unpaid caregiver burden, and cost-effectiveness. Qualitative data was analysed where available. MAIN RESULTS We identified 42 RCTs involving 7779 participants (6678 patients and 1101 caregivers/family members). Twenty-one studies were with cancer populations, 14 were with non-cancer populations (of which six were with heart failure patients), and seven with mixed cancer and non-cancer populations (mixed diagnoses). HSPC was offered in different ways and included the following models: ward-based, inpatient consult, outpatient, hospital-at-home or hospital outreach, and service provision across multiple settings which included hospital. For our main analyses, we pooled data from studies reporting adjusted endpoint values. Forty studies had a high risk of bias in at least one domain. Compared with usual care, HSPC improved patient HRQoL with a small effect size of 0.26 SMD over usual care (95% CI 0.15 to 0.37; I2 = 3%, 10 studies, 1344 participants, low-quality evidence, higher scores indicate better patient HRQoL). HSPC also improved other person-centred outcomes. It reduced patient symptom burden with a small effect size of -0.26 SMD over usual care (95% CI -0.41 to -0.12; I2 = 0%, 6 studies, 761 participants, very low-quality evidence, lower scores indicate lower symptom burden). HSPC improved patient satisfaction with care with a small effect size of 0.36 SMD over usual care (95% CI 0.41 to 0.57; I2 = 0%, 2 studies, 337 participants, low-quality evidence, higher scores indicate better patient satisfaction with care). Using home death as a proxy measure for achieving patient's preferred place of death, patients were more likely to die at home with HSPC compared to usual care (OR 1.63, 95% CI 1.23 to 2.16; I2 = 0%, 7 studies, 861 participants, low-quality evidence). Data on pain (4 studies, 525 participants) showed no evidence of a difference between HSPC and usual care (SMD -0.16, 95% CI -0.33 to 0.01; I2 = 0%, very low-quality evidence). Eight studies (N = 1252 participants) reported on adverse events and very low-quality evidence did not demonstrate an effect of HSPC on serious harms. Two studies (170 participants) presented data on caregiver burden and both found no evidence of effect of HSPC (very low-quality evidence). We included 13 economic studies (2103 participants). Overall, the evidence on cost-effectiveness of HSPC compared to usual care was inconsistent among the four full economic studies. Other studies that used only partial economic analysis and those that presented more limited resource use and cost information also had inconsistent results (very low-quality evidence). Quality of the evidence The quality of the evidence assessed using GRADE was very low to low, downgraded due to a high risk of bias, inconsistency and imprecision. AUTHORS' CONCLUSIONS Very low- to low-quality evidence suggests that when compared to usual care, HSPC may offer small benefits for several person-centred outcomes including patient HRQoL, symptom burden and patient satisfaction with care, while also increasing the chances of patients dying in their preferred place (measured by home death). While we found no evidence that HSPC causes serious harms, the evidence was insufficient to draw strong conclusions. Although these are only small effect sizes, they may be clinically relevant at an advanced stage of disease with limited prognosis, and are person-centred outcomes important to many patients and families. More well conducted studies are needed to study populations with non-malignant diseases and mixed diagnoses, ward-based models of HSPC, 24 hours access (out-of-hours care) as part of HSPC, pain, achieving patient preferred place of care, patient satisfaction with care, caregiver outcomes (satisfaction with care, burden, depression, anxiety, grief, quality of life), and cost-effectiveness of HSPC. In addition, research is needed to provide validated person-centred outcomes to be used across studies and populations.
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Affiliation(s)
- Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Adejoke O Oluyase
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Gunn Grande
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Chris Todd
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Fliss E Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Affiliation(s)
- Lisa Jane Brighton
- Health services researcher, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, UK
| | - Catherine J Evans
- Health services researcher, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, UK.,HEE/NIHR Senior Clinical Lecturer and Honorary Nurse Consultant in Palliative Care, Sussex Community NHS Foundation Trust, Brighton General Hospital, UK
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Sampson EL, Anderson JE, Candy B, Davies N, Ellis-Smith C, Gola A, Harding R, Kenten C, Kupeli N, Mead S, Moore KJ, Omar RZ, Sleeman KE, Stewart R, Ward J, Warren JD, Evans CJ. Empowering Better End-of-Life Dementia Care (EMBED-Care): A mixed methods protocol to achieve integrated person-centred care across settings. Int J Geriatr Psychiatry 2020; 35:820-832. [PMID: 31854477 DOI: 10.1002/gps.5251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Globally, the number of people with dementia who have palliative care needs will increase fourfold over the next 40 years. The Empowering Better End-of-Life Dementia Care (EMBED-Care) Programme aims to deliver a step change in care through a large sequential study, spanning multiple work streams. METHODS We will use mixed methods across settings where people with dementia live and die: their own homes, care homes, and hospitals. Beginning with policy syntheses and reviews of interventions, we will develop a conceptual framework and underpinning theory of change. We will use linked data sets to explore current service use, care transitions, and inequalities and predict future need for end-of-life dementia care. Longitudinal cohort studies of people with dementia (including young onset and prion dementias) and their carers will describe care transitions, quality of life, symptoms, formal and informal care provision, and costs. Data will be synthesised, underpinned by the Knowledge-to-Action Implementation Framework, to design a novel complex intervention to support assessment, decision making, and communication between patients, carers, and inter-professional teams. This will be feasibility and pilot tested in UK settings. Patient and public involvement and engagement, innovative work with artists, policymakers, and third sector organisations are embedded to drive impact. We will build research capacity and develop an international network for excellence in dementia palliative care. CONCLUSIONS EMBED-Care will help us understand current and future need, develop novel cost-effective care innovations, build research capacity, and promote international collaborations in research and practice to ensure people live and die well with dementia.
