Global Assessment of Palliative Care Need: Serious Health-Related Suffering Measurement Methodology

Inequities and gaps in palliative care access are a serious impediment to health systems especially low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions. In this paper, an updated methodology - SHS2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions. The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS. The discussion encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0.

'We are all in the same boat': a qualitative cross-sectional analysis of COVID-19 pandemic imagery in scientific literature and its use for people working in the German healthcare sector

Background

The COVID-19 pandemic presents a significant challenge to professional responders in healthcare settings. This is reflected in the language used to describe the pandemic in the professional literature of the respective professions. The aim of this multidisciplinary study was to analyze the linguistic imagery in the relevant professional literature and to determine the identification of different professional groups with it and its emotional effects.

Method

A list of 14 typical, widespread and differing imageries for COVID-19 in form of single sentences (e.g., "Until the pandemic is over, we can only run on sight.") were presented to 1,795 healthcare professionals in an online survey. The imageries had been extracted from a qualitative search in more than 3,500 international professional journals in medicine, psychology and theology. Ratings of agreement with these imageries and feelings about them were subjected to factor analysis.

Results

Based on the list of imageries presented, it was possible to identify three factors for high/low agreement by experiences, and two factors for high/low induced feelings. Broad agreement emerged for imageries on "fight against the crisis" and "lessons learned from the crisis", while imageries on "acceptance of uncontrollability" tended to be rejected. Imageries of "challenges" tended to lead to a sense of empowerment among subjects, while imageries of "humility" tended to lead to a sense of helplessness.

Conclusion

Based on the qualitative and subsequential quantitative analysis, several factors for imageries for the COVID-19 pandemic were identified that have been used in the literature. Agreement with imageries is mixed, as is the assessment of how helpful they are.

Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: An international Delphi study

BACKGROUND

The European Association for Palliative Care (EAPC) acknowledges palliative sedation as an important, broadly accepted intervention for patients with life-limiting disease experiencing refractory symptoms. The EAPC therefore developed 2009 a framework on palliative sedation. A revision was needed due to new evidence from literature, ongoing debate and criticism of methodology, terminology and applicability.

AIM

To provide evidence- and consensus-based guidance on palliative sedation for healthcare professionals involved in end-of-life care, for medical associations and health policy decision-makers.

DESIGN

Revision between June 2020 and September 2022 of the 2009 framework using a literature update and a Delphi procedure.

SETTING

European.

PARTICIPANTS

International experts on palliative sedation (identified through literature search and nomination by national palliative care associations) and a European patient organisation.

RESULTS

A framework with 42 statements for which high or very high level of consensus was reached. Terminology is defined more precisely with the terms suffering used to encompass distressing physical and psychological symptoms as well as existential suffering and refractory to describe the untreatable (healthcare professionals) and intolerable (patient) nature of the suffering. The principle of proportionality is introduced in the definition of palliative sedation. No specific period of remaining life expectancy is defined, based on the principles of refractoriness of suffering, proportionality and independent decision-making for hydration. Patient autonomy is emphasised. A stepwise pharmacological approach and a guidance on hydration decision-making are provided.

CONCLUSIONS

This is the first framework on palliative sedation using a strict consensus methodology. It should serve as comprehensive and soundly developed information for healthcare professionals.

[Concept-dependent and -independent care effects of site-specific care concepts using "pain" as an example]

BACKGROUND

Structures of palliative care, cross-sectoral transitions and care pathways of patients with palliative care needs were investigated at two sites. The systematic comparison of similarities and differences using the topic of 'pain' as an example is intended to provide information on the extent to which these are related to site-specific palliative care concepts (integrated and cooperative).

METHODS

The study follows a mixed-methods design. In addition to a document analysis of anonymised patient records (n = 774), expert interviews (n = 20), as well as interviews with patients, relatives (n = 60) and focus groups (n = 12), were conducted.

RESULTS

The systematic comparative analysis provides evidence for concept-independent commonalities (e.g. sociodemographic distribution, aggravated pain treatment) as well as concept-dependent differences (e.g. care pathways, facilitated continuous symptom control through integrated care structures) in the context of integrated or cooperative palliative care.

DISCUSSION

Commonalities and differences with regard to the topic of pain, as focused on here, and its organisational management become tangible as effects of the respective organisational structure (= concept-dependent) as well as concept-independent external influencing factors.

Interventions that may increase control at the end of life in persons with dementia: the cross-cultural CONT-END acceptability study protocol and pilot-testing

BACKGROUND

Interventions such as advance care planning (ACP), technology, or access to euthanasia may increase the sense of control over the end of life. In people with advanced dementia, the loss of cognitive and physical function limits the ability to control care. To date, little is known about the acceptability of these interventions from the perspective of persons with dementia and others involved. This study will examine the cross-cultural acceptability, and factors associated with acceptability, of four end-of-life interventions in dementia which contain an element of striving for control. Also, we report on the development and pilot testing of animation video vignettes that explain the interventions in a standardized manner.

METHODS

Cross-sectional mixed-methods vignette study. We assess acceptability of two ACP approaches, technology use at the end of life and euthanasia in persons with dementia, their family caregivers and physicians in six countries (Netherlands, Japan, Israel, USA, Germany, Switzerland). We aim to include 80 participants per country, 50 physicians, 15 persons with dementia, and 15 family caregivers. After viewing each animation video, participants are interviewed about acceptability of the intervention. We will examine differences in acceptability between group and country and explore other potentially associated factors including variables indicating life view, personality, view on dementia and demographics. In the pilot study, participants commented on the understandability and clarity of the vignettes and instruments. Based on their feedback, the scripts of the animation videos were clarified, simplified and adapted to being less slanted in a specific direction.

DISCUSSION

In the pilot study, the persons with dementia, their family caregivers and other older adults found the adapted animation videos and instruments understandable, acceptable, feasible, and not burdensome. The CONT-END acceptability study will provide insight into cross-cultural acceptability of interventions in dementia care from the perspective of important stakeholders. This can help to better align interventions with preferences. The study will also result in a more fundamental understanding as to how and when having control at the end of life in dementia is perceived as beneficial or perhaps harmful.

TRIAL REGISTRATION

The CONT-END acceptability study was originally registered at the Netherlands Trial Register (NL7985) at 31 August, 2019, and can be found on the International Clinical Trials Registry Platform.

Evaluation of a Study Protocol of the Application of Humor Interventions in Palliative Care Through a First Pilot Study

Background

Humor and laughter might have an alleviating effect on pain threshold and enhance coping and building relationships. However, randomized controlled studies in palliative care have struggled with high percentages of attrition and missing values.

Objectives

We aimed to evaluate a study protocol through a pilot study for the evaluation of a multistage humor intervention with psychological and physiological outcome parameters that may be applied successfully in a palliative care environment.

