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Guité-Verret A, Boivin J, Hanna AMR, Downar J, Bush SH, Marcoux I, Guay D, Tapp D, Lapenskie J, Gagnon B. Continuous palliative sedation until death: a qualitative study of palliative care clinicians' experiences. BMC Palliat Care 2024; 23:104. [PMID: 38637812 PMCID: PMC11027280 DOI: 10.1186/s12904-024-01426-2] [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: 09/21/2023] [Accepted: 04/02/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND The practice of continuous palliative sedation until death is the subject of much medical and ethical debate, which is reflected in the inconsistency that persists in the literature regarding the definition and indications of palliative sedation. AIM This study aims to gain a better understanding of palliative care clinicians' experiences with continuous palliative sedation. DESIGN We conducted a qualitative study based on focus group discussions. SETTING/PARTICIPANTS We conducted six focus groups with a total of 28 palliative care clinicians (i.e., 15 nurses, 12 physicians, and 1 end-of-life doula) from diverse care settings across Canada, where assisted dying has recently been legalized. RESULTS An interpretative phenomenological analysis was used to consolidate the data into six key themes: responding to suffering; grappling with uncertainty; adapting care to ensure ongoing quality; grounding clinical practice in ethics; combining medical expertise, relational tact, and reflexivity; and offering an alternative to assisted death. CONCLUSIONS Interaction with the patient's family, uncertainty about the patient's prognosis, the concurrent practice of assisted dying, and the treatment of existential suffering influence the quality of sedation and indicate a lack of clear palliative care guidelines. Nevertheless, clinicians exhibit a reflective and adaptive capacity that can facilitate good practice.
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Affiliation(s)
- Alexandra Guité-Verret
- Department of Psychology, Université du Québec à Montréal, Montréal, Canada
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
| | - Jessica Boivin
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
| | | | - James Downar
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Canada
- Department of Medicine, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Isabelle Marcoux
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Diane Guay
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- Faculty of Medicine and Health Sciences, Université de Sherbrooke, Québec, Canada
| | - Diane Tapp
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada
- CHU Québec-Université Laval Research Centre, Québec, Canada
- Faculty of Nursing, Université Laval, Québec, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Canada
- Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Canada
| | - Bruno Gagnon
- Réseau Québécois de Recherche en Soins Palliatifs et de fin de vie, Québec, Canada.
- CHU Québec-Université Laval Research Centre, Québec, Canada.
- Bruyère Research Institute, Ottawa, Canada.
- Department of Family and Emergency Medicine, Université Laval, Québec, Canada.
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Watt CL, Smith IC, Rice J, Murphy R, Breiner A, Duff MLV, Nogo D, Bush SH, McNeely S, Buenger U, Zehrt B, Zwicker J. Qualitative Analysis of Initial Palliative Care Consultations in Amyotrophic Lateral Sclerosis. J Pain Symptom Manage 2024:S0885-3924(24)00679-1. [PMID: 38574876 DOI: 10.1016/j.jpainsymman.2024.03.024] [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] [Received: 12/21/2023] [Revised: 02/27/2024] [Accepted: 03/25/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Palliative care (PC) benefits patients with amyotrophic lateral sclerosis (ALS), however the needs of patients and caregivers and the optimal timing of PC discussions remains unclear. This study reports the analysis of PC consult notes from a larger feasibility trial. The specific aims of this analysis were to i) identify the PC needs of patients with ALS via qualitative analysis and ii) identify characteristics of patients and caregivers that could predict specific PC needs. METHODS This study was nested within a nonrandomized, prospective study of patients with ALS (and their caregivers) being treated at a multidisciplinary ALS clinic. Exclusion criteria of the main study were age <18 years, inability to complete questionnaires, and prior receipt of PC. All patients were offered a PC consultation (PCC); those who accepted were included in this nested study. Consultation notes were reviewed and thematic and content analyses were conducted. The occurrence of themes across patient and caregiver contextual variables were examined. RESULTS Thirty-two PCCs were completed between October 2020 and April 2022. Six major themes were identified: PC roles (with subthemes encompassing the spectrum of specialist PC practice including symptom management and advance care planning), engagement with PC, patients' concerns for their caregivers, caregiver-specific concerns, finances, and COVID-19. An average of 12 topics were discussed per PCC (range = 3-22). Discussion of advance care planning, care coordination, and symptom management was common, and these topics were not discussed more frequently in PCCs with patients with lower functional status, more bulbar symptoms, or lower quality of life. Time from diagnosis did not impact topics of discussion. Patients reporting more symptoms of depression more frequently required psychological support, particularly regarding loss of independence, employment, and leisure activities. DISCUSSION Patients with ALS and their caregivers have a wide range of PC needs. These needs vary irrespective of time from diagnosis, functional status, or quality of life, therefore PCC is recommended for all patients with ALS. PCC should be individualized based on patient and caregiver preferences. TRIAL REGISTRATION INFORMATION The study was registered with ClinicalTrials.gov (NCT04257760; https://clinicaltrials.gov/ct2/show/NCT04257760) on February 6, 2020. The first enrollment occurred on October 20, 2020.
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Affiliation(s)
- Christine L Watt
- Department of Medicine, Division of Palliative Care (C.L.W., J.R., R.M., S.H.B.), University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; The Ottawa Hospital (C.L.W., J.R., R.M., A.B., S.M., B.Z., J.Z.), 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada; Bruyère Continuing Care (C.L.W., J.R., R.M., S.H.B.), 60 Cambridge St. N., Ottawa, Ontario K1R 7A5, Canada; Bruyère Research Institute (C.L.W., J.R., S.H.B.), 43 Bruyère St., Ottawa, Ontario K1N 5C8, Canada; Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada.
| | - Ian C Smith
- Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada
| | - Jill Rice
- Department of Medicine, Division of Palliative Care (C.L.W., J.R., R.M., S.H.B.), University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; The Ottawa Hospital (C.L.W., J.R., R.M., A.B., S.M., B.Z., J.Z.), 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada; Bruyère Continuing Care (C.L.W., J.R., R.M., S.H.B.), 60 Cambridge St. N., Ottawa, Ontario K1R 7A5, Canada; Bruyère Research Institute (C.L.W., J.R., S.H.B.), 43 Bruyère St., Ottawa, Ontario K1N 5C8, Canada; Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada
| | - Rebekah Murphy
- Department of Medicine, Division of Palliative Care (C.L.W., J.R., R.M., S.H.B.), University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; The Ottawa Hospital (C.L.W., J.R., R.M., A.B., S.M., B.Z., J.Z.), 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada; Bruyère Continuing Care (C.L.W., J.R., R.M., S.H.B.), 60 Cambridge St. N., Ottawa, Ontario K1R 7A5, Canada; Queensway Carleton Hospital (R.M.), 3045 Baseline Road, Ottawa, Ontario K2H 8P4, Canada
| | - Ari Breiner
- The Ottawa Hospital (C.L.W., J.R., R.M., A.B., S.M., B.Z., J.Z.), 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada; Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada; Department of Medicine (A.B.), Department of Neurology, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
| | - Maria L V Duff
- Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada
| | - Danica Nogo
- Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care (C.L.W., J.R., R.M., S.H.B.), University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; Bruyère Continuing Care (C.L.W., J.R., R.M., S.H.B.), 60 Cambridge St. N., Ottawa, Ontario K1R 7A5, Canada; Bruyère Research Institute (C.L.W., J.R., S.H.B.), 43 Bruyère St., Ottawa, Ontario K1N 5C8, Canada; Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada
| | - Susan McNeely
- The Ottawa Hospital (C.L.W., J.R., R.M., A.B., S.M., B.Z., J.Z.), 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada
| | - Usha Buenger
- Faculty of Medicine (U.B.), Division of Physical Medicine and Rehabilitation, The Ottawa Hospital Rehabilitation Centre 505 Smyth Road, Ottawa, Ontario K1H 8M2, Canada
| | - Belinda Zehrt
- The Ottawa Hospital (C.L.W., J.R., R.M., A.B., S.M., B.Z., J.Z.), 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada
| | - Jocelyn Zwicker
- The Ottawa Hospital (C.L.W., J.R., R.M., A.B., S.M., B.Z., J.Z.), 501 Smyth Rd, Ottawa, Ontario K1H 8L6, Canada; Ottawa Hospital Research Institute (C.L.W., I.C.S., J.R., A.B., M.D., D.N., S.H.B., J.Z.), 1053 Carling Ave, Ottawa, Ontario K1Y 4E9, Canada; Department of Medicine (A.B.), Department of Neurology, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
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McCoy M, Shorting T, Mysore VK, Fitzgibbon E, Rice J, Savigny M, Weiss M, Vincent D, Hagarty M, MacLeod KK, Ernecoff NC, Pattison R, Kornberg M, Bruni A, Bush SH, Kuluski K, Fiset V, Li C, Parsons HA, Lalumière G, Connolly T, Webber C, Isenberg SR. Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home (ACEPATH): Codesigning an intervention to improve patient and family caregiver experiences. Health Expect 2024; 27:e14002. [PMID: 38549352 PMCID: PMC10979115 DOI: 10.1111/hex.14002] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 04/01/2024] Open
Abstract
BACKGROUND Returning home from the hospital for palliative-focused care is a common transition, but the process can be emotionally distressing and logistically challenging for patients and caregivers. While interventions exist to aid in the transition, none have been developed in partnership with patients and caregivers. OBJECTIVE To undergo the initial stages of codesign to create an intervention (Advancing the Care Experience for patients receiving Palliative care as they Transition from hospital to Home [ACEPATH]) to improve the experience of hospital-to-home transitions for adult patients receiving palliative care and their caregiver(s). METHODS The codesign process consisted of (1) the development of codesign workshop (CDW) materials to communicate key findings from prior research to CDW participants; (2) CDWs with patients, caregivers and healthcare providers (HCPs); and (3) low-fidelity prototype testing to review CDW outputs and develop low-fidelity prototypes of interventions. HCPs provided feedback on the viability of low-fidelity prototypes. RESULTS Three patients, seven caregivers and five HCPs participated in eight CDWs from July 2022 to March 2023. CDWs resulted in four intervention prototypes: a checklist, quick reference sheets, a patient/caregiver workbook and a transition navigator role. Outputs from CDWs included descriptions of interventions and measures of success. In April 2023, the four prototypes were presented in four low-fidelity prototype sessions to 20 HCPs. Participants in the low-fidelity prototype sessions provided feedback on what the interventions could look like, what problems the interventions were trying to solve and concerns about the interventions. CONCLUSION Insights gained from this codesign work will inform high-fidelity prototype testing and the eventual implementation and evaluation of an ACEPATH intervention that aims to improve hospital-to-home transitions for patients receiving a palliative approach to care. PATIENT OR PUBLIC CONTRIBUTION Patients and caregivers with lived experience attended CDWs aimed at designing an intervention to improve the transition from hospital to home. Their direct involvement aligns the intervention with patients' and caregivers' needs when transitioning from hospital to home. Furthermore, four patient/caregiver advisors were engaged throughout the project (from grant writing through to manuscript writing) to ensure all stages were patient- and caregiver-centred.