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Affiliation(s)
- Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Janet E Anderson
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Centre for Population Ageing Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Clare Ellis-Smith
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Richard Harding
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Charlotte Kenten
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Simon Mead
- National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,MRC Prion Unit at UCL, Institute of Prion Diseases, UCL, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Jane Ward
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jason D Warren
- Dementia Research Centre, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Sussex Community NHS Foundation Trust, Brighton, UK
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Evans CJ, Yorganci E, Lewis P, Koffman J, Stone K, Tunnard I, Wee B, Bernal W, Hotopf M, Higginson IJ. Processes of consent in research for adults with impaired mental capacity nearing the end of life: systematic review and transparent expert consultation (MORECare_Capacity statement). BMC Med 2020; 18:221. [PMID: 32693800 PMCID: PMC7374835 DOI: 10.1186/s12916-020-01654-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 06/03/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Involving adults lacking capacity (ALC) in research on end of life care (EoLC) or serious illness is important, but often omitted. We aimed to develop evidence-based guidance on how best to include individuals with impaired capacity nearing the end of life in research, by identifying the challenges and solutions for processes of consent across the capacity spectrum. METHODS Methods Of Researching End of Life Care_Capacity (MORECare_C) furthers the MORECare statement on research evaluating EoLC. We used simultaneous methods of systematic review and transparent expert consultation (TEC). The systematic review involved four electronic databases searches. The eligibility criteria identified studies involving adults with serious illness and impaired capacity, and methods for recruitment in research, implementing the research methods, and exploring public attitudes. The TEC involved stakeholder consultation to discuss and generate recommendations, and a Delphi survey and an expert 'think-tank' to explore consensus. We narratively synthesised the literature mapping processes of consent with recruitment outcomes, solutions, and challenges. We explored recommendation consensus using descriptive statistics. Synthesis of all the findings informed the guidance statement. RESULTS Of the 5539 articles identified, 91 met eligibility. The studies encompassed people with dementia (27%) and in palliative care (18%). Seventy-five percent used observational designs. Studies on research methods (37 studies) focused on processes of proxy decision-making, advance consent, and deferred consent. Studies implementing research methods (30 studies) demonstrated the role of family members as both proxy decision-makers and supporting decision-making for the person with impaired capacity. The TEC involved 43 participants who generated 29 recommendations, with consensus that indicated. Key areas were the timeliness of the consent process and maximising an individual's decisional capacity. The think-tank (n = 19) refined equivocal recommendations including supporting proxy decision-makers, training practitioners, and incorporating legislative frameworks. CONCLUSIONS The MORECare_C statement details 20 solutions to recruit ALC nearing the EoL in research. The statement provides much needed guidance to enrol individuals with serious illness in research. Key is involving family members early and designing study procedures to accommodate variable and changeable levels of capacity. The statement demonstrates the ethical imperative and processes of recruiting adults across the capacity spectrum in varying populations and settings.
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Affiliation(s)
- C J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK.
- Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK.
| | - E Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - P Lewis
- Centre of Medical Law and Ethics, The Dickson Poon School of Law, King's College London, London, UK
| | - J Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - K Stone
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - I Tunnard
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
| | - B Wee
- Oxford University Hospitals NHS Foundation Trust and Harris Manchester College, University of Oxford, Oxford, UK
| | - W Bernal
- King's College Hospital, London, UK
| | - M Hotopf
- Psychological Medicine, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - I J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, Bessemer Road, London, SE5 9PJ, UK
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Macken L, Bremner S, Gage H, Touray M, Williams P, Crook D, Mason L, Lambert D, Evans CJ, Cooper M, Timeyin J, Steer S, Austin M, Parnell N, Thomson SJ, Sheridan D, Wright M, Isaacs P, Hashim A, Verma S. Randomised clinical trial: palliative long-term abdominal drains vs large-volume paracentesis in refractory ascites due to cirrhosis. Aliment Pharmacol Ther 2020; 52:107-122. [PMID: 32478917 DOI: 10.1111/apt.15802] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/12/2020] [Accepted: 04/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Palliative care remains suboptimal in end-stage liver disease. AIM To inform a definitive study, we assessed palliative long-term abdominal drains in end-stage liver disease to determine recruitment, attrition, safety/potential effectiveness, questionnaires/interview uptake/completion and make a preliminary cost comparison. METHODS A 12-week feasibility nonblinded randomised controlled trial comparing large-volume paracentesis vs long-term abdominal drains in refractory ascites due to end-stage liver disease with fortnightly home visits for clinical/questionnaire-based assessments. Study success criteria were attrition not >50%, <10% long-term abdominal drain removal due to complications, the long-term abdominal drain group to spend <50% ascites-related study time in hospital vs large-volume paracentesis group and 80% questionnaire/interview uptake/completion. RESULTS Of 59 eligible patients, 36 (61%) were randomised, 17 to long-term abdominal drain and 19 to large-volume paracentesis. Following randomisation, median number (IQR) of hospital ascitic drains (long-term abdominal drain group vs large-volume paracentesis group) were 0 (0-1) vs 4 (3-7); week 12 serum albumin (g/L) and serum creatinine (μmol/L) were 29 (26.5-32.5) vs 30 (25-35) and 104.5 (81-115.5) vs 127 (63-158) respectively. Total attrition was 42% (long-term abdominal drain group 47%, large-volume paracentesis group 37%). Median (IQR) fortnightly community/hospital/social care ascites-related costs and percentage study time in hospital were lower in the long-term abdominal drain group, £329 (253-580) vs £843 (603-1060) and 0% (0-0.74) vs 2.75% (2.35-3.84) respectively. Self-limiting cellulitis/leakage occurred in 41% (7/17) in the long-term abdominal drain group vs 11% (2/19) in the large-volume paracentesis group; peritonitis incidence was 6% (1/17) vs 11% (2/19) respectively. Questionnaires/interview uptake/completion were ≥80%; interviews indicated that long-term abdominal drains could transform the care pathway. CONCLUSIONS The REDUCe study demonstrates feasibility with preliminary evidence of long-term abdominal drain acceptability/effectiveness/safety and reduction in health resource utilisation. TRIAL REGISTRATION ISRCTN30697116, date assigned: 07/10/2015.
