Perceptions of Palliative Care Program Viability During the Pandemic: Qualitative Results From a National Survey

Background: Palliative care programs have played a significant role during the COVID-19 pandemic. However, the financial impact of the pandemic and operational challenges for palliative care programs have raised concerns for their future viability. Objectives: To explore palliative care program leaders' perceptions of the future viability of their programs in the context of the pandemic and inform future educational and program development. Methods: Surveys were sent to 1430 specialist palliative care program leaders, identified through the Center to Advance Palliative Care's contact lists, via email in May 2020 and January 2021. Leaders were asked why they were or were not concerned about the viability of their palliative care programs. Qualitative content analysis was applied to determine themes. Results: We received 440 responses. Most programs served hospital settings and were geographically located across all US regions. We identified four themes: 1) The importance of being valued by organizational leadership and peers, 2) The importance of adequate and supported palliative care staff, 3) The pandemic validated and accelerated the need for palliative care, and 4) The pandemic perpetuated organizational financial concerns. Conclusion: Findings provide insights about palliative care program viability from the perspective of program leaders during a global pandemic. Technical assistance to support palliative care teams and their relationships with stakeholders, methods to measure the impact of peer support, efforts to educate administrators about the value of palliative care, and efforts to reduce burnout are needed to sustain palliative care programs into the future.

The Experience of Black Patients With Serious Illness in the United States: A Scoping Review

CONTEXT

Black patients experience health disparities in access and quality of care.

OBJECTIVE

To identify and characterize the literature on the experiences of Black patients with serious illness across multiple domains - physical, spiritual, emotional, cultural, and healthcare utilization.

METHODS

We conducted a scoping review of US literature from the last ten years using the PRISMA-ScR framework. PubMed was used to conduct a comprehensive search, followed by recursive citation searches in Scopus. Two reviewers screened the resulting citations to determine eligibility for inclusion and extracted data, including study methods and sample populations. The included articles were categorized by topic and then further organized using the Social-Ecological Model.

RESULTS

From an initial review of 433 articles, a final sample of 160 were included in the scoping review. The majority of articles used quantitative research methods and were published in the last four years. Articles were categorized into 20 topics, ranging from Access to Hospice and Utilization (42 articles) to Community Outreach and Services (three articles). Three-quarters (76.3%) of the included studies provided evidence that racial disparities exist in serious illness care, while less than one-quarter examined causes of disparities. The most common Model levels were the Health Care System (102 articles) and Individual (71 articles) levels.

CONCLUSION

More articles focused on establishing evidence of disparities between Black and White patients than on understanding their root causes. Further investigation is warranted to understand how factors at the patient, provider, health system, and society levels interact to remediate disparities.

Palliative Care Team Perceptions of Standardized Palliative Care Referral Criteria Implementation in Hospital Settings

Background: Standardized referral criteria can aid in identifying patients who would benefit from palliative care consultation. Little is known, however, on palliative care team members' perceptions of these criteria. Objective: Describe palliative care programs' reasons for referral criteria implementation and their perception of the benefits or disadvantages of its use. Design: Online survey of National Palliative Care Registry™ participants who use standardized referral criteria. Results: Fifty-three programs participated. Late referrals (64.2%) were the most commonly cited reason for referral criteria implementation. The majority (77.4%) felt that referral criteria lead to positive outcomes, including earlier referrals for palliative care-appropriate patients (71.7%). Increases in staff workload and inappropriate referrals were identified as disadvantages of referral criteria use.* Conclusion: Palliative care program members identified both benefits and disadvantages of referral criteria use, but felt they had mostly productive results. *Correction added on March 18, 2021 after first online publication of December 18, 2020: In the Results section of the abstract, the third sentence was changed from "Increases in clinical volume and inappropriate referrals were identified as disadvantages of referral criteria use." to "Increases in staff workload and inappropriate referrals were identified as disadvantages of referral criteria use."

The National Palliative Care Registry: A Decade of Supporting Growth and Sustainability of Palliative Care Programs

Background: Palliative care program service delivery is variable, and programs often lack data to support and guide program development and growth. Objective: To review the development and key features of the National Palliative Care Registry™ ("the Registry") and describe recent findings from its surveys on hospital palliative care. Description: Established in 2008, the Registry data elements align with National Consensus Project (NCP) guidelines related to palliative care program structures and operations. The Registry provides longitudinal and comparative data that palliative care programs can use to support programmatic growth. Results: As of 2018, >1000 hospitals and 120 community sites have submitted data on their palliative care programs to the Registry. Over the past decade, the percentage of hospital admissions seen by palliative care teams (penetration) has increased from 2.5% to 5.3%. Higher penetration is correlated with teaching hospital status, having a palliative care trigger, and hospital size (p < 0.05). Although overall staffing has expanded, only 42% of Registry programs include the recommended four key disciplines: physician, advanced practice or other registered nurse, social worker, and chaplain. Compliance with NCP guidelines on key structures and processes vary across adult and pediatric programs. Conclusions: The Registry allows palliative care programs to optimize core structures and processes and understand their performance relative to their peers.