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Affiliation(s)
| | | | - Vinay Kumar Mysore
- Parsons School of Design, The New SchoolNew YorkNew YorkUSA
- OpenBoxBrooklynNew YorkUSA
| | | | - Jill Rice
- Bruyère Research InstituteOttawaOntarioCanada
- Bruyère Continuing CareOttawaOntarioCanada
- Department of Medicine, Division of Palliative CareUniversity of OttawaOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
| | | | | | | | - Meaghen Hagarty
- The Ottawa HospitalOttawaOntarioCanada
- Bruyère Continuing CareOttawaOntarioCanada
| | - Krystal Kehoe MacLeod
- Bruyère Research InstituteOttawaOntarioCanada
- Department of Medicine, Division of Palliative CareUniversity of OttawaOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
- Department of Family MedicineUniversity of OttawaOttawaOntarioCanada
| | | | | | | | | | - Shirley H. Bush
- Bruyère Research InstituteOttawaOntarioCanada
- Department of Medicine, Division of Palliative CareUniversity of OttawaOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Kerry Kuluski
- Institute for Better Health, Trillium Health PartnersMississaugaOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | - Valerie Fiset
- Champlain Hospice Palliative Care ProgramOttawaOntarioCanada
- School of Nursing, University of OttawaOttawaOntarioCanada
| | - Cecilia Li
- The Ottawa HospitalOttawaOntarioCanada
- Bruyère Continuing CareOttawaOntarioCanada
- Department of Medicine, Division of Palliative CareUniversity of OttawaOttawaOntarioCanada
| | - Henrique A. Parsons
- The Ottawa HospitalOttawaOntarioCanada
- Department of Medicine, Division of Palliative CareUniversity of OttawaOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Geneviève Lalumière
- Bruyère Continuing CareOttawaOntarioCanada
- Regional Palliative Consultation Team (RPCT)OttawaOntarioCanada
| | - Tara Connolly
- Accessibility InstituteCarleton UniversityOttawaOntarioCanada
| | - Colleen Webber
- Bruyère Research InstituteOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
| | - Sarina R. Isenberg
- Bruyère Research InstituteOttawaOntarioCanada
- Department of Medicine, Division of Palliative CareUniversity of OttawaOttawaOntarioCanada
- Ottawa Hospital Research InstituteOttawaOntarioCanada
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada
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Webber C, Milani C, Pugliese M, Lawlor PG, Bush SH, Watt C, Casey G, Knoefel F, Thavorn K, Momoli F, Tanuseputro P. Long-term cognitive impairment after probable delirium in long-term care residents: A population-based retrospective cohort study. J Am Geriatr Soc 2024; 72:1183-1190. [PMID: 37982327 DOI: 10.1111/jgs.18675] [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] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/05/2023] [Accepted: 10/13/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND The impact of delirium on cognition has not been well-studied in long-term care (LTC) residents. This study examined changes in cognition 1 year after a probable delirium episode among LTC residents, compared to LTC residents without probable delirium. We also evaluated whether the relationship between probable delirium and cognitive change differed according to a diagnosis of dementia. METHODS We conducted a population-based retrospective cohort study using linked health administrative data. The study population included adults aged 65+ residing in LTC in Ontario, Canada and assessed via the Resident Assessment Instrument-Minimum Dataset between January 1, 2016 and December 31, 2018. Probable delirium was ascertained via the delirium Clinical Assessment Protocol on the index assessment. Cognition was measured quarterly using the Cognitive Performance Scale (range 0-6, higher values indicate greater impairment). Cognitive decline up to 1 year after index was evaluated using multivariable proportional odds regression models. RESULTS Of 92,005 LTC residents, 2816 (3.1%) had probable delirium at index. Residents with probable delirium had an increased odds of cognitive decline compared to those without probable delirium, with adjusted odds ratios of 1.64 (95% confidence interval [CI] 1.35-1.99), 1.56 (95% CI 1.34-1.85), 1.57 (95% CI 1.32-1.86) and 1.50 (95% CI 1.25-1.80) after 1-3, 4-6, 7-9, and 10-12 months of follow-up. Residents with probable delirium and a comorbid dementia diagnosis had the highest adjusted odds of cognitive decline (adjusted odds ratio 5.57, 95% CI 4.79-6.48) compared to those without probable delirium or dementia. Residents with probable delirium were also more likely to die within 1 year than those without probable delirium (52.5% vs. 23.4%). CONCLUSIONS Probable delirium is associated with increased mortality and worsened cognition in LTC residents that is sustained months after the probable delirium episode. Efforts to prevent delirium in this population may help limit these adverse effects.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
| | | | | | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Genevieve Casey
- Division of Geriatrics, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Knoefel
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- ICES, Ottawa, Ontario, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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5
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Fremont D, Roberts RL, Webber C, Clarke AE, Milani C, Isenberg SR, Bush SH, Kobewka D, Turcotte L, Howard M, Boese K, Arya A, Robert B, Sinnarajah A, Simon JE, Lau J, Qureshi D, Downar J, Tanuseputro P. Changes in End-of-Life Symptom Management Prescribing among Long-Term Care Residents during COVID-19. J Am Med Dir Assoc 2024:104955. [PMID: 38438112 DOI: 10.1016/j.jamda.2024.01.024] [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: 10/25/2023] [Revised: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 03/06/2024]
Abstract
OBJECTIVE To examine changes in the prescribing of end-of-life symptom management medications in long-term care (LTC) homes during the COVID-19 pandemic. DESIGN Retrospective cohort study using routinely collected health administrative data in Ontario, Canada. SETTING AND PARTICIPANTS We included all individuals who died in LTC homes between January 1, 2017, and March 31, 2021. We separated the study into 2 periods: before COVID-19 (January 1, 2017, to March 17, 2020) and during COVID-19 (March 18, 2020, to March 31, 2021). METHODS For each LTC home, we measured the percentage of residents who died before and during COVID-19 who had a subcutaneous symptom management medication prescription in their last 14 days of life. We grouped LTC homes into quintiles based on their mean prescribing rates before COVID-19, and examined changes in prescribing during COVID-19 and COVID-19 outcomes across quintiles. RESULTS We captured 75,438 LTC residents who died in Ontario's 626 LTC homes during the entire study period, with 19,522 (25.9%) dying during COVID-19. The mean prescribing rate during COVID-19 ranged from 46.9% to 79.4% between the lowest and highest prescribing quintiles. During COVID-19, the mean prescribing rate in the lowest prescribing quintile increased by 9.6% compared to before COVID-19. Compared to LTC homes in the highest prescribing quintile, homes in the lowest prescribing quintile experienced the highest proportion of COVID-19 outbreaks (73.4% vs 50.0%), the largest mean outbreak intensity (0.27 vs 0.09 cases/bed), the highest mean total days with a COVID-19 outbreak (72.7 vs 24.2 days), and the greatest proportion of decedents who were transferred and died outside of LTC (22.1% vs 8.6%). CONCLUSIONS AND IMPLICATIONS LTC homes in Ontario had wide variations in the prescribing rates of end-of-life symptom management medications before and during COVID-19. Homes in the lower prescribing quintiles had more COVID-19 cases per bed and days spent in an outbreak.
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Affiliation(s)
- Deena Fremont
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Rhiannon L Roberts
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anna E Clarke
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christina Milani
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Kobewka
- Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Luke Turcotte
- Department of Health Sciences, Brock University, St Catharines, Ontario, Canada
| | - Michelle Howard
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kaitlyn Boese
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Amit Arya
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Kensington Research Institute, Toronto, Ontario, Canada
| | - Benoit Robert
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, Ontario, Canada
| | | | - Jessica E Simon
- Department of Oncology, Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Lau
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care, University Health Network, Toronto, Ontario, Canada
| | - Danial Qureshi
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - James Downar
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada; Department of Clinical Epidemiology, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
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Roberts RL, Milani C, Webber C, Bush SH, Boese K, Simon JE, Downar J, Arya A, Tanuseputro P, Isenberg SR. Measuring the Use of End-of-Life Symptom Relief Medications in Long-Term Care Homes-a Qualitative Study. Can Geriatr J 2024; 27:29-46. [PMID: 38433885 PMCID: PMC10896208 DOI: 10.5770/cgj.27.712] [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] [Subscribe] [Scholar Register] [Indexed: 03/05/2024] Open
Abstract
Background At the end of life, individuals may experience physical symptoms such as pain, and guidelines recommend medications to manage these symptoms. Yet, little is known about the symptom management long-term care (LTC) residents receive at the end of life. Our research team developed a metric-whether residents receive one or more prescriptions for an end-of-life symptom management medication in their last two weeks-to explore end-of-life care for LTC residents. This qualitative study aimed to inform the refinement of the end-of-life prescribing metric, including the acceptability and applicability to assess the quality of a resident's symptom management at end-of-life. Methods We conducted 14 semi-structured interviews with Ontario health-care providers (physicians and nurses) who work in LTC homes and family caregivers of residents who died in LTC. Interviews were conducted virtually between February 2021 and December 2022, and were analyzed using thematic analysis. Results We identified three major themes relating to perceptions of the metric: 1) appropriateness, 2) health-care provider applicability, and 3) caregiver applicability. Participants noted that the metric may be appropriate to assess end-of-life care, but noted important nuances. Regarding applicability, health-care providers found value in the metric and that it could inform their practice. Conversely, caregivers found limited value in the metric. Conclusion The proposed metric captures a very specific aspect of end-of-life care-whether end-of-life medications were prescribed or not. Participants deemed that the metric may reflect whether LTC homes have processes to manage a resident's end-of-life symptoms with medication. However, participants thought the metric could not provide a complete picture of end-of-life care and its quality.