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Lin CP, Evans CJ, Koffman J, Chen PJ, Hou MF, Harding R. Feasibility and acceptability of a culturally adapted advance care planning intervention for people living with advanced cancer and their families: A mixed methods study. Palliat Med 2020; 34:651-666. [PMID: 32081076 DOI: 10.1177/0269216320902666] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increasing evidence shows that advance care planning is effective in improving outcomes. However, its applicability and acceptability outside Western cultures remain unknown. Examination of relevant cultural adaptations is required prior to wider adoption. AIM To examine the feasibility and acceptability of a culturally adapted advance care planning intervention in a Taiwanese inpatient hospital for advanced cancer patients, family members and healthcare professionals. METHODS A single-group, non-controlled, mixed methods feasibility study guided by a previously developed logic model. The culturally adapted advance care planning intervention represented a one-time intervention, comprising pre-advance care planning preparation and follow-up consultation. Qualitative interviews explored participants' view on their involvement in the study. Patients' medical records were examined to assess intervention fidelity. Findings from both data sets were integrated following analysis. RESULTS N = 29 participants (n = 10 patients; n = 10 family members and n = 9 healthcare professionals) participated in the intervention, of who 28 completed follow-up interviews. Of the 10 advance care planning interventions delivered, most components (n = 10/13) were met. Key contextual moderators influencing the intervention feasibility included: (1) resource constraints resulting in increased workload; (2) care decisions informed by relatives' experiences of care; (3) the requirement for financial and policy support; and (4) a presumption for end-of-life care provision and surrogate decision-making. Six areas of intervention refinement were identified for future research. CONCLUSION Implementing a culturally adapted advance care planning intervention in an inpatient hospital setting in Taiwan is possible. The participants reported the intervention to be acceptable. However, careful attention to the conceptual underpinning using local primary data is imperative for its success.
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Affiliation(s)
- Cheng-Pei Lin
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.,Sussex Community NHS Foundation Trust, Brighton, UK
| | - Jonathan Koffman
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Ping-Jen Chen
- Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.,Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Ming-Feng Hou
- Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
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Yorganci E, Evans CJ, Johnson H, Barclay S, Murtagh FE, Yi D, Gao W, Pickles A, Koffman J. Understanding usual care in randomised controlled trials of complex interventions: A multi-method approach. Palliat Med 2020; 34:667-679. [PMID: 32081088 PMCID: PMC7238505 DOI: 10.1177/0269216320905064] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Evaluations of complex interventions compared to usual care provided in palliative care are increasing. Not describing usual care may affect the interpretation of an intervention's effectiveness, yet how it can be described remains unclear. AIM To demonstrate the feasibility of using multi-methods to describe usual care provided in randomised controlled trials (RCTs) of complex interventions, shown within a feasibility cluster RCT. DESIGN Multi-method approach comprising usual care questionnaires, baseline case note review and focus groups with ward staff completed at study end. Thematic analysis of qualitative data, descriptive statistics of quantitative data, followed by methodological triangulation to appraise approach in relation to study aim. SETTING/PARTICIPANTS Four general medical wards chosen from UK hospitals. Purposive sampling of healthcare professionals for usual care questionnaires, and focus groups. Review of 20 patients' notes from each ward who died during admission or within 100 days of discharge. RESULTS Twenty-three usual care questionnaires at baseline, two focus groups comprising 20 healthcare professionals and 80 case note reviews. Triangulation of findings resulted in understanding the usual care provided to the targeted population in terms of context, structures, processes and outcomes for patients, families and healthcare professionals. Usual care was described, highlighting (1) similarities and embedded practices, (2) heterogeneity and (3) subtle changes in care during the trial within and across sites. CONCLUSIONS We provide a feasible approach to defining usual care that can be practically adopted in different settings. Understanding usual care enhances the reliability of tested complex interventions, and informs research and policy priorities.
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Affiliation(s)
- Emel Yorganci
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Halle Johnson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Stephen Barclay
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Fliss Em Murtagh
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK.,Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Andrew Pickles
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jonathan Koffman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
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Brighton LJ, Evans CJ, Man WDC, Maddocks M. Improving Exercise-Based Interventions for People Living with Both COPD and Frailty: A Realist Review. Int J Chron Obstruct Pulmon Dis 2020; 15:841-855. [PMID: 32368030 PMCID: PMC7182688 DOI: 10.2147/copd.s238680] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/10/2020] [Indexed: 12/16/2022] Open
Abstract
Background People living with both chronic obstructive pulmonary disease (COPD) and frailty have high potential to benefit from exercise-based interventions, including pulmonary rehabilitation, but face challenges completing them. Research to understand ways to optimise exercise-based interventions in this group is lacking. We aimed to understand how exercise-based interventions might improve outcomes for people living with both COPD and frailty. Methods This realist review used database searches and handsearching until October 2019 to identify articles of relevance to exercise-based interventions for people living with COPD and frailty. A scoping search explored what is important about the context of living with COPD and frailty, and what mechanisms might be important in how exercise-based interventions result in their intended outcomes. Through discussion with stakeholders, the review scope was refined to areas deemed pertinent to improving care. We retained articles within this refined scope and identified additional articles through targeted handsearching. Data were extracted and synthesised in a narrative, prioritised by relevance and rigour. Results Of 344 records identified, 35 were included in the review and 20 informed the final synthesis. Important contextual factors to consider included: negative beliefs about themselves and exercise-based interventions; heterogenous presentation and comorbidities; decreased reserves and multidimensional loss; and experiencing unpredictable health and disruptions. In these circumstances, mechanisms that may help maximise outcomes from exercise-based interventions included: trusting relationships; creating a shared understanding of needs; having the capacity to address multidimensional concerns; being able to individualise approaches to needs and priorities; and flexible approaches to intervention delivery. Mixed-methods research and explicit theorising were often absent. Conclusion Building trusting relationships, understanding priorities, using individualised and multidisciplinary approaches, and flexible service delivery can improve the value of exercise-based interventions for people living with both COPD and frailty. Development and evaluation of new and adapted interventions should consider these principles.