Design

This pilot study utilized a pre-post design. The inclusion of a control group for the final study setting recruiting 120 patients is planned.

Setting/Subjects

The study was a monocenter study in a clinic for palliative care in Germany. All patients were eligible for recruitment. Seven patients were recruited for the pilot study.

Measurements

Interventions were developed using a humor training for psychiatric patients. Quantitative sensory testing for pain threshold testing and questionnaires on humor as a character trait, pain intensity, life satisfaction, and symptom burden were planned to be evaluated before and after three humor interventions.

Results

The feasibility of the original study design was re-evaluated after pilot testing. Only two out of the seven patients were able to complete two interventions, requiring modification. Fewer questionnaires, less complex physiological testing, and reduction from three to two interventions were then planned.

Conclusion

The initial planned research methodology must be adjusted for patients with high symptom burden. In the experimental group of the final study setting, the effects of one to two interventions will be evaluated measuring oxytocin levels in saliva and using standardized questionnaires to determine cheerfulness, life satisfaction and symptom burden, as well as assessing as-needed medication.

Trial registration

DRKS00028978 German Registry of Clinical Studies.

Development of Care Pathway for Assessment and Treatment of Fatigue in Palliative Care

Objectives

Fatigue is a frequent and burdensome symptom in patients with advanced disease in palliative care. However, it is under-assessed and undertreated in clinical practice, even though many treatment options have been identified in systematic reviews. Care pathways with defined and standardised steps have been recommended for effective management in the clinical setting. This paper describes a care pathway for managing fatigue in palliative care patients. This study aims to develop a care pathway with detailed guidance for screening, assessment, diagnosis, and treatment of fatigue in palliative care patients.

Material and methods

A collaborative effort of multidisciplinary clinicians participated in constructing the care pathway. The care pathway was developed using the following steps: (a) Developing an intervention; (b) piloting and feasibility; (c) evaluating the intervention; (d) reporting; and (e) implementation. This paper covers the first step, which includes the evidence base identification, theory identification/development, and process/outcomes modeling. A literature search was conducted to understand the extent of the fatigue problem in the palliative care setting and identify existing guidelines and strategies for managing fatigue. Consistent recommendations emanating from the included papers were then contributed to a care pathway. Patient representatives and palliative care professionals provided feedback on the draft.

Results

The care pathway address the following care processes: (1) Screening for the presence of fatigue; (2) assessment to evaluate the severity of fatigue; (3) diagnostic procedure, including history, physical examination, and laboratory finding; (4) therapeutic management pathway for clinical decision-making; and (5) valuation of treatment effect, using questionnaires, diaries and physical activity monitoring with body-worn sensors.

Conclusion

The development of a care pathway will help to implement regular and structured assessment, diagnosis, and treatment of fatigue for healthcare professionals treating palliative care patients. Reviewing the pathway with a multidisciplinary expert group and field testing the pathway will be the next steps toward implementation.

Cannabis-based medicines and medical cannabis for adults with cancer pain

BACKGROUND

Pain is a common symptom in people with cancer; 30% to 50% of people with cancer will experience moderate-to-severe pain. This can have a major negative impact on their quality of life. Opioid (morphine-like) medications are commonly used to treat moderate or severe cancer pain, and are recommended for this purpose in the World Health Organization (WHO) pain treatment ladder. Pain is not sufficiently relieved by opioid medications in 10% to 15% of people with cancer. In people with insufficient relief of cancer pain, new analgesics are needed to effectively and safely supplement or replace opioids.

OBJECTIVES

To evaluate the benefits and harms of cannabis-based medicines, including medical cannabis, for treating pain and other symptoms in adults with cancer compared to placebo or any other established analgesic for cancer pain.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 26 January 2023.

SELECTION CRITERIA

We selected double-blind randomised, controlled trials (RCT) of medical cannabis, plant-derived and synthetic cannabis-based medicines against placebo or any other active treatment for cancer pain in adults, with any treatment duration and at least 10 participants per treatment arm.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. The primary outcomes were 1. proportions of participants reporting no worse than mild pain; 2. Patient Global Impression of Change (PGIC) of much improved or very much improved and 3. withdrawals due to adverse events. Secondary outcomes were 4. number of participants who reported pain relief of 30% or greater and overall opioid use reduced or stable; 5. number of participants who reported pain relief of 30% or greater, or 50% or greater; 6. pain intensity; 7. sleep problems; 8. depression and anxiety; 9. daily maintenance and breakthrough opioid dosage; 10. dropouts due to lack of efficacy; 11. all central nervous system adverse events. We used GRADE to assess certainty of evidence for each outcome.

MAIN RESULTS

We identified 14 studies involving 1823 participants. No study assessed the proportions of participants reporting no worse than mild pain on treatment by 14 days after start of treatment. We found five RCTs assessing oromucosal nabiximols (tetrahydrocannabinol (THC) and cannabidiol (CBD)) or THC alone involving 1539 participants with moderate or severe pain despite opioid therapy. The double-blind periods of the RCTs ranged between two and five weeks. Four studies with a parallel design and 1333 participants were available for meta-analysis. There was moderate-certainty evidence that there was no clinically relevant benefit for proportions of PGIC much or very much improved (risk difference (RD) 0.06, 95% confidence interval (CI) 0.01 to 0.12; number needed to treat for an additional beneficial outcome (NNTB) 16, 95% CI 8 to 100). There was moderate-certainty evidence for no clinically relevant difference in the proportion of withdrawals due to adverse events (RD 0.04, 95% CI 0 to 0.08; number needed to treat for an additional harmful outcome (NNTH) 25, 95% CI 16 to endless). There was moderate-certainty evidence for no difference between nabiximols or THC and placebo in the frequency of serious adverse events (RD 0.02, 95% CI -0.03 to 0.07). There was moderate-certainty evidence that nabiximols and THC used as add-on treatment for opioid-refractory cancer pain did not differ from placebo in reducing mean pain intensity (standardised mean difference (SMD) -0.19, 95% CI -0.40 to 0.02). There was low-certainty evidence that a synthetic THC analogue (nabilone) delivered over eight weeks was not superior to placebo in reducing pain associated with chemotherapy or radiochemotherapy in people with head and neck cancer and non-small cell lung cancer (2 studies, 89 participants, qualitative analysis). Analyses of tolerability and safety were not possible for these studies. There was low-certainty evidence that synthetic THC analogues were superior to placebo (SMD -0.98, 95% CI -1.36 to -0.60), but not superior to low-dose codeine (SMD 0.03, 95% CI -0.25 to 0.32; 5 single-dose trials; 126 participants) in reducing moderate-to-severe cancer pain after cessation of previous analgesic treatment for three to four and a half hours (2 single-dose trials; 66 participants). Analyses of tolerability and safety were not possible for these studies. There was low-certainty evidence that CBD oil did not add value to specialist palliative care alone in the reduction of pain intensity in people with advanced cancer. There was no difference in the number of dropouts due to adverse events and serious adverse events (1 study, 144 participants, qualitative analysis). We found no studies using herbal cannabis.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence that oromucosal nabiximols and THC are ineffective in relieving moderate-to-severe opioid-refractory cancer pain. There is low-certainty evidence that nabilone is ineffective in reducing pain associated with (radio-) chemotherapy in people with head and neck cancer and non-small cell lung cancer. There is low-certainty evidence that a single dose of synthetic THC analogues is not superior to a single low-dose morphine equivalent in reducing moderate-to-severe cancer pain. There is low-certainty evidence that CBD does not add value to specialist palliative care alone in the reduction of pain in people with advanced cancer.