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Affiliation(s)
| | | | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, ON
- Bruyère Research Institute, Ottawa, ON
| | - Shirley H. Bush
- Ottawa Hospital Research Institute, Ottawa, ON
- Bruyère Research Institute, Ottawa, ON
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON
| | - Kaitlyn Boese
- Ottawa Hospital Research Institute, Ottawa, ON
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON
| | - Jessica E. Simon
- Department of Oncology, Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, ON
- Bruyère Research Institute, Ottawa, ON
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON
| | - Amit Arya
- Department of Family and Community Medicine, University of Toronto, Toronto, ON
- Kensington Research Institute, Toronto, ON
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, ON
- Bruyère Research Institute, Ottawa, ON
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON
| | - Sarina R. Isenberg
- Bruyère Research Institute, Ottawa, ON
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON
- Department of Family and Community Medicine, University of Toronto, Toronto, ON
- School of Epidemiology and Public Health, Faculty of Medicine, Ottawa, ON
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Tanuseputro P, Roberts RL, Milani C, Clarke AE, Webber C, Isenberg SR, Kobewka D, Turcotte L, Bush SH, Boese K, Arya A, Robert B, Sinnarajah A, Simon JE, Howard M, Lau J, Qureshi D, Fremont D, Downar J. Palliative End-of-Life Medication Prescribing Rates in Long-Term Care: A Retrospective Cohort Study. J Am Med Dir Assoc 2024; 25:532-538.e8. [PMID: 38242534 DOI: 10.1016/j.jamda.2023.11.026] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/21/2024]
Abstract
BACKGROUND Medications are often needed to manage distressing end-of-life symptoms (eg, pain, agitation). OBJECTIVES In this study, we describe the variation in prescribing rates of symptom relief medications at the end of life among long-term care (LTC) decedents. We evaluate the extent these medications are prescribed in LTC homes and whether prescribing rates of end-of-life symptom management can be used as an indicator of quality end-of-life care. DESIGN Retrospective cohort study using administrative health data. SETTING AND PARTICIPANTS LTC decedents in all 626 publicly funded LTC homes in Ontario, Canada, between January 1, 2017, and March 17, 2020. METHODS For each LTC home, we measured the percent of decedents who received 1+ prescription(s) for a subcutaneous end-of-life symptom management medication ("end-of-life medication") in their last 14 days of life. We then ranked LTC homes into quintiles based on prescribing rates. RESULTS We identified 55,916 LTC residents who died in LTC. On average, two-thirds of decedents (64.7%) in LTC homes were prescribed at least 1 subcutaneous end-of-life medication in the last 2 weeks of life. Opioids were the most common prescribed medication (overall average prescribing rate of 62.7%). LTC homes in the lowest prescribing quintile had a mean of 37.3% of decedents prescribed an end-of-life medication, and the highest quintile mean was 82.5%. In addition, across these quintiles, the lowest prescribing quintile had a high average (30.3%) of LTC residents transferred out of LTC in the 14 days compared with the highest prescribing quintile (12.7%). CONCLUSIONS AND IMPLICATIONS Across Ontario's LTC homes, there are large differences in prescribing rates for subcutaneous end-of-life symptom relief medications. Although future work may elucidate why the variability exists, this study provides evidence that administrative data can provide valuable insight into the systemic delivery of end-of-life care.
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Affiliation(s)
- Peter Tanuseputro
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada.
| | - Rhiannon L Roberts
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Christina Milani
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Anna E Clarke
- ICES uOttawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Daniel Kobewka
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Luke Turcotte
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Kaitlyn Boese
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Amit Arya
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Kensington Research Institute, Toronto, Ontario, Canada
| | - Benoit Robert
- Centre of Excellence in Frailty-Informed Care, Perley Health, Ottawa, Ontario, Canada
| | | | - Jessica E Simon
- Department of Oncology, Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Michelle Howard
- Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jenny Lau
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care, University Health Network, Toronto, Ontario, Canada
| | - Danial Qureshi
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Deena Fremont
- Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - James Downar
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Bruyère Continuing Care, Ottawa, Ontario, Canada
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Murphy R, Barnes CJ, Enright PD, Gratton V, Bush SH. Mapping an undergraduate medical education curriculum against national and international palliative care reference learning objectives. BMC Med Educ 2024; 24:105. [PMID: 38303063 PMCID: PMC10836050 DOI: 10.1186/s12909-024-05082-1] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/22/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND The teaching of palliative care competencies is an essential component of undergraduate medical education. There is significant variance in the palliative care content delivered in undergraduate medical curricula, revealing the utility of reference standards to guide curricular development and assessment. To evaluate our university's undergraduate palliative care teaching, we undertook a curriculum mapping exercise, comparing official learning objectives to the national Educating Future Physicians in Palliative and End-of-Life Care (EFPPEC) and the international Palliative Education Assessment Tool (PEAT) reference objectives. METHODS Multiple assessors independently compared our university's UGME learning objectives with EFPPEC and PEAT reference objectives to determine the degree-of-coverage. Visual curriculum maps were created to depict in which part of the curriculum each objective is delivered and by which medical specialty. RESULTS Of 122 EFPPEC objectives, 55 (45.1%) were covered fully, 42 (34.4%) were covered partially, and 25 (20.5%) were not covered by university objectives. Of 89 PEAT objectives, 40 (44.9%) were covered fully, 35 (39.3%) were covered partially, and 14 (15.7%) were not covered by university objectives. CONCLUSIONS The majority of EFPPEC and PEAT reference objectives are fully or partially covered in our university's undergraduate medical curriculum. Our approach could serve as a guide for others who endeavour to review their universities' specialty-specific medical education against reference objectives. Future curriculum development should target the elimination of identified gaps and evaluate the attainment of palliative care competencies by medical learners.
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Affiliation(s)
- Rebekah Murphy
- Department of Medicine, Division of Palliative Care, University of Ottawa, 451 Smyth Rd, Ottawa, ON, K1H 8M5, Canada.
- Department of Palliative Care, Bruyère Continuing Care, Saint-Vincent Hospital, 60 Cambridge St N, Ottawa, ON, K1R 7A5, Canada.
- Department of Medicine, Queensway Carleton Hospital, 3045 Baseline Rd, Ottawa, ON, K2H 8P4, Canada.
| | - Christopher J Barnes
- Department of Medicine, Division of Palliative Care, University of Ottawa, 451 Smyth Rd, Ottawa, ON, K1H 8M5, Canada
- Department of Palliative Care, Bruyère Continuing Care, Saint-Vincent Hospital, 60 Cambridge St N, Ottawa, ON, K1R 7A5, Canada
| | - Paula D Enright
- Department of Medicine, Division of Palliative Care, University of Ottawa, 451 Smyth Rd, Ottawa, ON, K1H 8M5, Canada
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada
| | - Valerie Gratton
- Department of Medicine, Division of Palliative Care, University of Ottawa, 451 Smyth Rd, Ottawa, ON, K1H 8M5, Canada
- Institut du Savoir Montfort, 713 Montréal Rd, Ottawa, ON, K1K 0T2, Canada
- Department of Family Medicine, Montfort Hospital, 713 Montréal Rd, Ottawa, ON, K1K 0T2, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, 451 Smyth Rd, Ottawa, ON, K1H 8M5, Canada
- Department of Palliative Care, Bruyère Continuing Care, Saint-Vincent Hospital, 60 Cambridge St N, Ottawa, ON, K1R 7A5, Canada
- Ottawa Hospital Research Institute, 1053 Carling Ave, Ottawa, ON, K1Y 4E9, Canada
- Bruyère Research Institute, 43 Bruyère St, Ottawa, ON, K1N 5C8, Canada
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Lapenskie J, Anderson K, Lawlor PG, Kabir M, Noel C, Heidinger B, Parsons HA, Cohen L, Gratton V, Besserer E, Adeli S, Murphy R, Warmels G, Bruni A, Bhimji K, Dyason C, Enright P, Desjardins I, Wooller K, Arsenault-Mehta K, Webber C, Bedard D, Iyengar A, Bush SH, Isenberg SR, Tanuseputro P, Vanderspank-Wright B, Downar J. Long-term bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study. Palliat Med 2024; 38:264-271. [PMID: 38229211 PMCID: PMC10865760 DOI: 10.1177/02692163231223394] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Severe grief is highly distressing and prevalent up to 1 year post-death among people bereaved during the first wave of COVID-19, but no study has assessed changes in grief severity beyond this timeframe. AIM Understand the trajectory of grief during the pandemic by reassessing grief symptoms in our original cohort 12-18 months post-death. DESIGN Prospective matched cohort study. SETTINGS/PARTICIPANTS Family members of decedents who died in an acute care hospital between November 1, 2019 and August 31, 2020 in Ottawa, Canada. Family members of patients who died of COVID (COVID +ve) were matched 2:1 with those who died of non-COVID illness (COVID -ve) during pandemic wave 1 or immediately prior to its onset (pre-COVID). Grief was assessed using the Inventory of Complicated Grief (ICG). RESULTS Follow-up assessment was completed by 92% (111/121) of family members in the initial cohort. Mean ICG score on the 12-18-month assessment was 19.9 (SD = 11.8), and severe grief (ICG > 25) was present in 28.8% of participants. One-third (33.3%) had either a persistently high (>25) or worsening ICG score (⩾4-point increase between assessments). Using a modified Poisson regression analysis, persistently high or worsening ICG scores were associated with endotracheal intubation in the deceased, but not cause of death (COVID +ve, COVID -ve, pre-COVID) or physical presence of the family member in the final 48 h of life. CONCLUSIONS Severe grief is a substantial source of psychological morbidity in the wake of the COVID-19 pandemic, persisting more than a year post-death. Our findings highlight an acute need for effective and scalable means of addressing severe grief.