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Affiliation(s)
- Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
- Brighton General Hospital, Sussex Community NHS Foundation Trust, Brighton, UK
| | - William D C Man
- National Heart and Lung Institute, Imperial College, London, UK
- Harefield Respiratory Research Group, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
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Finucane AM, Bone AE, Evans CJ, Gomes B, Meade R, Higginson IJ, Murray SA. The impact of population ageing on end-of-life care in Scotland: projections of place of death and recommendations for future service provision. BMC Palliat Care 2019; 18:112. [PMID: 31829177 PMCID: PMC6907353 DOI: 10.1186/s12904-019-0490-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Accepted: 11/15/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Global annual deaths are rising. It is essential to examine where future deaths may occur to facilitate decisions regarding future service provision and resource allocation. AIMS To project where people will die from 2017 to 2040 in an ageing country with advanced integrated palliative care, and to prioritise recommendations based on these trends. METHODS Population-based trend analysis of place of death for people that died in Scotland (2004-2016) and projections using simple linear modelling (2017-2040); Transparent Expert Consultation to prioritise recommendations in response to projections. RESULTS Deaths are projected to increase by 15.9% from 56,728 in 2016 (32.8% aged 85+ years) to 65,757 deaths in 2040 (45% aged 85+ years). Between 2004 and 2016, proportions of home and care home deaths increased (19.8-23.4% and 14.5-18.8%), while the proportion of hospital deaths declined (58.0-50.1%). If current trends continue, the numbers of deaths at home and in care homes will increase, and two-thirds will die outside hospital by 2040. To sustain current trends, priorities include: 1) to increase and upskill a community health and social care workforce through education, training and valuing of care work; 2) to build community care capacity through informal carer support and community engagement; 3) to stimulate a realistic public debate on death, dying and sustainable funding. CONCLUSION To sustain current trends, health and social care provision in the community needs to grow to support nearly 60% more people at the end-of-life by 2040; otherwise hospital deaths will increase.
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Affiliation(s)
- Anne M. Finucane
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, UK
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Anna E. Bone
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Bessemer Road, Denmark Hill, London, SE5 9PJ UK
| | - Catherine J. Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Bessemer Road, Denmark Hill, London, SE5 9PJ UK
| | - Barbara Gomes
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Bessemer Road, Denmark Hill, London, SE5 9PJ UK
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Richard Meade
- Policy and Public Affairs for Scotland, Marie Curie, Edinburgh, Scotland, UK
| | - Irene J. Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Bessemer Road, Denmark Hill, London, SE5 9PJ UK
| | - Scott A. Murray
- Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
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Kinley J, Ellis-Smith C, Hurt M, McIvor K, Evans CJ. A collaborative approach in dementia care to improve clinical effectiveness and priorities for research through audit. Int J Palliat Nurs 2019; 25:588-595. [PMID: 31855518 DOI: 10.12968/ijpn.2019.25.12.588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND To provide appropriate cost-effective care for an ageing population, realignment of care provision to conditions common in advanced age, notably, dementia and multi-morbidities is required. The use of outcome measures in practice may enable this. AIM A collaborative baseline audit was undertaken to understand how best to implement outcome measures into services for people with dementia across clinical settings. METHODS An academic institution set up a 6-month collaborative baseline audit in 11 English sites. Measures comprised: symptoms/concerns (Integrated Palliative care Outcome Scale for Dementia); Phase of Illness; functional status (Australia-modified Karnofsky Performance Scale); and dementia severity (Functional Assessment Staging). FINDINGS Measures were completed at first assessment for 225 people with dementia across nine sites. Their completion promoted comprehensive assessments, but challenges also existed, including recording the prevalence/severity of non-physical symptoms by proxy. CONCLUSIONS The joining together of clinical academic expertise enabled mobilisation of expert knowledge into and from clinical practice.
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Affiliation(s)
- Julie Kinley
- Formerly Nurse Consultant for Care Homes, Care Home Project Team, London
| | - Clare Ellis-Smith
- Lecturer in Palliative Care, Cicely Saunders Institute of Palliative Care, King's College London
| | - Michael Hurt
- Formerly Head of Older People and Dementia, NHS Walsall Clinical Commissioning Group, Walsall
| | - Karen McIvor
- Dementia Nurse Specialist, Royal Trinity Hospice, London
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, King's College London and HEE/NIHR Senior Clinical Lecturer and Honorary Nurse Consultant in Palliative Care, Sussex Community NHS Foundation Trust, Brighton
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Lin CP, Evans CJ, Koffman J, Sheu SJ, Hsu SH, Harding R. What influences patients' decisions regarding palliative care in advance care planning discussions? Perspectives from a qualitative study conducted with advanced cancer patients, families and healthcare professionals. Palliat Med 2019; 33:1299-1309. [PMID: 31368854 DOI: 10.1177/0269216319866641] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The concept of advance care planning is largely derived from Western countries. However, the decision-making process and drivers for choosing palliative care in non-Western cultures have received little attention. AIM To explore the decision-making processes and drivers of receiving palliative care in advance care planning discussions from perspectives of advanced cancer patients, families and healthcare professionals in northern Taiwan. METHOD Semi-structured qualitative interviews with advanced cancer patients, their families and healthcare professionals independently from inpatient oncology and hospice units. Thematic analysis with analytical rigour enhanced by dual coding and exploration of divergent views. RESULTS Forty-five participants were interviewed (n = 15 from each group). Three main decision-making trajectories were identified: (1) 'choose palliative care' was associated with patients' desire to reduce physical suffering from treatments, avoid being a burden to families and society, reduce futile treatments and donate organs to help others; (2) 'decline palliative care' was associated with patients weighing up perceived benefits to others as more important than benefits for themselves; and (3) 'no opportunity to choose palliative care' was associated with lack of opportunities to discuss potential benefits of palliative care, lack of staff skill in end-of-life communication, and cultural factors, notably filial piety. CONCLUSION Choice for palliative care among advanced cancer patients in Taiwan is influenced by three decision-making trajectories. Opinions from families are highly influential, and patients often lack information on palliative care options. Strategies to facilitate decision-making require staff confidence in end-of-life discussions, working with the patients and their family while respecting the influence of filial piety.