Parallel opioid crises: brakes on sustainable development?

This Review perspective analyzes the parallel 'opioid crises' - one of access, the other of excess - affecting different demographic groups in distinct regions of the world, in terms of a knowledge gap between the founding 20th-century regulatory frameworks around 'drugs', including opioids, and evolving 21st-century clinical developments in public health, palliative care, addiction medicine, and regulatory sciences. Identifying the parallel crises as such is a positive step that can enable governance and science to catch up to one another and realign. As it is now, the opioid crises are acting as brakes on development as defined by the United Nations (UN) 2030 Agenda for Sustainable Development (SDGs). Both crises affect UN member states' ability to reach the Goal 3 'Ensure healthy lives and promote well-being for all at all ages' of the Sustainable Development Goals (SDGs). Among the nine targets for Goal 3, the two opioid crises affect progress toward Target 3.5, on strengthening the prevention and treatment of substance abuse, including narcotic drug abuse, and Target 3.8, providing Universal Health Coverage (UHC), and adequate access to essential medicines. The parallel opioid crises, which both represent misalignment between anachronistic governance structures and epistemic developments, have several things in common beyond the opioid molecules themselves: regulatory and health system deficits that interact pathologically with baked in cultural stigma around psychoactive substances, stigma evident in the designation of these substances in international law as 'narcotic drugs'. Community regeneration, educational development, and governance reforms can now replace politicized rather than evidence-based and public health-promoting drug policies that block progress toward both SDG 3 targets in different countries for different reasons. Quantification of serious health-related suffering (SHS) pertaining to a range of health conditions and demographic groups now provides the epidemiological evidence to legitimate such a timely paradigm shift.

[Who is afraid of Ockham's razor? : A discourse analysis on resilience in palliative care (2000-2021)]

BACKGROUND

The concept of resilience is becoming increasingly disseminated from material science into various fields of science. It is infiltrating medical fields predominantly via psychology and is also recommended for coping with the special burdens in pain management and palliative care. A precise definition of the term and its operationalization pose problems.

AIM

A critical stocktaking of the use of this term in the discourse of palliative care research.

METHOD

Analytical discourse analysis of a text corpus from palliative medical care publications in the time period from 2000 to 2021, obtained by means of a systematic literature search.

RESULTS

In the research discourse of palliative care, resilience is a topic primarily as a strategy for self-optimization of employees (e.g., burnout prophylaxis with the aim of preserving the workforce). Only rarely does the question of whether it offers potential for patients and their families take center stage, and then more as a catchword than as a concrete concept. The reason is that there is so far no adequate operationalization of the concept of resilience. Furthermore, there is a lack of sufficient justification for the relevance of the concept in patient care of palliative medicine.

CONCLUSION

There is a lack of qualified contributions of palliative research to the metadiscourse about resilience, especially in the context of affected patients. A successful operationalization of the term requires a highly complex multidimensionality of the palliative path of an interdisciplinary approach. There is a lack of ethical standards that prevent an affirmative instrumentalizing application of the term.

Humour interventions for patients in palliative care-a randomized controlled trial

PURPOSE

The effect of humour on end-of-life patients could be beneficial and is worth investigating. However, data on humour interventions for patients in palliative care are scarce. This study evaluated the effects of a humour intervention in a palliative care setting.

METHODS

A two-step intervention was developed based on the humour habits programme by McGhee. Patients were assisted to remember funny episodes from their past and recognize humorous aspects of the present and encouraged to produce humour. The intervention and control group completed questionnaires on life satisfaction, cheerfulness, symptom burden, and perceived stress and if possible gave saliva samples to investigate oxytocin levels. The study was a randomized controlled monocentre study on patients treated in a palliative care ward. Participants had to be conscious and alert enough to complete data collection. Overall, 55 patients were included and randomized to the intervention or control group.

RESULTS

Parameters in the control group did not change significantly. In the intervention group, seriousness, bad mood, and stress were reduced. Cheerfulness increased significantly after the intervention. However, the methodologically complex intervention setting was too exhausting for the majority of patients.

CONCLUSION

Patients who were able to participate benefited from the effects of the intervention on multiple levels. For future research simple interventions, biomarkers for well-being and assessments by staff or proxies are needed to include patients with reduced cognitive and physical performance status at the end of their lives.

TRIAL REGISTRATION

DRKS00028978 German Registry of Clinical Studies.

Regulations on palliative sedation: an international survey across eight European countries

BACKGROUND

Palliative sedation is a commonly accepted medical practice. This study aims to clarify how palliative sedation is regulated in various countries and whether this may impact its practice.

METHODS

An online survey requesting regulations on palliative sedation was conducted in Belgium, Germany, Hungary, Italy, The Netherlands, Spain, Romania and the UK. Purposive sampling strategy was used to identify clinicians from different medical fields and legal experts for each country. Regulations were analyzed using the principles of the European Association for Palliative Care Framework on palliative sedation. Country reports describing how palliative sedation is regulated were elaborated.

RESULTS

One hundred and thirty-nine out of 223 (62%) participants identified 31 laws and other regulations affecting palliative sedation. In Spain, 12 regional laws recognize palliative sedation as a right of the patient at the end of life when there are refractory symptoms. In Italy, the law of informed consent and advance directives specifically recognizes the doctor can use deep sedation when there are refractory symptoms. There are also general medical laws that, while not explicitly referring to palliative sedation, regulate sedation-related principles: the obligation of doctors to honour advance directives, informed consent, the decision-making process and the obligation to document the whole process. In Germany, the Netherlands and the UK, palliative sedation is also regulated through professional guidelines that are binding as good practice with legal significance.

CONCLUSIONS

Palliative sedation is considered in the general law of medical practice, in laws regarding the patient's autonomy, and through professional guidelines.

[Postoperative pain experience after proximal femur fracture in dementia]

BACKGROUND

The present study aimed to assess the postoperative pain experience in cognitive deficit patients with special reference to sensory or affective pain quality.