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Affiliation(s)
- Julie Lapenskie
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Koby Anderson
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Peter G. Lawlor
- Bruyère Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
| | - Monisha Kabir
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Chelsea Noel
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Brandon Heidinger
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | - Henrique A. Parsons
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Leila Cohen
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Valérie Gratton
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Samantha Adeli
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Rebekah Murphy
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
- Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Grace Warmels
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Adrianna Bruni
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Khadija Bhimji
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Claire Dyason
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Paula Enright
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Isabelle Desjardins
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Krista Wooller
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
| | | | | | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
| | - Sarina R Isenberg
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
- Institut du Savoir Montfort, Ottawa, ON, Canada
| | - Brandi Vanderspank-Wright
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- School of Nursing, University of Ottawa, Ottawa, ON, Canada
| | - James Downar
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Australian Centre for Health Law Research, Queensland University of Technology School of Law, Brisbane, QLD, Australia
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Webber C, Milani C, Bjerre LM, Lawlor PG, Bush SH, Watt CL, Pugliese M, Knoefel F, Casey G, Momoli F, Thavorn K, Tanuseputro P. Potentially Inappropriate Prescribing in Long-Term Care and its Relationship With Probable Delirium. J Am Med Dir Assoc 2024; 25:130-137.e4. [PMID: 37743042 DOI: 10.1016/j.jamda.2023.08.019] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES This study examined potentially inappropriate prescribing (PIP) of medication and its association with probable delirium among long-term care (LTC) residents in Ontario, Canada. DESIGN Population-based cross-sectional study using provincial health administrative data, including LTC assessment data via the Resident Assessment Instrument-Minimum Dataset version 2.0 (RAI-MDS 2.0). SETTING AND PARTICIPANTS LTC residents in Ontario between January 1, 2016, and December 31, 2019. METHODS We used residents' first RAI-MDS 2.0 assessment in the study period as the index assessment. Probable delirium was identified via the delirium Clinical Assessment Protocol. Medication use in the 2 weeks preceding assessment was captured using medication claims data. PIP was measured using the STOPP/START criteria and 2015 Beers criteria, with residents classified as having 0, 1, 2, or 3+ instances of PIP. Relationships between PIP and probable delirium was assessed via bivariate and multivariable logistic regression models. RESULTS The study population included 171,190 LTC residents (mean age 84.5 years, 66.8% female, 62.9% with dementia). More than half (51.8%) of residents had 1+ instances of PIP and 21% had 3+ instances of PIP according to the STOPP/START criteria; PIP prevalence was slightly lower when assessed using Beers criteria (36.5% with 1+, 11.1% with 3+). Overall, 3.7% of residents had probable delirium. The prevalence of probable delirium increased as the number of instances of PIP increased, with residents with 3+ instances of STOPP/START PIP being 1.66 times more likely (95% CI 1.56-1.77) to have probable delirium compared to those with no instances of PIP. Similar findings were observed when PIP was measured using the Beers criteria. Central nervous system (CNS)-related PIP criteria showed a stronger association with probable delirium than non-CNS-related PIP criteria. CONCLUSIONS AND IMPLICATIONS This population-based study highlighted that PIP was highly prevalent in long-term care residents and was associated with an increased prevalence of probable delirium.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ontario, Canada.
| | | | - Lise M Bjerre
- ICES, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada; Institut du savoir Montfort, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine L Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael Pugliese
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES, Ontario, Canada
| | - Frank Knoefel
- Bruyère Research Institute, Ottawa, Ontario, Canada; Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Genevieve Casey
- Division of Geriatrics, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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11
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Bush SH, Bronicki K, Dionne M, Lelievre N, Lawlor PG, Kabir M. Implementation of the Richmond Agitation-Sedation Scale (palliative version) on an inpatient palliative care unit. BMC Palliat Care 2023; 22:171. [PMID: 37924037 PMCID: PMC10625230 DOI: 10.1186/s12904-023-01298-y] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND The Richmond Agitation-Sedation Scale - Palliative version (RASS-PAL) tool is a brief observational tool to quantify a patient's level of agitation or sedation. The objective of this study was to implement the RASS-PAL tool on an inpatient palliative care unit and evaluate the implementation process. METHODS Quality improvement implementation project using a short online RASS-PAL self-learning module and point-of-care tool. Participants were staff working on a 31-bed inpatient palliative care unit who completed the RASS-PAL self-learning module and online evaluation survey. RESULTS The self-learning module was completed by 49/50 (98%) of regular palliative care unit staff (nurses, physicians, allied health, and other palliative care unit staff). The completion rate of the self-learning module by both regular and casual palliative care unit staff was 63/77 (82%). The follow-up online evaluation survey was completed by 23/50 (46%) of respondents who regularly worked on the palliative care unit. Respondents agreed (14/26; 54%) or strongly agreed (10/26; 38%) that the self-learning module was implemented successfully, with 100% agreement that it was effective for their educational needs. CONCLUSION Using an online self-learning module is an effective method to engage and educate interprofessional staff on the RASS-PAL tool as part of an implementation strategy.
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Affiliation(s)
- Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.
- Bruyère Research Institute, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
- Bruyère Continuing Care, Ottawa, ON, Canada.
| | - Katarzyna Bronicki
- Department of Radiation Medicine, The Ottawa Hospital Cancer Centre, Ottawa, ON, Canada
| | - Michel Dionne
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
| | | | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyère Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Bruyère Continuing Care, Ottawa, ON, Canada
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12
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Lawlor P, Cohen L, Adeli SR, Besserer E, Gratton V, Murphy R, Warmels G, Bruni A, Kabir M, Noel C, Heidinger B, Anderson K, Arsenault-Mehta K, Wooller K, Lapenskie J, Webber C, Bedard D, Enright P, Desjardins I, Bhimji K, Dyason C, Iyengar A, Bush SH, Isenberg S, Tanuseputro P, Vanderspank-Wright B, Downar J, Parsons H. Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada. BMJ Open 2023; 13:e075518. [PMID: 37669840 PMCID: PMC10481717 DOI: 10.1136/bmjopen-2023-075518] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 08/23/2023] [Indexed: 09/07/2023] Open
Abstract
OBJECTIVE To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic. DESIGN In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents. SETTING Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170). MAIN OUTCOME MEASURES Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs. RESULTS The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses. CONCLUSIONS COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice.
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Affiliation(s)
- Peter Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Leila Cohen
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | | | - Ella Besserer
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Valérie Gratton
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Medicine, Hopital Monfort, Ottawa, Ontario, Canada
| | - Rebekah Murphy
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Grace Warmels
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Adrianna Bruni
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Monisha Kabir
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Chelsea Noel
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Brandon Heidinger
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Koby Anderson
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | | | - Krista Wooller
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Lapenskie
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel Bedard
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Paula Enright
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Isabelle Desjardins
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Khadija Bhimji
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Claire Dyason
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Akshai Iyengar
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Sarina Isenberg
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Peter Tanuseputro
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Brandi Vanderspank-Wright
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada
| | - James Downar
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Henrique Parsons
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
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Featherstone I, Siddiqi N, Jones L, Coppo E, Sheldon T, Hosie A, Wolkowski A, Bush SH, Taylor J, Teodorczuk A, Johnson MJ. 'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium. Palliat Med 2023:2692163231170655. [PMID: 37129262 DOI: 10.1177/02692163231170655] [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: 05/03/2023]
Abstract
BACKGROUND Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. AIM(S) To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care. DESIGN Qualitative interview study using behaviour change theory from a critical realist stance. SETTING/PARTICIPANTS Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. RESULTS We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. CONCLUSIONS Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.
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Affiliation(s)
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Lesley Jones
- Hull York Medical School, University of Hull, Hull, UK
| | - Eleonora Coppo
- Cardinal Massaia Hospital of Asti, Asti, Piemonte, Italy
| | - Trevor Sheldon
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent's Health Network, Sydney, NSW, Australia
- IMPAACT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Andrew Teodorczuk
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- The Prince Charles Hospital, Metro North Mental Health, Brisbane, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Boland JW, Kabir M, Spilg EG, Webber C, Bush SH, Murtagh F, Lawlor PG. Over a third of palliative medicine physicians meet burnout criteria: Results from a survey study during the COVID-19 pandemic. Palliat Med 2023; 37:343-354. [PMID: 36789968 PMCID: PMC9936168 DOI: 10.1177/02692163231153067] [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] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND Palliative medicine physicians may be at higher risk of burnout due to increased stressors and compromised resilience during the COVID-19 pandemic. Burnout prevalence and factors influencing this among UK and Irish palliative medicine physicians is unknown. AIM To determine the prevalence of burnout and the degree of resilience among UK and Irish palliative medicine physicians during the COVID-19 pandemic, and associated factors. DESIGN Online survey using validated assessment scales assessed burnout and resilience: The Maslach Burnout Inventory Human Services Survey for Medical Personnel [MBI-HSS (MP)] and the Connor-Davidson Resilience Scale (CD-RISC). Additional tools assessed depressive symptoms, alcohol use, and quality of life. SETTING/PARTICIPANTS Association of Palliative Medicine of UK and Ireland members actively practising in hospital, hospice or community settings. RESULTS There were 544 respondents from the 815 eligible participants (66.8%), 462 provided complete MBI-HSS (MP) data and were analysed. Of those 181/462 (39.2%) met burnout criteria, based on high emotional exhaustion or depersonalisation subscales of the MBI-HSS (MP). A reduced odds of burnout was observed among physicians who worked ⩽20 h/week (vs 31-40 h/week, adjusted odds ratio (aOR) 0.03, 95% confidence interval (CI) 0.002-0.56) and who had a greater perceived level of clinical support (aOR 0.70, 95% CI 0.62-0.80). Physicians with higher levels of depressive symptoms had higher odds of burnout (aOR 18.32, 95% CI 6.75-49.73). Resilience, mean (SD) CD-RISC score, was lower in physicians who met burnout criteria compared to those who did not (62.6 (11.1) vs 70.0 (11.3); p < 0.001). CONCLUSIONS Over one-third of palliative medicine physicians meet burnout criteria. The provision of enhanced organisational and colleague support is paramount in both the current and future pandemics.