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Affiliation(s)
- Cheng-Pei Lin
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,Sussex Community NHS Foundation Trust, Brighton, UK
| | - Jonathan Koffman
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Shuh-Jen Sheu
- Institution of Community Health Care, School of Nursing, National Yang Ming University, Taipei, Taiwan
| | - Su-Hsuan Hsu
- Centre of Long-term Care Planning and Development, Taipei City Hospital, Taipei, Taiwan
| | - Richard Harding
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Bone AE, Evans CJ, Henson LA, Gao W, Higginson IJ. Patterns of emergency department attendance among older people in the last three months of life and factors associated with frequent attendance: a mortality follow-back survey. Age Ageing 2019; 48:680-687. [PMID: 31127300 DOI: 10.1093/ageing/afz043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 02/01/2019] [Accepted: 04/09/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND frequent emergency department (ED) attendance at the end of life disrupts care continuity and contradicts most patients' preference for home-based care. OBJECTIVE to examine factors associated with frequent (≥3) end of life ED attendances among older people to identify opportunities to improve care. METHODS pooled data from two mortality follow-back surveys in England. Respondents were family members of people aged ≥65 who died four to ten months previously. We used multivariable modified Poisson regression to examine illness, service and sociodemographic factors associated with ≥3 ED attendances, and directed content analysis to explore free-text responses. RESULTS 688 respondents (responses from 42.0%); most were sons/daughters (60.5%). Mean age at death was 85 years. 36.5% had a primary diagnosis of cancer and 16.3% respiratory disease. 80/661 (12.1%) attended ED ≥3 times, accounting for 43% of all end of life attendances. From the multivariable model, respiratory disease (reference cancer) and ≥2 comorbidities (reference 0) were associated with frequent ED attendance (adjusted prevalence ratio 2.12, 95% CI 1.21-3.71 and 1.81, 1.07-3.06). Those with ≥7 community nursing contacts (reference 0 contacts) were more likely to frequently attend ED (2.65, 1.49-4.72), whereas those identifying a key health professional were less likely (0.58, 0.37-0.88). Analysis of free-text found inadequate community support, lack of coordinated care and untimely hospital discharge were key issues. CONCLUSIONS assigning a key health professional to older people at increased risk of frequent end of life ED attendance, e.g. those with respiratory disease and/or multiple comorbidities, may reduce ED attendances by improving care coordination.
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Affiliation(s)
- Anna E Bone
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, UK
- Sussex Community NHS Foundation Trust, Brighton, UK
| | - Lesley A Henson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, UK
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de Wolf-Linder S, Dawkins M, Wicks F, Pask S, Eagar K, Evans CJ, Higginson IJ, Murtagh FEM. Which outcome domains are important in palliative care and when? An international expert consensus workshop, using the nominal group technique. Palliat Med 2019; 33:1058-1068. [PMID: 31185812 PMCID: PMC6691595 DOI: 10.1177/0269216319854154] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND When capturing patient-level outcomes in palliative care, it is essential to identify which outcome domains are most important and focus efforts to capture these, in order to improve quality of care and minimise collection burden. AIM To determine which domains of palliative care are most important for measurement of outcomes, and the optimal time period over which these should be measured. DESIGN An international expert consensus workshop using nominal group technique. Data were analysed descriptively, and weighted according to ranking (1-5, lowest to highest priority) of domains. Participants' rationales for their choices were analysed thematically. SETTING/PARTICIPANTS In all, 33 clinicians and researchers working globally in palliative care outcome measurement participated. Two groups (n = 16; n = 17) answered one question each (either on domains or optimal timing). This workshop was conducted at the 9th World Research Congress of the European Association for Palliative Care in 2016. RESULTS Participants' years of experience in palliative care and in outcome measurement ranged from 10.9 to 14.7 years and 5.8 to 6.4 years, respectively. The mean scores (weighted by rank) for the top-ranked domains were 'overall wellbeing/quality of life' (2.75), 'pain' (2.06), and 'information needs/preferences' (2.06), respectively. The palliative measure 'Phase of Illness' was recommended as the preferred measure of time period over which the domains were measured. CONCLUSION The domains of 'overall wellbeing/quality of life', 'pain', and 'information needs/preferences' are recommended for regular measurement, assessed using 'Phase of Illness'. International adoption of these recommendations will help standardise approaches to improving the quality of palliative care.
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Affiliation(s)
- Susanne de Wolf-Linder
- School of Health Professions, Institute of Nursing, Zurich University of Applied Sciences, Winterthur, Switzerland
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Marsha Dawkins
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Francesca Wicks
- Cambridge Institute for Medical Research, University of Cambridge, Cambridge, UK
| | - Sophie Pask
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Kathy Eagar
- Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW, Australia
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Fliss E M Murtagh
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Bone AE, Evans CJ, Etkind SN, Sleeman KE, Gomes B, Aldridge M, Keep J, Verne J, Higginson IJ. Factors associated with older people's emergency department attendance towards the end of life: a systematic review. Eur J Public Health 2019; 29:67-74. [PMID: 30481305 PMCID: PMC6345149 DOI: 10.1093/eurpub/cky241] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background Emergency department (ED) attendance for older people towards the end of life is common and increasing, despite most preferring home-based care. We aimed to review the factors associated with older people’s ED attendance towards the end of life. Methods Systematic review using Medline, Embase, PsychINFO, CINAHL and Web of Science from inception to March 2017. Included studies quantitatively examined factors associated with ED attendance for people aged ≥65 years within the last year of life. We assessed study quality using the QualSyst tool and determined evidence strength based on quality, quantity and consistency. We narratively synthesized the quantitative findings. Results Of 3824 publications identified, 21 were included, combining data from 1 565 187 participants. 17/21 studies were from the USA and 19/21 used routinely collected data. We identified 47 factors and 21 were included in the final model. We found high strength evidence for associations between ED attendance and palliative/hospice care (adjusted effect estimate range: 0.1–0.94); non-white ethnicity (1.03–2.16); male gender (1.04–1.83, except 0.70 in one sub-sample) and rural areas (0.98–1.79). The final model included socio-demographic, illness and service factors, with largest effect sizes for service factors. Conclusions In this synthesis, receiving palliative care was associated with lower ED attendance in the last year of life for older adults. This has implications for service models for older people nearing the end of life. However, there is limited evidence from European countries and none from low or middle-income countries, which warrants further research.
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Affiliation(s)
- Anna E Bone
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK
| | - Simon N Etkind
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Katherine E Sleeman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
| | - Barbara Gomes
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Melissa Aldridge
- Icahn School of Medicine at Mount Sinai, Department of Geriatrics and Palliative Medicine, New York, USA
| | - Jeff Keep
- King's College Hospital NHS Foundation Trust, London, UK
| | | | - Irene J Higginson
- King's College London, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, London, UK
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Brighton LJ, Selman LE, Bristowe K, Edwards B, Koffman J, Evans CJ. Emotional labour in palliative and end-of-life care communication: A qualitative study with generalist palliative care providers. Patient Educ Couns 2019; 102:494-502. [PMID: 30879492 DOI: 10.1016/j.pec.2018.10.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 09/10/2018] [Accepted: 10/15/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To explore generalist palliative care providers' experiences of emotional labour when undertaking conversations around palliative and end-of-life care with patients and families, to inform supportive strategies. METHODS Semi-structured interviews conducted with generalist staff (those providing 'primary' or 'general' palliative care, not palliative care specialists) who had attended a communication workshop. Sampling was purposive (by gender, profession, experience). Data were analysed using a framework approach; a sample of transcripts were double-coded for rigour. Data collection and analysis were informed by theories of emotional labour, coping, and communication. RESULTS Four ambulance staff, three nurses, two speech and language therapists, and one therapy assistant were interviewed. Five themes emerged: emotions experienced; emotion 'display rules'; emotion management; support needs; and perceived impact of emotional labour. Participants reported balancing 'human' and 'professional' expressions of emotion. Support needs included time for emotion management, workplace cultures that normalise emotional experiences, formal emotional support, and palliative and end-of-life care skills training. CONCLUSION Diverse strategies to support the emotional needs of generalist staff are crucial to ensure high-quality end-of-life care and communication, and to support staff well-being. PRACTICE IMPLICATIONS Both formal and informal support is required, alongside skills training, to enable a supportive workplace culture and individual development.