METHODS

Nineteen patients with normal cognition up to cognitive impairments according to the DemTect screening-tool were studied regarding their postoperative pain experience after proximal femur fracture. The numerical rating scale (NRS), the cognitive DemTect questionnaire, the pain sensation questionnaire (SES), and a quantitative sensory test (QST) were used as examination instruments.

RESULTS

The mean ± SD age of the patients was 83.8 ± 10.0 years. Of the 19 patients, 6 (31.6%) had normal cognitive abilities. In 4 patients (21.1%) there were indications of mild cognitive impairments, and in 9 patients (47.4%) the suspicions of the presence of dementia arose. The mean postoperative pain intensity (NRS) was 4.0 (1.6). With comparable analgesic therapy, the reported pain intensities did not differ between the three patient groups with different cognitive impairments and the first three postoperative treatment days. There were no statistically significant differences between the groups for the sensory or affective total scores of the pain sensation scale. The QST parameters deep pain (PPT), superficial mechanical pain after needle stimulation (MPT), and the superficial sensitivity to light touch stimuli (MDT) showed a significantly increased sensitivity of the operated side. For the sensation of vibration (VDT) no differences between operated and healthy extremities could be proven.

DISCUSSION

The postoperative pain experience does not differ between patients with normal and limited cognition. The quantitative sensory testing showed mechanical hyperalgesia in the operated area. The study points to the importance of adequate postoperative pain management even in those with dementia.

Depressive Symptoms and Palliative Care Concerns Among Patients With Non-communicable Diseases in Two Southern African Countries

CONTEXT

Non-communicable diseases (NCDs), associated with health-related suffering, can benefit from palliative care in resource-limited settings, where over four-fifths of these deaths occur.

OBJECTIVE

To measure the prevalence of depressive symptoms, palliative care-related concerns, physical and other psychological symptoms among adult patients with NCDs in Malawi and Namibia.

METHODS

This multi-center, cross-sectional study consecutively recruited outpatients from four tertiary referral hospitals. Stepwise regression analysis was used to assess factors associated with physical and psychological symptom burden.

RESULTS

Among 457 participants, primary diagnosis was cancer (n=147, 32%); cardiovascular disease (CVD) (n=130, 28%), chronic respiratory disease (CRESD) (n=73, 16%) or diabetes (n=107, 23%). Over half were female (58.9%; n=269), mean age was 48 (SD=15.7). Clinically significant psychological distress was identified among cancer (57.2%), diabetes (57.0%), CRESD (45.2%) and CVD patients (43.1%), with criterion for major depression symptoms met for cancer (42.9%), diabetes (39.2%), CVD (30.0%) and CRESD (28.8%). Most severe palliative care concerns were: first sharing feelings (i.e., not at all/not very often), reported by CVD (28%), CRESD (23%), cancer (22%) and diabetes (21%) patients; second help and advice (i.e., none/very little), among cancer (28%), CVD (26%), diabetes (22%), and CRESD (16%) patients. High prevalence of moderate-to-severe pain was reported (cancer 54%, CVD 41%, CRESD 38%, diabetes 38%). Functional status, age, and presence of comorbidities were associated with physical and psychological symptom distress.

CONCLUSION

Given the high burden of physical and psychosocial symptoms and symptom distress, the findings highlight the need for integrated person-centered palliative care for NCDs to optimize care outcomes.

GPs’ involvement in specialised palliative home care: A mixed methods study in Germany

Background

General practitioners (GPs) are important providers of palliative home care (PHC). To deliver adequate palliative care, cooperation with specialised PHC teams is necessary. Specialised PHC is a type of care for severely ill patients by specialised providers. Little is known about the involvement of German GPs in specialised PHC.

Objectives

To analyse GPs’ experience with realised and desired involvement in specialised PHC. Realised involvement means GPs took part in specialised PHC patients’ care. Desired involvement is GPs’ hoped-for cooperation with specialised PHC teams: GPs could state whether they want to stay involved, be informed, or provide medical services themselves after referral to specialised PHC.

Methods

Mixed methods design (focus group with 6 GPs; survey of 445 GPs in North Rhine, Germany, about their experiences in PHC/specialised PHC): Qualitative data was interpreted using content analysis. The authors developed a questionnaire and performed descriptive analysis based on qualitative results.

Results

GPs are mostly satisfied with specialised PHC teams’ care, although they report cooperation is not always optimal. GPs describe a high satisfaction with quality of care by specialised PHC teams. However, physicians with higher PC knowledge are less satisfied with specialised PHC. Also, GPs are often less involved in specialised PHC than they wish, especially when they have a higher PC qualification.

Conclusion

In general, GPs are satisfied with the quality of care provided by specialised PHC teams but GPs do not always perceive cooperation as optimal. Involvement of GPs in specialised PHC needs to be improved.

Influence of Palliative Care Qualifications on the Job Stress Factors of General Practitioners in Palliative Care: A Survey Study

Due to demographic change, the number of patients in palliative care (PC) is increasing. General Practitioners (GPs) are important PC providers who often have known their patients for a long time. PC can be demanding for GPs. However, there are few studies on the job stress factors of GPs performing PC and the potential influence of their PC training. To get more insights, a postal survey was performed with GPs in North Rhine, Germany. The questionnaire was based on a literature search, qualitative pre-studies, and the Hospital Consultants' Job Stress & Satisfaction Questionnaire (HCJSSQ). Participants state that a high level of responsibility, conflicting demands, and bureaucracy are the most important stressors they experienced in PC. The influence of PC qualification level on their perceived job stress factors is low. Only advanced but not specialist qualification shows a correlation with renumeration-related stress. Gender and work experience are more dominant influences. In our study, female GPs and physicians with more work experience tend to be more stressed. In conclusion, organisational barriers, such as administration, should be reduced and renumeration should be increased to facilitate the daily work of GPs.

Review of European Guidelines on Palliative Sedation: A Foundation for the Updating of the European Association for Palliative Care Framework

In 2009, the European Association for Palliative Care (EAPC) developed a framework on palliative sedation, acknowledging this practice as an important and ethically acceptable intervention of last resort for terminally ill patients experiencing refractory symptoms. Before and after that, other guidelines on palliative sedation have been developed in Europe with variations in terminology and concepts. As part of the Palliative Sedation project (Horizon 2020 Funding No. 825700), a revision of the EAPC framework is planned. The aim of this article is to analyze the most frequently used palliative sedation guidelines as reported by experts from eight European countries to inform the discussion of the new framework. The three most reported documents per country were identified through an online survey among 124 clinical experts in December 2019. Those meeting guideline criteria were selected. Their content was assessed against the EAPC framework on palliative sedation. The quality of their methodology was evaluated with the Appraisal Guideline Research and Evaluation (AGREE) II instrument. Nine guidelines were included. All recognize palliative sedation as a last-resort treatment for refractory symptoms, but the criterion of refractoriness remains a matter of debate. Most guidelines recognize psychological or existential distress as (part of) an indication and some make specific recommendations for such cases. All agree that the assessment should be multiprofessional, but they diverge on the expertise required by the attending physician/team. Regarding decisions on hydration and nutrition, it is proposed that these should be independent of those for palliative sedation, but there is no clear consensus on the decision-making process. Several weaknesses were highlighted, particularly in areas of rigor of development and applicability. The identified points of debate and methodological weaknesses should be considered in any update or revision of the guidelines analyzed to improve the quality of their content and the applicability of their recommendations.