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Affiliation(s)
- Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK.,Hull York Medical School, University of York, UK
| | | | - Edward G Spilg
- Division of Geriatric Medicine, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Shirley H Bush
- Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada
| | - Fliss Murtagh
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK
| | - Peter G Lawlor
- Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada
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15
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Warmels G, Roberts A, Haddad J, Chomienne MH, Bush SH, Gratton V. Comparing Adherence with Best Practices in End-of-Life Care After Implementing the End-of-Life Order Set: A Quality Improvement Project in an Ottawa Academic Hospital. Palliat Med Rep 2023; 4:100-107. [PMID: 37095865 PMCID: PMC10122227 DOI: 10.1089/pmr.2022.0070] [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] [Accepted: 02/27/2023] [Indexed: 04/26/2023] Open
Abstract
Background Physicians in acute care require tools to assist them in transitioning patients from a "life prolonging" approach to "end-of-life care," and standardized order sets can be a useful strategy. The end-of-life order set (EOLOS) was developed and implemented in the medical wards of a community academic hospital. Objective To compare adherence with best practices in end-of-life care after implementing the EOLOS. Methods We conducted a retrospective chart review of admitted patients with expected deaths in the year preceding EOLOS implementation ("before EOLOS" group), and in the 12 to 24 months following EOLOS implementation ("after EOLOS" group). Results A total of 295 charts were included: 139 (47%) in the "before EOLOS" group and 156 (53%) in the "after EOLOS" group, of which 117/156 charts (75%) had a completed EOLOS. The "after EOLOS" group demonstrated more "do not resuscitate" orders and more written communication to team members about comfort goals of care. There was a decrease in nonbeneficial interventions in the last 24 hours of life in the "after EOLOS" group: high-flow oxygen, intravenous antibiotics, and deep vein thrombosis/venous thromboembolism prophylaxis. The "after EOLOS" group demonstrated increased prescription of all common end-of-life medications, except for opioids, which had a high preexisting rate of prescription. Patients in the "after EOLOS" group showed a higher rate of spiritual care and palliative care consult team consultation. Conclusion Findings support standardized order sets as a good framework allowing generalist hospital staff to improve adherence to established palliative care principles and improve end-of-life care of hospital inpatients.
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Affiliation(s)
- Grace Warmels
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Anne Roberts
- Department of Palliative Care, Montfort Hospital, Ottawa, Ontario, Canada
| | - John Haddad
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Marie-Hélène Chomienne
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Shirley H. Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Valerie Gratton
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
- Department of Family Medicine, Montfort Hospital, Ottawa, Ontario, Canada
- Address correspondence to: Valerie Gratton, MD, CCFP-PC, Department of Family Medicine, Montfort Hospital, 713 Montreal Road, Ottawa, Ontario K1K 0T2, Canada.
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16
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Campos E, Isenberg SR, Lovblom LE, Mak S, Steinberg L, Bush SH, Goldman R, Graham C, Kavalieratos D, Stukel T, Tanuseputro P, Quinn KL. Supporting the Heterogeneous and Evolving Treatment Preferences of Patients With Heart Failure Through Collaborative Home-Based Palliative Care. J Am Heart Assoc 2022; 11:e026319. [PMID: 36172958 DOI: 10.1161/jaha.122.026319] [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: 11/16/2022]
Abstract
Background We characterized the treatment preferences, care setting, and end-of-life outcomes among patients with advanced heart failure supported by a collaborative home-based model of palliative care. Methods and results This decedent cohort study included 250 patients with advanced heart failure who received collaborative home-based palliative care for a median duration of 1.9 months of follow-up in Ontario, Canada, from April 2013 to July 2019. Patients were categorized into 1 of 4 groups according to their initial treatment preferences. Outcomes included location of death (out of hospital versus in hospital), changes in treatment preferences, and health service use. Among patients who initially prioritized quantity of life, 21 of 43 (48.8%) changed their treatment preferences during follow-up (mean 0.28 changes per month). The majority of these patients changed their preferences to avoid hospitalization and focus on comfort at home (19 of 24 changes, 79%). A total of 207 of 250 (82.8%) patients experienced an out-of-hospital death. Patients who initially prioritized quantity of life had decreased odds of out-of-hospital death (versus in-hospital death; adjusted odds ratio, 0.259 [95% CI, 0.097-0.693]) and more frequent hospitalizations (mean 0.45 hospitalizations per person-month) compared with patients who initially prioritized quality of life at home. Conclusions Our results yield a more detailed understanding of the interaction of advanced care planning and patient preferences. Shared decision making for personalized treatment is dynamic and can be enacted earlier than at the very end of life.
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Affiliation(s)
- Erin Campos
- Department of Medicine University of Toronto Toronto Ontario
| | - Sarina R Isenberg
- Bruyère Research Institute Ottawa Ontario.,Department of Medicine University of Ottawa Ottawa Ontario.,Department of Family and Community Medicine University of Toronto Toronto Ontario
| | | | - Susanna Mak
- Department of Medicine University of Toronto Toronto Ontario.,Department of Medicine Sinai Health System Toronto Ontario.,Division of Cardiology Sinai Health System Toronto Ontario
| | - Leah Steinberg
- Department of Family and Community Medicine University of Toronto Toronto Ontario.,Department of Medicine Sinai Health System Toronto Ontario.,Interdepartmental Division of Palliative Care Sinai Health System Toronto Ontario
| | - Shirley H Bush
- Bruyère Research Institute Ottawa Ontario.,Department of Medicine University of Ottawa Ottawa Ontario.,Ottawa Hospital Research Institute University of Ottawa Ottawa Ontario
| | - Russell Goldman
- Interdepartmental Division of Palliative Care Sinai Health System Toronto Ontario.,Temmy Latner Centre for Palliative Care Toronto Ontario
| | | | - Dio Kavalieratos
- Division of Palliative Medicine Emory University School of Medicine Atlanta Georgia
| | | | - Peter Tanuseputro
- Bruyère Research Institute Ottawa Ontario.,Department of Medicine University of Ottawa Ottawa Ontario.,Ottawa Hospital Research Institute University of Ottawa Ottawa Ontario.,ICES Toronto Ontario.,ICES Ottawa Ontario
| | - Kieran L Quinn
- Department of Medicine University of Toronto Toronto Ontario.,Department of Medicine Sinai Health System Toronto Ontario.,Interdepartmental Division of Palliative Care Sinai Health System Toronto Ontario.,Temmy Latner Centre for Palliative Care Toronto Ontario.,ICES Toronto Ontario.,ICES Ottawa Ontario
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17
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Downar J, Parsons HA, Cohen L, Besserer E, Adeli S, Gratton V, Murphy R, Warmels G, Bruni A, Bhimji K, Dyason C, Enright P, Desjardins I, Wooller K, Kabir M, Noel C, Heidinger B, Anderson K, Arsenault-Mehta K, Lapenskie J, Webber C, Bedard D, Iyengar A, Bush SH, Isenberg SR, Tanuseputro P, Vanderspank-Wright B, Lawlor P. Bereavement outcomes in family members of those who died in acute care hospitals before and during the first wave of COVID-19: A cohort study. Palliat Med 2022; 36:1305-1312. [PMID: 35786109 PMCID: PMC9446458 DOI: 10.1177/02692163221109711] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 01/26/2023]
Abstract
BACKGROUND The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic. AIM To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic. DESIGN Prospective, matched cohort study. SETTING/PARTICIPANTS Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID -ve) or immediately prior to its onset (pre-COVID). We abstracted decedents' medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised. RESULTS We abstracted data for 425 decedents (85 COVID +ve, 170 COVID -ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts (p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased. CONCLUSION Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.
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Affiliation(s)
- James Downar
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada.,Australian Centre for Health Law Research, Queensland University of Technology School of Law, Brisbane, QLD, Australia
| | - Henrique A Parsons
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Leila Cohen
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada
| | | | - Samantha Adeli
- Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Valérie Gratton
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Institut du Savoir Montfort, Ottawa, ON, Canada
| | - Rebekah Murphy
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada.,Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Grace Warmels
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada.,Queensway-Carleton Hospital, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Adrianna Bruni
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada.,Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Khadija Bhimji
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada.,Queensway-Carleton Hospital, Ottawa, ON, Canada
| | - Claire Dyason
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Paula Enright
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
| | - Isabelle Desjardins
- The Ottawa Hospital, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Krista Wooller
- The Ottawa Hospital, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Monisha Kabir
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Chelsea Noel
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Brandon Heidinger
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Koby Anderson
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Julie Lapenskie
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | | | | | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada
| | - Sarina R Isenberg
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Peter Tanuseputro
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Peter Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
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18
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Green A, Hosie A, Phillips JL, Kochovska S, Noble B, Brassil M, Cumming A, Lawlor PG, Bush SH, Davis JM, Edwards L, Hunt J, Wilcock J, Phillipson C, Wesley Ely E, Parr C, Lovell M, Agar M. Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study. Palliat Med 2022; 36:1273-1284. [PMID: 36062724 DOI: 10.1177/02692163221113163] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials. AIM To explore patient, family, clinician and volunteer ('stakeholder') perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the 'PRESERVE pilot study'. DESIGN A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie's Behaviour Change Wheel and the Theoretical Domains Framework. SETTING/PARTICIPANTS Thirty-nine people involved in the trial: nurses (n = 17), physicians (n = 6), patients (n = 6), family caregivers (n = 4), physiotherapists (n = 3), a social worker, a pastoral care worker and a volunteer. RESULTS Participants' perspectives aligned with the 'capability', 'opportunity' and 'motivation' domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention). CONCLUSION This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care.Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168.