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Affiliation(s)
- Lisa Jane Brighton
- King's College London, Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, London, UK.
| | - Lucy Ellen Selman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Katherine Bristowe
- King's College London, Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, London, UK.
| | - Beth Edwards
- King's College London, Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, London, UK.
| | - Jonathan Koffman
- King's College London, Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, London, UK.
| | - Catherine J Evans
- King's College London, Cicely Saunders Institute of Palliative Care, Policy, and Rehabilitation, London, UK; Sussex Community NHS Foundation Trust, Brighton General Hospital, Brighton, UK.
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Lin CP, Evans CJ, Koffman J, Armes J, Murtagh FEM, Harding R. The conceptual models and mechanisms of action that underpin advance care planning for cancer patients: A systematic review of randomised controlled trials. Palliat Med 2019; 33:5-23. [PMID: 30362897 PMCID: PMC6291906 DOI: 10.1177/0269216318809582] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND: No systematic review has focused on conceptual models underpinning advance care planning for patients with advanced cancer, and the mechanisms of action in relation to the intended outcomes. AIM: To appraise conceptual models and develop a logic model of advance care planning for advanced cancer patients, examining the components, processes, theoretical underpinning, mechanisms of action and linkage with intended outcomes. DESIGN: A systematic review of randomised controlled trials was conducted, and was prospectively registered on PROSPERO. Narrative synthesis was used for data analysis. DATA SOURCES: The data sources were MEDLINE, CINAHL, PsycINFO, EMBASE, CENTRAL, PROSPERO, CareSearch, and OpenGrey with reference chaining and hand-searching from inception to 31 March 2017, including all randomised controlled trials with advance care planning for cancer patients in the last 12 months of life. Cochrane quality assessment tool was used for quality appraisal. RESULTS: Nine randomised controlled trials were included, with only four articulated conceptual models. Mechanisms through which advance care planning improved outcomes comprised (1) increasing patients' knowledge of end-of-life care, (2) strengthening patients' autonomous motivation, (3) building patients' competence to undertake end-of-life discussions and (4) enhancing shared decision-making in a trustful relationship. Samples were largely highly educated Caucasian. CONCLUSION: The use of conceptual models underpinning the development of advance care planning is uncommon. When used, they identify the individual behavioural change. Strengthening patients' motivation and competence in participating advance care planning discussions are key mechanisms of change. Understanding cultural feasibility of the logic model for different educational levels and ethnicities in non-Western countries should be a research priority.
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Affiliation(s)
- Cheng-Pei Lin
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Catherine J Evans
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,2 Sussex Community NHS Foundation Trust, Brighton, UK
| | - Jonathan Koffman
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Jo Armes
- 3 School of Health Sciences, University of Surrey, Guildford, UK
| | - Fliss E M Murtagh
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,4 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Richard Harding
- 1 Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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46
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Jensen SKG, Pangelinan M, Björnholm L, Klasnja A, Leemans A, Drakesmith M, Evans CJ, Barker ED, Paus T. Associations between prenatal, childhood, and adolescent stress and variations in white-matter properties in young men. Neuroimage 2018; 182:389-397. [PMID: 29066395 PMCID: PMC5911246 DOI: 10.1016/j.neuroimage.2017.10.033] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Revised: 08/30/2017] [Accepted: 10/16/2017] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE Previous studies have shown that both pre- and post-natal adversities, the latter including exposures to stress during childhood and adolescence, explain variation in structural properties of white matter (WM) in the brain. While previous studies have examined effects of independent stress exposures within one developmental period, such as childhood, we examine effects of stress across development using data from a prospective longitudinal study. More specifically, we ask how stressful events during prenatal development, childhood, and adolescence relate to variation in WM properties in early adulthood in young men recruited from a birth cohort. METHOD Using data from 393 mother-son pairs from a community-based birth cohort from England (Avon Longitudinal Study of Parents and Children), we examined how stressful life events relate to variation in different structural properties of WM in the corpus callosum and across the whole brain in early adulthood in men aged 18-21 years. We distinguish between stress occurring during three developmental periods: a) prenatal maternal stress, b) postnatal stress within the first four years of life, c) stress during adolescence (age 12-16 years). To obtain a comprehensive quantification of variation in WM, we assess structural properties of WM using four different measures, namely fractional anisotropy (FA), mean diffusivity (MD), magnetization transfer ratio (MTR) and myelin water fraction (MWF). RESULTS The developmental model shows that prenatal stress is associated with lower MTR and MWF in the genu and/or splenium of the corpus callosum, and with lower MTR in global (lobar) WM. Stress during early childhood is associated with higher MTR in the splenium, and stress during adolescence is associated with higher MTR in the genu and lower MD in the splenium. We see no associations between postnatal stress and variation in global (lobar) WM. CONCLUSIONS The current study found evidence for independent effects of stress on WM properties during distinct neurodevelopmental periods. We speculate that these independent effects are due to differences in the developmental processes unfolding at different developmental time points. We suggest that associations between prenatal stress and WM properties may relate to abnormalities in neurogenesis, affecting the number and density of axons, while postnatal stress may interfere with processes related to myelination or radial growth of axons. Potential consequences of prenatal glucocorticoid exposure should be considered in obstetric care.