Responsive Behaviors and Pain Management in Hospital Dementia Care: A Before and After Comparison of the “Serial Trial Intervention”

Purpose

Responsive behavior, often referred to as behavioral and psychological symptoms of dementia (BPSD), is among the most critical disorders in dementia whereby nursing personnel in hospitals are increasingly confronted with such symptoms. The purpose was to reduce the level of BPSD in an acute hospital environment through a stepwise procedure followed by the initiation of a needs-oriented treatment.

Methods

An open, prospective, interventional study with before-after comparisons was used to implement “Serial Trial Intervention” (STI) in three hospital wards (internal medicine, surgery, geriatric) after its adaption for hospital setting which was supplemented with a detailed pain assessment. Participants were 65 years and older. Potential causes of BPSD were clarified in a stepwise procedure and, if possible, eliminated. The primary outcome was the reduction in BPSD measured by the Neuropsychiatric Inventory (NPI-Q-12) while secondary outcomes were through the use of non-pharmacological and pharmacological interventions.

Results

No significant reduction in NPI-Q-12 could be found. However, significantly more mobilizations and changes of position were carried out. Higher antipsychotic use was seen in the after-groups presumably due to the higher rates of delirium and cognitive impairment. Furthermore, the data showed no increase in analgesic use.

Conclusion

No significant reduction in NPI-Q-12 was observed in the before-after study. The use of antipsychotics even increased most probably due to a higher incidence of deliriousness in the after-group. However, STI seemed to improve attention to underlying causes of BPSD as well as pain. Proof that STI leads to NPI-Q-12 reduction in hospitals is still pending.

Optimizing the Global Nursing Workforce to Ensure Universal Palliative Care Access and Alleviate Serious Health-Related Suffering Worldwide

CONTEXT

Palliative care access is fundamental to the highest attainable standard of health and a core component of universal health coverage. Forging universal palliative care access is insurmountable without strategically optimizing the nursing workforce and integrating palliative nursing into health systems at all levels. The COVID-19 pandemic has underscored both the critical need for accessible palliative care to alleviate serious health-related suffering and the key role of nurses to achieve this goal.

OBJECTIVES

1) Summarize palliative nursing contributions to the expansion of palliative care access; 2) identify emerging nursing roles in alignment with global palliative care recommendations and policy agendas; 3) promote nursing leadership development to enhance universal access to palliative care services.

METHODS

Empirical and policy literature review; best practice models; recommendations to optimize the palliative nursing workforce.

RESULTS

Nurses working across settings provide a considerable untapped resource that can be leveraged to advance palliative care access and palliative care program development. Best practice models demonstrate promising approaches and outcomes related to education and training, policy and advocacy, and academic-practice partnerships.

CONCLUSION

An estimated 28 million nurses account for 59% of the international healthcare workforce and deliver up to 90% of primary health services. It has been well-documented that nurses are often the first or only healthcare provider available in many parts of the world. Strategic investments in international and interdisciplinary collaboration, as well as policy changes and the safe expansion of high-quality nursing care, can optimize the efforts of the global nursing workforce to mitigate serious health-related suffering.

Schnittstellen in der Versorgung am Lebensende

Zusammenfassung. Schnittstellen stehen oft im Zusammenhang mit einer hohen Symptomlast, einem stetig wachsenden Versorgungsnetz und / oder einem häufigen Wechsel zwischen ambulanter und stationärer Versorgung. Schnittstellenproblematiken treten auf der Organisations-, Kommunikations-, Informations- und Wissensebene sowie beim Vernetzen von Institutionen auf. Hinweise auf Versorgungsdefizite am Lebensende und inwiefern eine nicht gelingende Symptomlinderung oder ein häufiger ambulanter und stationärer Versorgungswechsel abgefedert werden kann, wird anhand von Studienergebnissen erörtert. Am Lebensende sind offene empathische Gespräche, Symptomlinderung, psychosoziale Unterstützung und gegebenenfalls die Adressierung spiritueller Fragen bei bedarfsgerechter Anbindung an Einrichtungen und Dienste wichtige Grundpfeiler für Sterbende und Hinterbliebene. Ein Einblick in die unterschiedlichen hospizlichen und palliativen Versorgungsangebote im ambulanten und stationären Bereich, die mit ihren Angeboten auch Hinterbliebene mit einbeziehen, rundet diesen Beitrag ab.

[Perceptions on the use of opioids in COVID-19 : A survey of members of the German Association for Palliative Medicine]

BACKGROUND

Opioids efficiently alleviate pain and dyspnea. However, guidelines on symptom management with opioids differ, which may lead to an uncertainty concerning opioid indication and ethical implication among medical staff, especially when caring for COVID-19 patients.

AIMS

We aimed to examine the perception of members of the German Association for Palliative Medicine (DGP) concerning the administration of morphine as the gold standard opioid (subsequently termed M/O) for symptom control within and outside of a palliative care (PC) setting, including care for COVID-19 patients.

METHODS

DGP members received an anonymized online questionnaire (Survey Monkey®) containing questions regarding their perception of symptom management with M/O in general and in particular concerning COVID-19 patients. Participants were asked to rate their perception within and outside of a PC setting.

RESULTS

Of the 6129 DGP members, N = 506 participated. DGP physicians and nurses perceived handling of M/O as "certain and confident" (98%) and "clearly regulated" within PC (95%) but rated it significantly lower for outside PC (48%/38%). When caring for COVID-19 patients, handling of M/O was even less often rated "certain and confident" (26%) or "clearly regulated" (23%) for outside PC. Dyspnea (99%/52%), relief from the dying process (62%/37%), restlessness (30%/15%) and fear or panic (27%/13%) were more frequently rated as general indications for morphine within versus outside PC. Most participants (89%) wished to involve palliative care consultation teams.

CONCLUSIONS

DGP members perceived substantial uncertainty in the handling of M/O for medical fields outside PC. Uniform interdisciplinary guidelines for symptom control, more education, and involvement of a PC consultation team should be increasingly considered in the future.