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Affiliation(s)
- Anna Green
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Annmarie Hosie
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,School of Nursing & Midwifery, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, Darlinghurst, NSW, Australia
| | - Jane L Phillips
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Slavica Kochovska
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Beverly Noble
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meg Brassil
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Health Care, Sydney, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Jan Maree Davis
- Department of Palliative Care, Calvary Health Care Kogarah, Kogarah, NSW, Australia
| | - Layla Edwards
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane Hunt
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Julie Wilcock
- Ingham Institute, Liverpool Hospital, Liverpool, NSW, Australia
| | - Carl Phillipson
- Central Adelaide Palliative Care Service, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Cynthia Parr
- HammondCare, Greenwich Hospital, Greenwich, NSW, Australia
| | - Melanie Lovell
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,HammondCare, Greenwich Hospital, Greenwich, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Meera Agar
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,Ingham Institute, Liverpool Hospital, Liverpool, NSW, Australia.,South West Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
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19
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Bush SH, Skinner E, Lawlor PG, Dhuper M, Grassau PA, Pereira JL, MacDonald AR, Parsons HA, Kabir M. Adaptation, implementation, and mixed methods evaluation of an interprofessional modular clinical practice guideline for delirium management on an inpatient palliative care unit. Palliat Care 2022; 21:128. [PMID: 35841014 PMCID: PMC9287908 DOI: 10.1186/s12904-022-01010-6] [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] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Using delirium clinical guidelines may align interprofessional clinical practice and improve the care of delirious patients and their families. The aim of this project was to adapt, implement and evaluate an interprofessional modular delirium clinical practice guideline for an inpatient palliative care unit. METHODS The setting was a 31-bed adult inpatient palliative care unit within a university-affiliated teaching hospital. Participants for the evaluation were interprofessional team members. Using integration of guideline adaptation and an education initiative, an interprofessional guideline adaptation group developed a face-to-face 'starter kit' module and four online self-learning modules. The mixed methods evaluation comprised pre-and post-implementation review of electronic patient records, an online survey, and analysis of focus groups/ interviews using an iterative, inductive thematic analysis approach. RESULTS Guideline implementation took 12 months. All palliative care unit staff attended a 'starter kit' session. Overall completion rate of the four e-Learning modules was 80.4%. After guideline implementation, nursing documentation of non-pharmacological interventions occurring before medication administration was observed. There was 60% less scheduled antipsychotic use and an increase in 'as needed' midazolam use. The online survey response rate was 32% (25/77). Most participants viewed the guideline's implementation favourably. Six key themes emerged from the qualitative analysis of interviews and focus groups with ten participants: prior delirium knowledge or experiences, challenges of facilitating change, impacts on practice, collaborative effort of change, importance of standardized guidelines, and utility of guideline elements. CONCLUSIONS Guideline implementation warrants concerted effort, time, and management support. Interprofessional team support facilitates the modular approach of guideline adaptation and implementation, leading to a change in clinical practice.
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Affiliation(s)
- Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada. .,Bruyère Research Institute, Ottawa, ON, Canada. .,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,Department of Palliative Medicine, Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.
| | - Elise Skinner
- Department of Palliative Medicine, Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Palliative Medicine, Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada
| | - Misha Dhuper
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Pamela A Grassau
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Department of Palliative Medicine, Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.,School of Social Work, Carleton University, Ottawa, ON, Canada
| | - José L Pereira
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Pallium Canada, Ottawa, ON, Canada
| | - Alistair R MacDonald
- Bruyère Research Institute, Ottawa, ON, Canada.,Perth and Smiths Falls District Hospital, Smiths Falls, ON, Canada
| | - Henrique A Parsons
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Department of Palliative Medicine, Bruyère Continuing Care, 43 Bruyère Street, Ottawa, ON, K1N 5C8, Canada.,The Ottawa Hospital, Ottawa, ON, Canada
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Lawlor P, Parsons H, Adeli SR, Besserer E, Cohen L, Gratton V, Murphy R, Warmels G, Bruni A, Kabir M, Noel C, Heidinger B, Anderson K, Arsenault-Mehta K, Wooller K, Lapenskie J, Webber C, Bedard D, Enright P, Desjardins I, Bhimji K, Dyason C, Iyengar A, Bush SH, Isenberg S, Tanuseputro P, Vanderspank-Wright B, Downar J. Comparative end-of-life communication and support in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada. BMJ Open 2022; 12:e062937. [PMID: 35760548 PMCID: PMC9237652 DOI: 10.1136/bmjopen-2022-062937] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To compare end-of-life in-person family presence, patient-family communication and healthcare team-family communication encounters in hospitalised decedents before and during the COVID-19 pandemic. DESIGN In a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group. SETTING One quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada. PARTICIPANTS Decedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170). MAIN OUTCOME MEASURES End-of-life (last 48 hours) in-person family presence and virtual (video) patient-family communication, and end-of-life (last 5 days) virtual team-family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team-family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs. RESULTS End-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2-0.73) and 0.09 (0.04-0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team-family communication encounters: IRRs=0.76 (0.64-0.9) and 0.61 (0.47-0.79) for in-person, and IRRs=2.6 (2.1-3.3) and 4.8 (3.7-6.1) for telephone communications, respectively. Virtual team-family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51-8.95). CONCLUSIONS In hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team-family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team-family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study.
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Affiliation(s)
- Peter Lawlor
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Henrique Parsons
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | | | - Ella Besserer
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Leila Cohen
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Valérie Gratton
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Rebekah Murphy
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Grace Warmels
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Adrianna Bruni
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Monisha Kabir
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Chelsea Noel
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Department of Psychology, University of Ottawa, Ottawa, Ontario, Canada
| | - Brandon Heidinger
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Koby Anderson
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
| | | | - Krista Wooller
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Julie Lapenskie
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Colleen Webber
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Daniel Bedard
- Institut du Savoir Montfort, Ottawa, Ontario, Canada
| | - Paula Enright
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Isabelle Desjardins
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Khadija Bhimji
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
| | - Claire Dyason
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Akshai Iyengar
- Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarina Isenberg
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brandi Vanderspank-Wright
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Nursing, University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada
| | - James Downar
- Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada
- Divisions of Palliative Care and Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Graham C, Schonnop R, Killackey T, Kavalieratos D, Bush SH, Steinberg L, Mak S, Quinn K, Isenberg SR. Exploring Health Care Providers' Experiences of Providing Collaborative Palliative Care for Patients With Advanced Heart Failure At Home: A Qualitative Study. J Am Heart Assoc 2022; 11:e024628. [PMID: 35730640 PMCID: PMC9333360 DOI: 10.1161/jaha.121.024628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The HeartFull Collaborative is a regionally organized model of care which involves specialist palliative care and cardiology health care providers (HCPs) in a collaborative, home-based palliative care approach for patients with advanced heart failure (AHF). We evaluated HCP perspectives of barriers and facilitators to providing coordinated palliative care for patients with AHF at home. Methods and Results We conducted a qualitative study with 17 HCPs (11 palliative care and 6 cardiology) who were involved in the HeartFull Collaborative from April 2013 to March 2020. Individual, semi-structured interviews were held with each practitioner from November 2019 to March 2020. We used an interpretivist and inductive thematic analysis approach. We identified facilitators at 2 levels: (1) individual HCP level (on-going professional education to expand competency) and (2) interpersonal level (shared care between specialties, effective communication within the care team). Ongoing barriers were identified at 2 levels: (1) individual HCP level (e.g. apprehension of cardiology practitioners to introduce palliative care) and (2) system level (e.g. lack of availability of personal support worker hours). Conclusions Our results suggest that a collaborative shared model of care delivery between palliative care and cardiology improves knowledge exchange, collaboration and communication between specialties, and leads to more comprehensive patient care. Addressing ongoing barriers will help improve care delivery. Findings emphasize the acceptability of the program from a provider perspective, which is encouraging for future implementation. Further research is needed to improve prognostication, assess patient and caregiver perspectives regarding this model of care, and assess the economic feasibility and impact of this model of care.
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Affiliation(s)
- Cassandra Graham
- Division of Palliative Medicine, Department of Medicine University of Toronto Toronto Canada.,Division of Palliative Care University Health Network Toronto Canada
| | - Rebecca Schonnop
- Department of Emergency Medicine University of Alberta Edmonton Canada.,Department of Emergency Medicine Royal Alexandra Hospital Edmonton Canada
| | - Tieghan Killackey
- Child Health Evaluative Sciences The Hospital for Sick Children Toronto Canada
| | - Dio Kavalieratos
- Division of Palliative Medicine Emory University Atlanta Georgia
| | - Shirley H Bush
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Clinical Epidemiology Program Ottawa Hospital Research Institute Ottawa Canada.,Bruyere Continuing Care Ottawa Canada
| | - Leah Steinberg
- Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada.,Division of Palliative Care SinaiHealth Toronto Canada
| | - Susanna Mak
- Division of Cardiology, Department of Medicine University of Toronto Toronto Canada.,Division of Cardiology Department of Medicine SinaiHealth Toronto Canada
| | - Kieran Quinn
- Department of Medicine University of Toronto Toronto Canada.,ICES Toronto and Ottawa Canada.,Institute of Health Policy, Management and Evaluation University of Toronto Toronto Canada.,Department of Medicine SinaiHealth Toronto Canada
| | - Sarina R Isenberg
- Bruyere Research Institute Ottawa Canada.,Division of Palliative Care, Department of Medicine University of Ottawa Ottawa Canada.,Division of Palliative Care, Department of Family & Community Medicine University of Toronto Toronto Canada
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Wolfe A, Watt CL, Downar J, Bush SH. Use and Discontinuation of Milrinone for Advanced Heart Failure in an Academic Palliative Care Unit: A Case Report and Discussion of Recommendations. J Pain Palliat Care Pharmacother 2022; 36:24-33. [PMID: 35234559 DOI: 10.1080/15360288.2022.2027058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The use of intravenous inotropic medications in advanced heart failure (HF) has been shown to improve symptoms and decrease hospitalizations, prompting support for their use as a palliative measure for symptom management. Recommendations regarding inotrope management and method of discontinuation at the end of life are not specifically detailed in the literature and current guidelines. This case report describes the use of milrinone in a patient with advanced HF during the terminal phase of illness in a non-monitored palliative care unit setting, including dose reduction and discontinuation of milrinone. Increased patient anxiety during the weaning process was managed with midazolam. The provision of individualized milrinone therapy in non-monitored palliative care settings is feasible and well-tolerated using the presented detailed recommendations for its use and administration, monitoring, dose reduction and discontinuation and proactive symptom management at the end of life. Further research is needed for the optimal management of terminally ill patients with advanced HF.Supplemental data for this article is available online at here. show.
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Agar MR, Siddiqi N, Hosie A, Boland JW, Johnson MJ, Featherstone I, Lawlor PG, Bush SH, Page V, Amgarth-Duff I, Garcia M, Disalvo D, Rose L. Outcomes and measures of delirium interventional studies in palliative care to inform a core outcome set: A systematic review. Palliat Med 2021; 35:1761-1775. [PMID: 34448431 DOI: 10.1177/02692163211040186] [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: 11/16/2022]
Abstract
BACKGROUND Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement. AIM To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions. DESIGN Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. DATA SOURCES We searched six electronic databases (1980-November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions. RESULTS From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life. CONCLUSION The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.