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Affiliation(s)
- Sarah K G Jensen
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom; Department of Pediatrics, Boston Children's Hospital, Boston, MA USA; Harvard Medical School, Boston, MA, USA
| | | | | | - Anja Klasnja
- Rotman Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Alexander Leemans
- Image Sciences Institute, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark Drakesmith
- Neuroscience and Mental Health Research Institute, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - C J Evans
- CUBRIC, School of Psychology, Cardiff University, Cardiff, United Kingdom
| | - Edward D Barker
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College, London, United Kingdom
| | - Tomáš Paus
- Rotman Research Institute, University of Toronto, Toronto, Ontario, Canada; Departments of Psychology and Psychiatry, University of Toronto, Toronto, Canada; Child Mind Institute, New York, USA.
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47
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Affiliation(s)
- Anna E Bone
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London SE5 9PJ, UK.
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London SE5 9PJ, UK; Sussex Community NHS Foundation Trust, Brighton, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London SE5 9PJ, UK
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Pask S, Pinto C, Bristowe K, van Vliet L, Nicholson C, Evans CJ, George R, Bailey K, Davies JM, Guo P, Daveson BA, Higginson IJ, Murtagh FEM. A framework for complexity in palliative care: A qualitative study with patients, family carers and professionals. Palliat Med 2018; 32:1078-1090. [PMID: 29457743 DOI: 10.1177/0269216318757622] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Palliative care patients are often described as complex but evidence on complexity is limited. We need to understand complexity, including at individual patient-level, to define specialist palliative care, characterise palliative care populations and meaningfully compare interventions/outcomes. Aim: To explore palliative care stakeholders’ views on what makes a patient more or less complex and insights on capturing complexity at patient-level. Design: In-depth qualitative interviews, analysed using Framework analysis. Participants/setting: Semi-structured interviews across six UK centres with patients, family, professionals, managers and senior leads, purposively sampled by experience, background, location and setting (hospital, hospice and community). Results: 65 participants provided an understanding of complexity, which extended far beyond the commonly used physical, psychological, social and spiritual domains. Complexity included how patients interact with family/professionals, how services’ respond to needs and societal perspectives on care. ‘Pre-existing’, ‘cumulative’ and ‘invisible’ complexity are further important dimensions to delivering effective palliative and end-of-life care. The dynamic nature of illness and needs over time was also profoundly influential. Adapting Bronfenbrenner’s Ecological Systems Theory, we categorised findings into the microsystem (person, needs and characteristics), chronosystem (dynamic influences of time), mesosystem (interactions with family/health professionals), exosystem (palliative care services/systems) and macrosystem (societal influences). Stakeholders found it acceptable to capture complexity at the patient-level, with perceived benefits for improving palliative care resource allocation. Conclusion: Our conceptual framework encompasses additional elements beyond physical, psychological, social and spiritual domains and advances systematic understanding of complexity within the context of palliative care. This framework helps capture patient-level complexity and target resource provision in specialist palliative care.
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Affiliation(s)
- Sophie Pask
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Cathryn Pinto
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Katherine Bristowe
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Liesbeth van Vliet
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Caroline Nicholson
- 2 Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, King's College London, London, UK
| | - Catherine J Evans
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.,3 Sussex Community NHS Foundation Trust, Brighton, UK
| | | | - Katharine Bailey
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Joanna M Davies
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Ping Guo
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Barbara A Daveson
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Fliss E M Murtagh
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.,5 Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Bone AE, Gomes B, Etkind SN, Verne J, Murtagh FEM, Evans CJ, Higginson IJ. What is the impact of population ageing on the future provision of end-of-life care? Population-based projections of place of death. Palliat Med 2018; 32:329-336. [PMID: 29017018 PMCID: PMC5788077 DOI: 10.1177/0269216317734435] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
BACKGROUND Population ageing represents a global challenge for future end-of-life care. Given new trends in place of death, it is vital to examine where the rising number of deaths will occur in future years and implications for health and social care. AIM To project where people will die from 2015 to 2040 across all care settings in England and Wales. DESIGN Population-based trend analysis and projections using simple linear modelling. Age- and gender-specific proportions of deaths in hospital, care home, home, hospice and 'other' were applied to numbers of expected future deaths. Setting/population: All deaths (2004-2014) from death registration data and predicted deaths (2015-2040) from official population forecasts in England and Wales. RESULTS Annual deaths are projected to increase from 501,424 in 2014 (38.8% aged 85 years and over) to 635,814 in 2040 (53.6% aged 85 years and over). Between 2004 and 2014, proportions of home and care home deaths increased (18.3%-22.9% and 16.7%- 21.2%) while hospital deaths declined (57.9%-48.1%). If current trends continue, numbers of deaths in care homes and homes will increase by 108.1% and 88.6%, with care home the most common place of death by 2040. If care home capacity does not expand and additional deaths occur in hospital, hospital deaths will start rising by 2023. CONCLUSION To sustain current trends, end-of-life care provision in care homes and the community needs to double by 2040. An infrastructure across care settings that supports rising annual deaths is urgently needed; otherwise, hospital deaths will increase.
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Affiliation(s)
- Anna E Bone
- 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Barbara Gomes
- 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,2 Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Simon N Etkind
- 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | | | - Fliss E M Murtagh
- 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,4 Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Catherine J Evans
- 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK.,5 Brighton General Hospital, Sussex Community NHS Foundation Trust, Brighton, UK
| | - Irene J Higginson
- 1 Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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Schneider FRN, Sana H, Evans CJ, Bestenlehner JM, Castro N, Fossati L, Gräfener G, Langer N, Ramírez-Agudelo OH, Sabín-Sanjulián C, Simón-Díaz S, Tramper F, Crowther PA, de Koter A, de Mink SE, Dufton PL, Garcia M, Gieles M, Hénault-Brunet V, Herrero A, Izzard RG, Kalari V, Lennon DJ, Maíz Apellániz J, Markova N, Najarro F, Podsiadlowski P, Puls J, Taylor WD, van Loon JT, Vink JS, Norman C. An excess of massive stars in the local 30 Doradus starburst. Science 2018; 359:69-71. [PMID: 29302009 DOI: 10.1126/science.aan0106] [Citation(s) in RCA: 127] [Impact Index Per Article: 21.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 11/30/2017] [Indexed: 11/02/2022]
Abstract
The 30 Doradus star-forming region in the Large Magellanic Cloud is a nearby analog of large star-formation events in the distant universe. We determined the recent formation history and the initial mass function (IMF) of massive stars in 30 Doradus on the basis of spectroscopic observations of 247 stars more massive than 15 solar masses ([Formula: see text]). The main episode of massive star formation began about 8 million years (My) ago, and the star-formation rate seems to have declined in the last 1 My. The IMF is densely sampled up to 200 [Formula: see text] and contains 32 ± 12% more stars above 30 [Formula: see text] than predicted by a standard Salpeter IMF. In the mass range of 15 to 200 [Formula: see text], the IMF power-law exponent is [Formula: see text], shallower than the Salpeter value of 2.35.