National strategy for palliative care of severely ill and dying people and their relatives in pandemics (PallPan) in Germany - study protocol of a mixed-methods project

Background

In the SARS-CoV-2 pandemic, general and specialist Palliative Care (PC) plays an essential role in health care, contributing to symptom control, psycho-social support, and providing support in complex decision making. Numbers of COVID-19 related deaths have recently increased demanding more palliative care input. Also, the pandemic impacts on palliative care for non-COVID-19 patients. Strategies on the care for seriously ill and dying people in pandemic times are lacking. Therefore, the program ‘Palliative care in Pandemics’ (PallPan) aims to develop and consent a national pandemic plan for the care of seriously ill and dying adults and their informal carers in pandemics including (a) guidance for generalist and specialist palliative care of patients with and without SARS-CoV-2 infections on the micro, meso and macro level, (b) collection and development of information material for an online platform, and (c) identification of variables and research questions on palliative care in pandemics for the national pandemic cohort network (NAPKON).

Methods

Mixed-methods project including ten work packages conducting (online) surveys and qualitative interviews to explore and describe i) experiences and burden of patients (with/without SARS-CoV-2 infection) and their relatives, ii) experiences, challenges and potential solutions of health care professionals, stakeholders and decision makers during the SARS-CoV-2 pandemic. The work package results inform the development of a consensus-based guidance. In addition, best practice examples and relevant literature will be collected and variables for data collection identified.

Discussion

For a future “pandemic preparedness” national and international recommendations and concepts for the care of severely ill and dying people are necessary considering both generalist and specialist palliative care in the home care and inpatient setting.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00898-w.

COVID-19 und Palliativversorgung

Die Palliativversorgung kann in der „severe acute respiratory syndrome coronavirus type 2“(SARS-CoV-2)-Pandemie mit ihrem Fachwissen, ihren Fähigkeiten und Haltungen sowohl zur Therapiezielfindung als auch zur Entscheidungsfindung bei knappen Ressourcen beitragen. Sie liefert Empfehlungen zur Kontrolle der Symptome Luftnot, Unruhe und Angst und bietet Konzepte, wie die Kommunikation mit Patienten und Angehörigen trotz der pandemiebedingten Einschränkungen gelingen kann. In dem Projekt „Nationale Strategie für Palliativversorgung in Pandemiezeiten“ (PallPan) wurden auf der Grundlage von 16 Teilstudien insgesamt 32 Handlungsempfehlungen für Patienten, Angehörige/Pflegende, Mitarbeitende und Entscheidungsträger im Gesundheitswesen vorgelegt. Dazu gehören auch Hilfestellungen zur „Trauer in besonderen Zeiten“.

Moral Distress in Hospitals During the First Wave of the COVID-19 Pandemic: A Web-Based Survey Among 3,293 Healthcare Workers Within the German Network University Medicine

Objective: The present study aimed to investigate the correlation between moral distress and mental health symptoms, socio-demographic, occupational, and COVID-19-related variables, and to determine differences in healthcare workers’ (HCW) moral distress during the first wave of the COVID-19 pandemic.

Method: Data from 3,293 HCW from a web-based survey conducted between the 20th of April and the 5th of July 2020 were analyzed. We focused on moral distress (Moral Distress Thermometer, MDT), depressive symptoms (Patient Health Questionnaire-2, PHQ-2), anxiety symptoms (Generalized Anxiety Disorder-2, GAD-2), and increased general distress of nurses, physicians, medical-technical assistants (MTA), psychologists/psychotherapists, and pastoral counselors working in German hospitals.

Results: The strongest correlations for moral distress were found with depressive symptoms, anxiety symptoms, occupancy rate at current work section, and contact with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nurses and MTA experienced significantly higher moral distress than physicians, psychologists/psychotherapists, and pastoral counselors. The average level of moral distress reported by nurses from all work areas was similar to levels which before the pandemic were only experienced by nurses in intensive or critical care units.

Conclusion: Results indicate that moral distress is a relevant phenomenon among HCW in hospitals during the COVID-19 pandemic, regardless of whether they work at the frontline or not and requires urgent attention.

Audiobooks from terminally ill parent for their children - a qualitative evaluation

Background

Improving the quality of life is one of the main objectives of palliative care. Biographical approaches are often used in combination with leaving a legacy in a range of different interventions such as Dignity Therapy or Life Review. This study presents an evaluation of audiobook biographies for palliative care patients with young children.

Methods

Young parents diagnosed with a life-limiting disease could participate and create an audiobook for their young children. The audiobook itself was recorded over several days and edited by qualified radio journalists. After providing informed consent participants were interviewed twice over the course of the intervention regarding expectations, concerns, motivation, and experiences. Interviews and notes were transcribed verbatim and were analyzed using content analysis. The contents of the audiobooks are not part of the evaluation.

Results

The data were collected from February 2017 till September 2020. Fifty-four patients with ninety-six children at a mean age of 7 years were included and created an audiobook. The main theme of all interviews were the children. Within this field identified main topics were legacy, motivation, usage, benefit, aims, difficulties and worries in descending order. All patients would recommend the intervention.

Conclusion

Creating an audiobook as a legacy to their children seemed to help the diseased parents to cope with their limited life span.

Impact of COVID-19 Pandemic on Palliative Care Workers: An International Cross-sectional Study

Objectives:

The COVID-19 pandemic and the measures taken to mitigate spread have affected countries in different ways. Healthcare workers, in particular, have been impacted by the pandemic and by these measures. This study aims to explore how COVID-19 has impacted on palliative care (PC) workers around the world.

Materials and Methods:

Online survey to members of the International Association for Hospice and PC during the initial months of the COVID-19 pandemic. Convenience sampling was used. Statistical descriptive and contingency analyses and Chi-square tests with P < 0.05 were conducted.

Results:

Seventy-nine participants (RR = 16%) from 41 countries responded. Over 93% of those who provide direct patient care reported feeling very or somewhat competent in PC provision for patients with COVID-19. Eighty-four felt unsafe or somewhat safe when caring for patients with COVID-19. Level of safety was associated with competence (P ≤ 0.000). Over 80% reported being highly or somewhat affected in their ability to continue working in their PC job, providing care to non-COVID patients and in staff availability in their workplace. About 37% reported that availability and access to essential medicines for PC were highly or somewhat affected, more so in low-income countries (P = 0.003).

Conclusion:

The results from this study highlight the impact of COVID-19 on the provision of PC. It is incumbent on government officials, academia, providers and affected populations, to develop and implement strategies to integrate PC in pandemic response, and preparedness for any similar future events, by providing appropriate and comprehensive education, uninterrupted access to essential medicines and personal protective equipment and ensure access to treatment and care, working together with all levels of society that is invested in care of individuals and populations at large. The long-term effects of the pandemic are still unknown and future research is needed to monitor and report on the appropriateness of measures.