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Affiliation(s)
- Meera R Agar
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,South West Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Ingham Institute of Applied Medical Research, Sydney, NSW, Australia
| | - Najma Siddiqi
- Hull York Medical School, Department of Health Sciences, University of York, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Annmarie Hosie
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, East Sydney, NSW, Australia
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Imogen Featherstone
- Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Valerie Page
- Watford General Hospital, Watford, Hertfordshire, UK
| | - Ingrid Amgarth-Duff
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Maja Garcia
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Domenica Disalvo
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Isenberg SR, Killackey T, Saunders S, Scott M, Ernecoff NC, Bush SH, Varenbut J, Lovrics E, Stern MA, Hsu AT, Bernstein M, Zimmermann C, Wentlandt K, Mahtani R. "Going Home [Is] Just a Feel-Good Idea With No Structure": A Qualitative Exploration of Patient and Family Caregiver Needs When Transitioning From Hospital to Home in Palliative Care. J Pain Symptom Manage 2021; 62:e9-e19. [PMID: 33631330 DOI: 10.1016/j.jpainsymman.2021.02.026] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 02/14/2021] [Accepted: 02/17/2021] [Indexed: 10/22/2022]
Abstract
CONTEXT Hospital-to-home transitions, particularly at the end of life, can be challenging for patients and their family caregivers. Therefore, there is a need to better understand gaps in expectations and experiences of these transitions. Theory can inform the creation of an intervention aimed at improving the hospital-to-home transition. OBJECTIVES 1) Explore patients' and caregivers' expectations and subsequent experiences of the hospital-to-home transition while receiving palliative care, and 2) build a substantive grounded theory to enhance the understanding of hospital-to-home transitions from the patient and caregiver perspective. METHODS Longitudinal, prospective qualitative study with semistructured interviews at hospital discharge and three to four weeks after discharge home. We recruited adults receiving inpatient palliative care who were being discharged to home-based palliative care, and their family caregivers from two academic health centers in Toronto, Canada. Thirty-nine participants: 18 patients, 7 caregivers, and 7 patient-caregiver dyads participated. We conducted 52 interviews. We conducted a grounded theory qualitative study. RESULTS Through examining the expectations and subsequent experiences of the transition, and exploring the gaps between them, we identified various transitions needs: health and well-being needs, and practical needs (i.e., transportation, setting up the home for care, care providers in the home). Several enablers and disablers modified the likelihood of needs being met (e.g., caregiver role, education on symptom management, uncertainty, financial resources). CONCLUSION Our substantive grounded theory highlighted potentially measurable constructs that can be further tested. Future interventions should target the enablers/disablers to ensure health and well-being and practical needs are met in the transition.
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Affiliation(s)
- Sarina R Isenberg
- Bruyère Research Institute, Ottawa, Canada; Department of Medicine, University of Ottawa, Ottawa, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Canada.
| | - Tieghan Killackey
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
| | - Stephanie Saunders
- Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada; University of Ottawa, School of Epidemiology and Public Health, Ottawa, Canada
| | - Natalie C Ernecoff
- Division of General Internal Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada; Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Canada
| | - Jaymie Varenbut
- Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Canada
| | - Emily Lovrics
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; Temmy Latner Centre for Palliative Care, Sinai Health System, Toronto, Canada
| | | | - Amy T Hsu
- Bruyère Research Institute, Ottawa, Canada; The Ottawa Hospital Research Institute, Ottawa, Canada; University of Ottawa, Department of Family Medicine, Ottawa, Canada
| | - Mark Bernstein
- Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada; Division of Neurosurgery, Toronto Western Hospital, Toronto, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada; Division of Palliative Medicine, Department of Medicine, University of Toronto, Toronto, Canada
| | - Kirsten Wentlandt
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada; Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Canada
| | - Ramona Mahtani
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada; Temmy Latner Centre for Palliative Care, Sinai Health, Toronto, Canada
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Featherstone I, Hosie A, Siddiqi N, Grassau P, Bush SH, Taylor J, Sheldon T, Johnson MJ. The experience of delirium in palliative care settings for patients, family, clinicians and volunteers: A qualitative systematic review and thematic synthesis. Palliat Med 2021; 35:988-1004. [PMID: 33784915 PMCID: PMC8189008 DOI: 10.1177/02692163211006313] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Delirium is common in palliative care settings and is distressing for patients, their families and clinicians. To develop effective interventions, we need first to understand current delirium care in this setting. AIM To understand patient, family, clinicians' and volunteers' experience of delirium and its care in palliative care contexts. DESIGN Qualitative systematic review and thematic synthesis (PROSPERO 2018 CRD42018102417). DATA SOURCES The following databases were searched: CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, Embase, MEDLINE and PsycINFO (2000-2020) for qualitative studies exploring experiences of delirium or its care in specialist palliative care services. Study selection and quality appraisal were independently conducted by two reviewers. RESULTS A total of 21 papers describing 16 studies were included. In quality appraisal, trustworthiness (rigour of methods used) was assessed as high (n = 5), medium (n = 8) or low (n = 3). Three major themes were identified: interpretations of delirium and their influence on care; clinicians' responses to the suffering of patients with delirium and the roles of the family in delirium care. Nursing staff and other clinicians had limited understanding of delirium as a medical condition with potentially modifiable causes. Practice focused on alleviating patient suffering through person-centred approaches, which could be challenging with delirious patients, and medication use. Treatment decisions were also influenced by the distress of family and clinicians and resource limitations. Family played vital roles in delirium care. CONCLUSIONS Increased understanding of non-pharmacological approaches to delirium prevention and management, as well as support for clinicians and families, are important to enable patients' multi-dimensional needs to be met.
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Affiliation(s)
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - Pamela Grassau
- School of Social Work, Carleton University, Ottawa, ON, Canada
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Department of Palliative Care, Bruyere Continuing Care, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Trevor Sheldon
- Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Webber C, Watt CL, Bush SH, Lawlor PG, Talarico R, Tanuseputro P. Hospitalization Outcomes of Delirium in Patients Admitted to Acute Care Hospitals in Their Last Year of Life: A Population-Based Retrospective Cohort Study. J Pain Symptom Manage 2021; 61:1118-1126.e5. [PMID: 33157179 DOI: 10.1016/j.jpainsymman.2020.10.029] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Delirium is a highly distressing neurocognitive disorder for patients at the end of life. OBJECTIVES To compare hospitalization outcomes between patients with and without delirium admitted to acute care hospitals in the last year of life. METHODS Using linked administrative data from ICES (previously known as the Institute for Clinical Evaluative Sciences), this population-based retrospective cohort study included adults who died in Ontario between January 1, 2014 and December 31, 2016 and were admitted to an acute care hospital in their last year of life. Delirium was identified via diagnosis codes on the hospitalization discharge record. Outcomes included lengths of stay, discharge location, and in-hospital mortality. We used multivariable generalized estimating equations to compare outcomes between patients with and without delirium. RESULTS Of 208,715 decedents, 9.3% experienced delirium in at least one hospitalization in the last year of life. The mean hospitalization lengths of stay was 13.8 days in patients with delirium (SD = 21.1) or 1.80 times longer (95% CI = 1.75-1.84) compared with those without delirium. Among patients discharged alive, patients with delirium were 1.32 times (95% CI = 1.27-1.38) more likely to be discharged to another institution rather than discharged home. There was no difference in in-hospital mortality between patients with and without delirium (relative risk = 1.01; 95% CI = 0.98-1.05). CONCLUSION In the last year of life, hospitalized patients with recorded delirium experience poorer outcomes, including longer lengths of stay and increased risk of postdischarge institution use, compared with those without delirium. These outcomes illustrate added burden for patients, their families, and the health care system, thus highlighting the need for delirium prevention and early detection in addition to informed transitional care decisions.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada.
| | - Christine L Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Watt CL, Scott M, Webber C, Sikora L, Bush SH, Kabir M, Boland JW, Woodhouse R, Sands MB, Lawlor PG. Delirium screening tools validated in the context of palliative care: A systematic review. Palliat Med 2021; 35:683-696. [PMID: 33588640 DOI: 10.1177/0269216321994730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 01/01/2023]
Abstract
BACKGROUND Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review. AIM To systematically review studies that validate delirium screening tools conducted in palliative care settings. DESIGN Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed. DATA SOURCES Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded. RESULTS Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias. CONCLUSIONS The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.