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Affiliation(s)
- F R N Schneider
- Department of Physics, University of Oxford, Keble Road, Oxford OX1 3RH, UK
| | - H Sana
- Institute of Astrophysics, KU Leuven, Celestijnenlaan 200D, 3001 Leuven, Belgium
| | - C J Evans
- UK Astronomy Technology Centre, Royal Observatory Edinburgh, Blackford Hill, Edinburgh EH9 3HJ, UK
| | - J M Bestenlehner
- Max-Planck-Institut für Astronomie, Königstuhl 17, 69117 Heidelberg, Germany.,Department of Physics and Astronomy, Hicks Building, Hounsfield Road, University of Sheffield, Sheffield S3 7RH, UK
| | - N Castro
- Department of Astronomy, University of Michigan, 1085 South University Avenue, Ann Arbor, MI 48109, USA
| | - L Fossati
- Austrian Academy of Sciences, Space Research Institute, Schmiedlstraße 6, 8042 Graz, Austria
| | - G Gräfener
- Argelander-Institut für Astronomie der Universität Bonn, Auf dem Hügel 71, 53121 Bonn, Germany
| | - N Langer
- Argelander-Institut für Astronomie der Universität Bonn, Auf dem Hügel 71, 53121 Bonn, Germany
| | - O H Ramírez-Agudelo
- UK Astronomy Technology Centre, Royal Observatory Edinburgh, Blackford Hill, Edinburgh EH9 3HJ, UK
| | - C Sabín-Sanjulián
- Departamento de Física y Astronomía, Universidad de La Serena, Avenida Juan Cisternas no. 1200 Norte, La Serena, Chile
| | - S Simón-Díaz
- Instituto de Astrofísica de Canarias, E-38205 La Laguna, Tenerife, Spain.,Departamento de Astrofísica, Universidad de La Laguna, E-38206 La Laguna, Tenerife, Spain
| | - F Tramper
- European Space Astronomy Centre, Mission Operations Division, P.O. Box 78, 28691 Villanueva de la Cañada, Madrid, Spain
| | - P A Crowther
- Department of Physics and Astronomy, Hicks Building, Hounsfield Road, University of Sheffield, Sheffield S3 7RH, UK
| | - A de Koter
- Astronomical Institute Anton Pannekoek, Amsterdam University, Science Park 904, 1098 XH Amsterdam, Netherlands.,Institute of Astrophysics, KU Leuven, Celestijnenlaan 200D, 3001 Leuven, Belgium
| | - S E de Mink
- Astronomical Institute Anton Pannekoek, Amsterdam University, Science Park 904, 1098 XH Amsterdam, Netherlands
| | - P L Dufton
- Astrophysics Research Centre, School of Mathematics and Physics, Queen's University Belfast, Belfast BT7 1NN, Northern Ireland, UK
| | - M Garcia
- Centro de Astrobiología, CSIC-INTA, Carretera de Torrejón a Ajalvir km-4, E-28850 Torrejón de Ardoz, Madrid, Spain
| | - M Gieles
- Department of Physics, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, GU2 7XH, UK
| | - V Hénault-Brunet
- National Research Council, Herzberg Astronomy and Astrophysics, 5071 West Saanich Road, Victoria, British Columbia V9E 2E7, Canada.,Department of Astrophysics/Institute for Mathematics, Astrophysics and Particle Physics, Radboud University, P.O. Box 9010, NL-6500 GL Nijmegen, Netherlands
| | - A Herrero
- Instituto de Astrofísica de Canarias, E-38205 La Laguna, Tenerife, Spain.,Departamento de Astrofísica, Universidad de La Laguna, E-38206 La Laguna, Tenerife, Spain
| | - R G Izzard
- Department of Physics, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, GU2 7XH, UK.,Institute of Astronomy, The Observatories, Madingley Road, Cambridge CB3 0HA, UK
| | - V Kalari
- Departamento de Astronomía, Universidad de Chile, Camino El Observatorio 1515, Las Condes, Santiago, Casilla 36-D, Chile
| | - D J Lennon
- European Space Astronomy Centre, Mission Operations Division, P.O. Box 78, 28691 Villanueva de la Cañada, Madrid, Spain
| | - J Maíz Apellániz
- Centro de Astrobiología, CSIC-INTA, European Space Astronomy Centre campus, camino bajo del castillo s/n, E-28 692 Villanueva de la Cañada, Spain
| | - N Markova
- Institute of Astronomy with National Astronomical Observatory, Bulgarian Academy of Sciences, P.O. Box 136, 4700 Smoljan, Bulgaria
| | - F Najarro
- Centro de Astrobiología, CSIC-INTA, Carretera de Torrejón a Ajalvir km-4, E-28850 Torrejón de Ardoz, Madrid, Spain
| | - Ph Podsiadlowski
- Department of Physics, University of Oxford, Keble Road, Oxford OX1 3RH, UK.,Argelander-Institut für Astronomie der Universität Bonn, Auf dem Hügel 71, 53121 Bonn, Germany
| | - J Puls
- Ludwig-Maximilians-Universität München, Universitätssternwarte, Scheinerstrasse 1, 81679 München, Germany
| | - W D Taylor
- UK Astronomy Technology Centre, Royal Observatory Edinburgh, Blackford Hill, Edinburgh EH9 3HJ, UK
| | - J Th van Loon
- Lennard-Jones Laboratories, Keele University, Staffordshire ST5 5BG, UK
| | - J S Vink
- Armagh Observatory, College Hill, Armagh BT61 9DG, Northern Ireland, UK
| | - C Norman
- Johns Hopkins University, Homewood Campus, Baltimore, MD 21218, USA.,Space Telescope Science Institute, 3700 San Martin Drive, Baltimore, MD 21218, USA
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