Imiglucerase low-dose therapy for paediatric Gaucher disease--a long-term cohort study

BACKGROUND

Gaucher disease is the most common lysosomal storage disorder caused by the insufficiency of the lysosomal enzyme, glucocerebrosidase. This deficiency results in absent or inefficient conversion of glucocerebroside (a membrane lipid) to ceramide and glucose. Accumulation of glucocerebroside occurs primarily in macrophage lysosomes (i.e. monocytes and macrophages) during phagocytic degradation of red blood cells. Clinical symptoms arise due to the displacement of normal cells by lipid-engorged Gaucher cells. Enzyme replacement therapy (ERT) targets the macrophage system and has been shown to be successful in the treatment of type 1 Gaucher disease in adults and children. ERT (60 U/kg) every 2 weeks decreases and often reverses organomegaly and haematological complications and improves quality of life for patients with type 1 Gaucher disease. The present study describes the course of 9 paediatric patients followed up for 2 - 10 years receiving low-dose imiglucerase therapy (+/- 10 U/kg every 2 weeks) for moderate to severe type 1 Gaucher disease.

OBJECTIVES

To evaluate the efficacy of low-dose imiglucerase therapy in paediatric Gaucher disease.

SUBJECTS AND METHODS

Data were recorded at a single centre for 9 paediatric patients. Assessment of response included serial measurements of haemoglobin (Hb) concentrations, platelet count, angiotensin-converting enzyme (ACE) and total acid phosphatase (TAP) levels. Growth was assessed by serial determinations of body weight and height, plotted against standard growth charts. Organ size (liver and spleen) was measured clinically and also radiologically, where possible.

RESULTS

In this low-dose imiglucerase treatment group: (i) there was a significant increase in Hb over time--normal Hb levels were achieved in 7 of the 9 patients after a mean of 3.7 years; (ii) platelet counts increased over time, reaching normal levels in 7 patients; (iii) there was a significant decrease in both ACE and TAP over time; (iv) heights and weights of the subjects increased significantly over time with treatment, normalising to the expected growth percentiles; and (v) organ size (liver and spleen) reduced with therapy in all patients measured.

CONCLUSION

ERT with low-dose imiglucerase (+/- 10 U/kg/fortnight) ameliorates Gaucher disease-associated anaemia and thrombocytopenia. Low-dose ERT is effective and may be considered in resource-poor clinical situations when other alternatives are not available.

The role of the iminosugar N-butyldeoxynojirimycin (miglustat) in the management of type I (non-neuronopathic) Gaucher disease: a position statement

N-Butyldeoxynojirimycin (NB-DNJ, miglustat 'Zavesca') is an orally active iminosugar which inhibits the biosynthesis of macromolecular substrates that accumulate pathologically in glycosphingolipidoses. Clinical trials of NB-DNJ in patients with Gaucher's disease demonstrate the therapeutic potential of such substrate inhibitors in the glycolipid storage disorders. However, macrophage-targetted enzyme replacement using intravenous mannose-terminated human glucocerebrosidase (imiglucerase, Cerezyme) is highly effective in ameliorating many of the manifestations of Gaucher's disease and is a treatment in widespread use. Given that imiglucerase and miglustat are now both licensed for the treatment of Gaucher's disease, there is a need to review their therapeutic status. Here the treatment of type 1 (non-neuronopathic) Gaucher disease is evaluated with particular reference to the emerging role of oral N-butyldeoxynojirimycin (miglustat) as a substrate-reducing agent. This position statement represents the consensus viewpoint of an independent international advisory council to the European Working Group on Gaucher Disease.

Hypertension as the major problem of idiopathic arterial calcification of infancy

We describe two infants with severe hypertension associated with idiopathic arterial calcification of infancy. In both children, blood pressure control was refractory to aggressive antihypertensive therapy. There was radiologic and laboratory evidence of renovascular disease requiring the use of specific renin antagonists and later nephrectomy, resulting in moderate improvement of hypertension. Although on occasion there is a familial incidence, in the vast majority of cases the diagnosis hinges on a high index of suspicion.

Idiopathic iliofemoral arterial occlusion in a neonate. A case report

Spontaneous iliofemoral arterial occlusion in a 28-hour-old infant is described. A good result was obtained with conservative management. Early diagnosis and prompt therapy will prevent the loss of potentially salvageable limbs.

Type I histiocytosis X presenting as biliary atresia. A case report

Histiocytosis X may present in a variety of ways. We report a patient who presented with the unusual feature of infiltration of the hepatic duct with histiocytes, manifesting as biliary atresia.