Top Ten Tips Palliative Clinicians Should Know About Evidence-Based Advocacy

The escalating global burden of serious health-related suffering makes the need for funded policies that integrate palliative care (PC) into the continuum of services more urgent than ever. Palliative specialists are uniquely positioned to merge their clinical expertise with empirical evidence to advocate for improved PC delivery. There is a vital feedback loop between advocacy and clinical practice that palliative specialists can leverage to influence key stakeholders and decision makers and bridge PC policy deficits. Sustained interdisciplinary partnerships are critical to evidence-based PC advocacy that addresses resource gaps, social injustice, and unmet and disparate needs. Although PC advocacy may appear optional or even frivolous at times, it is an essential skill for any practitioner working to improve care for seriously ill individuals and their families. This article highlights 10 pragmatic tips that palliative specialists can use to advocate for policy changes that enhance PC access and equity at institutional, local, national, and global levels.

Sense of coherence, social support and religiosity as resources for medical personnel during the COVID-19 pandemic: A web-based survey among 4324 health care workers within the German Network University Medicine

Introduction

The COVID-19 pandemic resulted in severe detrimental effects on the mental well-being of health care workers (HCW). Consequently, there has been a need to identify health-promoting resources in order to mitigate the psychological impact of the pandemic on HCW.

Objective

Our objective was to investigate the association of sense of coherence (SOC), social support and religiosity with self-reported mental symptoms and increase of subjective burden during the COVID-19 pandemic in HCW.

Methods

Our sample comprised 4324 HCW of four professions (physicians, nurses, medical technical assistants (MTA) and pastoral workers) who completed an online survey from 20 April to 5 July 2020. Health-promoting resources were assessed using the Sense of Coherence Scale Short Form (SOC-3), the ENRICHD Social Support Inventory (ESSI) and one item on religiosity derived from the Scale of Transpersonal Trust (TPV). Anxiety and depression symptoms were measured with the PHQ-2 and GAD-2. The increase of subjective burden due to the pandemic was assessed as the retrospective difference between burden during the pandemic and before the pandemic.

Results

In multiple regressions, higher SOC was strongly associated with fewer anxiety and depression symptoms. Higher social support was also related to less severe mental symptoms, but with a smaller effect size, while religiosity showed minimal to no correlation with anxiety or depression. In professional group analysis, SOC was negatively associated with mental symptoms in all groups, while social support only correlated significantly with mental health outcomes in physicians and MTA. In the total sample and among subgroups, an increase of subjective burden was meaningfully associated only with a weaker SOC.

Conclusion

Perceived social support and especially higher SOC appeared to be beneficial for mental health of HCW during the COVID-19 pandemic. However, the different importance of the resources in the respective occupations requires further research to identify possible reasons.

Resilience in Adult Health Science Revisited-A Narrative Review Synthesis of Process-Oriented Approaches

Purpose: This article aims to identify how the term “resilience” is addressed in adult health science due to ongoing criticism about the lack of consistency in its conceptualization.

Method: Two databases (PubMed and PsycArticles) were searched to retrieve reviews published from 2015 up until 2020 on the general conceptualization of resilience. All reviews had to meet specific inclusion criteria, which resulted in the inclusion of 18 articles. After discussing different conceptualizations regarding the process-oriented approach of resilience in adult health research, we will highlight some mechanisms that are supposed to be involved in the resilience process.

Results: Research on resilience in health sciences confronts three core difficulties: defining positive outcome for a processual construct, describing different trajectories within the process, and identifying mechanisms that mediate resilience.

Conclusion: The definition of resilience in mental health research as a multidimensional adaptation process is widely accepted, and multiple research paradigms have contributed to a better understanding of the concept. However, the definition of a processual construct in a way that allows for high expert consensus and a valid operationalization for empirical studies remains a challenge. Future research should focus on the assessment of multiple cross-domain outcomes and international and interdisciplinary prospective mixed-method longitudinal designs to fill in the missing links.

No evidence to support the impact of migration background on treatment response rates and cancer survival: a retrospective matched-pair analysis in Germany

Background

Immigration has taken the central stage in world politics, especially in the developed countries like Germany, where the continuous flow of immigrants has been well documented since 1960s. Strikingly, emerging data suggest that migrant patients have a poorer response to the treatment and lower survival rates in their new host country, raising concerns about health disparities. Herein, we present our investigation on the treatment response rate and cancer survival in German patients with and without an immigrant background that were treated at our comprehensive cancer center in Germany.

Methods

Initially, we considered 8162 cancer patients treated at the Center for Integrated Oncology (CIO), University Hospital Bonn, Germany (April 2002–December 2015) for matched-pair analysis. Subsequently, the German patients with a migration background and those from the native German population were manually identified and catalogued using a highly specific name-based algorithm. The clinical parameters such as demographic characteristics, tumor characteristics, defined staging criteria, and primary therapy were further adjusted. Using these stringent criteria, a total of 422 patients (n = 211, Germans with migration background; n = 211, native German population) were screened to compare for the treatment response and survival rates (i.e., 5-year overall survival, progression-free survival, and time to progression).

Results

Compared to the cohort with migration background, the cohort without migration background was slightly older (54.9 vs. 57.9 years) while having the same sex distribution (54.5% vs. 55.0% female) and longer follow-up time (36.9 vs. 42.6 months). We did not find significant differences in cancer survival (5-year overall survival, P = 0.771) and the response rates (Overall Remission Rate; McNemar’s test, P = 0.346) between both collectives.

Conclusion

Contrary to prior reports, we found no significant differences in cancer survival between German patients with immigrant background and native German patients. Nevertheless, the advanced treatment protocols implemented at our comprehensive cancer center may possibly account for the low variance in outcome. To conduct similar studies with a broader perspective, we propose that certain risk factors (country-of-origin-specific infections, dietary habits, epigenetics for chronic diseases etc.) should be considered, specially in the future studies that will recruit new arrivals from the 2015 German refugee crisis.

Fatigue in advanced disease associated with palliative care: A systematic review of non-pharmacological treatments

BACKGROUND

Fatigue is a common complaint reported by patients with advanced disease, impacting their daily activities and quality of life. The pathophysiology is incompletely understood, and evidence-based treatment approaches are needed.

AIM

This systematic review aims to evaluate the efficacy of non-pharmacological interventions as treatment for fatigue in advanced disease.

DESIGN

The review design follows the Cochrane guidelines for systematic reviews of interventions.

DATA SOURCES

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PsycINFO, PubMed, ClinicalTrials.gov and a selection of journals up to February 28th 2019, for randomised controlled trials (RCTs) investigating the effect of non-pharmacological treatments for fatigue in advanced disease associated with palliative care. Further potentially relevant studies were identified from the reference lists in relevant reviews, and in studies considered for this review.

RESULTS

We screened 579 publications; 15 met the inclusion criteria, with data from 1179 participants: 815 were treated with physical exercise, 309 with psycho-educational therapy and 55 with an energy restoration approach. Sources of potential bias included lack of description of blinding and allocation concealment methods, and small study sizes. Physical exercise as treatment for fatigue in patients with advanced cancer was supported by moderate-quality evidence.

CONCLUSION

Physical exercise should be considered as a measure to reduce fatigue in patients with advanced cancer, but data on other advanced diseases is lacking. Due to the differences between studies, no clear recommendations can be made with respect to the best type of physical therapy. Restoration exercise and psycho-educational therapy are promising treatment options, although further research is needed.

Clinical Aspects of Palliative Sedation in Prospective Studies. A Systematic Review

CONTEXT

Near the end of life when patients experience refractory symptoms, palliative sedation may be considered as a last treatment. Clinical guidelines have been developed, but they are mainly based on expert opinion or retrospective chart reviews. Therefore, evidence for the clinical aspects of palliative sedation is needed.

OBJECTIVES

To explore clinical aspects of palliative sedation in recent prospective studies.

METHODS

Systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and registered at PROSPERO. PubMed, CINAHL, Cochrane, MEDLINE, and EMBASE were searched (January 2014-December 2019), combining sedation, palliative care, and prospective. Article quality was assessed.

RESULTS

Ten prospective articles were included, involving predominantly patients with cancer. Most frequently reported refractory symptoms were delirium (41%-83%), pain (25%-65%), and dyspnea (16%-59%). In some articles, psychological and existential distress were mentioned (16%-59%). Only a few articles specified the tools used to assess symptoms. Level of sedation assessment tools were the Richmond Agitation Sedation Scale, Ramsay Sedation Scale, Glasgow Coma Scale, and Bispectral Index monitoring. The palliative sedation practice shows an underlying need for proportionality in relation to symptom intensity. Midazolam was the main sedative used. Other reported medications were phenobarbital, promethazine, and anesthetic medication-propofol. The only study that reported level of patient's discomfort as a palliative sedation outcome showed a decrease in patient discomfort.

CONCLUSION

Assessment of refractory symptoms should include physical evaluation with standardized tools applied and interviews for psychological and existential evaluation by expert clinicians working in teams. Future research needs to evaluate the effectiveness of palliative sedation for refractory symptom relief.

How to measure the effects and potential adverse events of palliative sedation? An integrative review

BACKGROUND

Palliative sedation is the monitored use of medications intended to relieve refractory suffering. The assessment of palliative sedation has been focused on the assess of the level of consciousness but a more comprehensive approach to assessment is needed.

AIM

To understand how the potential effects and possible adverse events of palliative sedation in Palliative Care patients are measured.

DESIGN

Integrative review of most recent empirical research.

DATA SOURCES

Cochrane Library, Embase, Medline, PubMed, and CINAHL were searched (2010-2020) using the terms sedation, palliative care, terminal care, assessment. Limits included studies in English and adults. Inclusion criteria were: scientific assessment papers, effects and complications of palliative sedation; patients with incurable illness.

RESULTS

Out of 588 titles, 26 fulfilled inclusion criteria. The Discomfort Scale-Dementia of Alzheimer Type and Patient Comfort Score were used to assess comfort. The Richmond Agitation-Sedation Scale and The Ramsay Sedation Scale are the most used to measure its effect. Refractory symptoms were assessed through multi-symptom or specific scales; except for psychological or existential distress. Delirium was assessed using the Memorial Delirium Assessment Scale and pain through the Critical Care Pain Observation Tool. The use of technical approaches to monitor effects is upcoming. There is lack of measurement of possible adverse events and variability in timing measurement.

CONCLUSIONS

There are palliative care validated instruments to assess the sedation effect but this review shows the need for a more standardized approach when assessing it. Instruments should be used within an experienced and trained expert, providing a holistic assessment.

Integrating Palliative Care by Virtue of Diplomacy; A Cross-sectional Group Interview Study of the Roles and Attitudes of Palliative Care Professionals to Further Integrate Palliative Care in Europe

Background: Palliative care involves the care for patients with severe and advanced diseases with a focus on quality of life and symptom management. Integration of palliative care with curative and/or chronic care is expected to lead to better results in terms of quality of life and reduced costs. Although initiatives in different countries in Europe choose different structures to integrate care, they face similar challenges when it comes to creating trust and aligning visions, cultures and professional values. This paper sets out to answer the following research question: what roles and attitudes do palliative care professionals need to adopt to further integrate palliative care in Europe?

Methods: As part of the European Union (EU)-funded research project InSup-C (Integrated Supportive and Palliative Care). (2012-2016), 19 semi-structured group interviews with 136 (palliative) care professionals in 5 European countries (Germany, the United Kingdom, Belgium, the Netherlands, Hungary) were conducted. A thematic analysis was conducted.

Results: Integration of palliative care calls for diplomatic professionals that can bring a cultural shift: to get palliative care, with its particular focus on the four dimensions (physical, psychological, social, spiritual), integrated into historically established medical procedures and guidelines. This requires (a) to find an entrance (for telling a normative story), and (b) to maintain and deepen relationships (in order to build trust). It means using the appropriate words and sending a univocal team message to patients and being grateful, modest, and aiming for a quiet revolution with curation oriented healthcare professionals.

Conclusion: Diplomacy appears to be essential to palliative care providers for realizing trust and what can be defined as normative integration between palliative and curative and/or chronic medicine. It requires a practical wisdom about the culture and goals of regular care, as well as keeping a middle road between assimilating with values in regular medicine and standing up for the basic values central to palliative care.

Redefining Palliative Care-A New Consensus-Based Definition

CONTEXT

The International Association for Hospice and Palliative Care developed a consensus-based definition of palliative care (PC) that focuses on the relief of serious health-related suffering, a concept put forward by the Lancet Commission Global Access to Palliative Care and Pain Relief.

OBJECTIVE

The main objective of this article is to present the research behind the new definition.

METHODS

The three-phased consensus process involved health care workers from countries in all income levels. In Phase 1, 38 PC experts evaluated the components of the World Health Organization definition and suggested new/revised ones. In Phase 2, 412 International Association for Hospice and Palliative Care members in 88 countries expressed their level of agreement with the suggested components. In Phase 3, using results from Phase 2, the expert panel developed the definition.

RESULTS

The consensus-based definition is as follows: Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers. The definition includes a number of bullet points with additional details as well as recommendations for governments to reduce barriers to PC.

CONCLUSION

Participants had significantly different perceptions and interpretations of PC. The greatest challenge faced by the core group was trying to find a middle ground between those who think that PC is the relief of all suffering and those who believe that PC describes the care of those with a very limited remaining life span.