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Affiliation(s)
- Christine L Watt
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lindsey Sikora
- University of Ottawa, Health Sciences Library, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Rebecca Woodhouse
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Megan B Sands
- University of New South Wales Prince of Wales Clinical School, Randwick, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Webber C, Chan R, Scott M, Brown C, Spruin S, Hsu AT, Bush SH, Isenberg SR, Quinn K, Scott J, Tanuseputro P. Delivery of Palliative Care in Acute Care Hospitals: A Population-Based Retrospective Cohort Study Describing the Level of Involvement and Timing of Inpatient Palliative Care in the Last Year of Life. J Palliat Med 2020; 24:1000-1010. [PMID: 33337265 DOI: 10.1089/jpm.2020.0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/22/2022] Open
Abstract
Background: Much end-of-life care is provided in hospital, yet little is known about the delivery of palliative care during end-of-life hospitalizations. Objectives: To characterize the level of palliative care involvement across hospitalizations in the last year of life. Methods: A population-based retrospective cohort study of adults in Ontario, Canada, who died between April 1, 2012, and March 31, 2017, and had at least one acute care hospitalization in their last year of life. Using linked administrative health data, we developed a hierarchy of inpatient palliative care involvement reflecting the degree to which care was delivered with palliative intent. This hierarchy was based on palliative care diagnosis and service provider codes on hospitalization records and physician claims. We examined variations in the level of palliative care involvement across key patient characteristics. Results: In the last year of life, 65.1% of hospitalizations had no indication of palliative care involvement, 16.7% had a low level of involvement, 13.5% had a medium level of involvement, and 4.7% had a high level of involvement. Most hospitalizations with palliative care involvement (85.6%) occurred in the two months before death. Compared to patients who received no inpatient palliative care, patients who received a high level of palliative care involvement tended to be younger, died of cancer, resided in urban or lower income neighborhoods, and had fewer chronic conditions. Discussion: While many hospitalizations occurred in the last year of life, the majority did not involve palliative care, and very few had a high level of palliative care involvement.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Raphael Chan
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Mary Scott
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Catherine Brown
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah Spruin
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,ICES, Ottawa, Ontario, Canada
| | - Amy T Hsu
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarina R Isenberg
- Temmy Latner Centre for Palliative Care and Lunenfeld Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada.,Department of Family and Community Medicine and University of Toronto, Toronto, Ontario, Canada
| | - Kieran Quinn
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Scott
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
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Wang C, Grassau P, Lawlor PG, Webber C, Bush SH, Gagnon B, Kabir M, Spilg EG. Burnout and resilience among Canadian palliative care physicians. BMC Palliat Care 2020; 19:169. [PMID: 33158428 PMCID: PMC7648393 DOI: 10.1186/s12904-020-00677-z] [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] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/27/2020] [Indexed: 11/23/2022] Open
Abstract
Background Physicians experience high rates of burnout, which may negatively impact patient care. Palliative care is an emotionally demanding specialty with high burnout rates reported in previous studies from other countries. We aimed to estimate the prevalence of burnout and degree of resilience among Canadian palliative care physicians and examine their associations with demographic and workplace factors in a national survey. Methods Physician members of the Canadian Society of Palliative Care Physicians and Société Québécoise des Médecins de Soins Palliatifs were invited to participate in an electronic survey about their demographic and practice arrangements and complete the Maslach Burnout Inventory for Medical Professionals (MBI-HSS (MP)), and Connor-Davidson Resilience Scale (CD-RISC). The association of categorical demographic and practice variables was examined in relation to burnout status, as defined by MBI-HSS (MP) score. In addition to bivariable analyses, a multivariable logistic regression analysis, reporting odds ratios (OR), was conducted. Mean CD-RISC score differences were examined in multivariable linear regression analysis. Results One hundred sixty five members (29%) completed the survey. On the MBI-HSS (MP), 36.4% of respondents reported high emotional exhaustion (EE), 15.1% reported high depersonalization (DP), and 7.9% reported low personal accomplishment (PA). Overall, 38.2% of respondents reported a high degree of burnout, based on having high EE or high DP. Median CD-RISC resilience score was 74, which falls in the 25th percentile of normative population. Age over 60 (OR = 0.05; CI, 0.01–0.38), compared to age ≤ 40, was independently associated with lower burnout. Mean CD-RISC resilience scores were lower in association with the presence of high burnout than when burnout was low (67.5 ± 11.8 vs 77.4 ± 11.2, respectively, p < 0.0001). Increased mean CD-RISC score differences (higher resilience) of 7.77 (95% CI, 1.97–13.57), 5.54 (CI, 0.81–10.28), and 8.26 (CI, 1.96–14.57) occurred in association with age > 60 as compared to ≤40, a predominantly palliative care focussed practice, and > 60 h worked per week as compared to ≤40 h worked, respectively. Conclusions One in three Canadian palliative care physicians demonstrate a high degree of burnout. Burnout prevention may benefit from increasing resilience skills on an individual level while also implementing systematic workplace interventions across organizational levels. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-020-00677-z.
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Affiliation(s)
- Cindy Wang
- Department of Medicine, Division of Palliative Care, University of Ottawa, 43 Bruyère St., Ottawa, ON, K1N 5C8, Canada
| | - Pamela Grassau
- School of Social Work, Carleton University, 1125 Colonel By Dr., Ottawa, ON, K1S 5B6, Canada
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, Bruyère Research Institute, and Ottawa Hospital Research Institute, University of Ottawa, 43 Bruyère St., Ottawa, ON, K1N 5C8, Canada
| | - Colleen Webber
- Ottawa Hospital Research Institute and Bruyère Research Institute, 43 Bruyère St., Ottawa, ON, K1N 5C8, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, Bruyère Research Institute, and Ottawa Hospital Research Institute, University of Ottawa, 43 Bruyère St., Ottawa, ON, K1N 5C8, Canada
| | - Bruno Gagnon
- Palliative Care, Department of Family Medicine and Emergency Medicine, Cancer Research Centre, Laval University, 6, rue McMahon 1899-6, Québec, Québec, G1R 2J6, Canada
| | - Monisha Kabir
- Bruyère Research Institute, 43 Bruyère St., Ottawa, ON, K1N 5C8, Canada
| | - Edward G Spilg
- Department of Medicine, Division of Geriatric Medicine, University of Ottawa and Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
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Lawlor PG, McNamara-Kilian MT, MacDonald AR, Momoli F, Tierney S, Lacaze-Masmonteil N, Dasgupta M, Agar M, Pereira JL, Currow DC, Bush SH. Melatonin to prevent delirium in patients with advanced cancer: a double blind, parallel, randomized, controlled, feasibility trial. Palliat Care 2020; 19:163. [PMID: 33087111 PMCID: PMC7579814 DOI: 10.1186/s12904-020-00669-z] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delirium is highly problematic in palliative care (PC). Preliminary data indicate a potential role for melatonin to prevent delirium, but no randomized controlled trials (RCTs) are reported in PC. METHODS Patients aged ≥18 years, with advanced cancer, admitted to an inpatient Palliative Care Unit (PCU), having a Palliative Performance Scale rating ≥ 30%, and for whom consent was obtained, were included in the study. Patients with delirium on admission were excluded. The main study objectives were to assess the feasibility issues of conducting a double-blind RCT of exogenous melatonin to prevent delirium in PC: recruitment, retention, procedural acceptability, appropriateness of outcome measures, and preliminary efficacy and safety data. Study participants were randomized in a double-blind, parallel designed study to receive daily melatonin 3 mg or placebo orally at 21:00 over 28 days or less if incident delirium, death, discharge or withdrawal occurred earlier. Delirium was diagnosed using the Confusion Assessment Method. Efficacy endpoints in the melatonin and placebo groups were compared using time-to-event analysis: days from study entry to onset of incident delirium. RESULTS Over 16 months, 60/616 (9.7%; 95% CI: 7.5-12.4%) screened subjects were enrolled. The respective melatonin (n = 30) vs placebo (n = 30) outcomes were: incident delirium in 11/30 (36.7%; 95%CI: 19.9-56.1%) vs 10/30 (33%; 95% CI: 17.3-52.8%); early discharge (6 vs 5); withdrawal (6 vs 3); death (0 vs 1); and 7 (23%) vs 11 (37%) reached the 28-day end point. The 25th percentile time-to-event were 9 and 18 days (log rank, χ2 = 0.62, p = 0.43) in melatonin and placebo groups, respectively. No serious trial medication-related adverse effects occurred and the core study procedures were acceptable. Compared to those who remained delirium-free during their study participation, those who developed delirium (n = 21) had poorer functional (p = 0.036) and cognitive performance (p = 0.013), and in particular, poorer attentional capacity (p = 0.003) at study entry. CONCLUSIONS A larger double-blind RCT is feasible, but both subject accrual and withdrawal rates signal a need for multisite collaboration. The apparent trend for shorter time to incident delirium in the melatonin group bodes for careful monitoring in a larger trial. TRIAL REGISTRATION Registered on July 21st 2014 with ClinicalTrials.gov : NCT02200172 .
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Affiliation(s)
- Peter G. Lawlor
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | | | - Franco Momoli
- grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, London, Canada
| | - Sallyanne Tierney
- grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | - Monidipa Dasgupta
- grid.39381.300000 0004 1936 8884Department of Geriatric Medicine, Department of Medicine, University of Western Ontario, London, Canada
| | - Meera Agar
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Jose L. Pereira
- grid.25073.330000 0004 1936 8227Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Canada
| | - David C. Currow
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Shirley H. Bush
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
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Webber C, Watt CL, Bush SH, Lawlor PG, Talarico R, Tanuseputro P. The occurrence and timing of delirium in acute care hospitalizations in the last year of life: A population-based retrospective cohort study. Palliat Med 2020; 34:1067-1077. [PMID: 32515283 DOI: 10.1177/0269216320929545] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 12/25/2022]
Abstract
BACKGROUND Delirium is a distressing neurocognitive disorder that is common among terminally ill individuals, although few studies have described its occurrence in the acute care setting among this population. AIM To describe the prevalence of delirium in patients admitted to acute care hospitals in Ontario, Canada, in their last year of life and identify factors associated with delirium. DESIGN Population-based retrospective cohort study using linked health administrative data. Delirium was identified through diagnosis codes on hospitalization records. SETTING/PARTICIPANTS Ontario decedents (1 January 2014 to 31 December 2016) admitted to an acute care hospital in their last year of life, excluding individuals age of <18 years or >105 years at admission, those not eligible for the provincial health insurance plan between their hospitalization and death dates, and non-Ontario residents. RESULTS Delirium was recorded as a diagnosis in 8.2% of hospitalizations. The frequency of delirium-related hospitalizations increased as death approached. Delirium prevalence was higher in patients with dementia (prevalence ratio: 1.43; 95% confidence interval: 1.36-1.50), frailty (prevalence ratio: 1.67; 95% confidence interval: 1.56-1.80), or organ failure-related cause of death (prevalence ratio: 1.23; 95% confidence interval: 1.16-1.31) and an opioid prescription (prevalence ratio: 1.17; 95% confidence interval: 1.12-1.21). Prevalence also varied by age, sex, chronic conditions, antipsychotic use, receipt of long-term care or home care, and hospitalization characteristics. CONCLUSION This study described the occurrence and timing of delirium in acute care hospitals in the last year of life and identified factors associated with delirium. These findings can be used to support delirium prevention and early detection in the hospital setting.
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Affiliation(s)
- Colleen Webber
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,ICES uOttawa, Ottawa, ON, Canada
| | - Christine L Watt
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H Bush
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter G Lawlor
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | | | - Peter Tanuseputro
- The Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,ICES uOttawa, Ottawa, ON, Canada.,Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
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Kabir M, Rice JL, Bush SH, Lawlor PG, Webber C, Grassau PA, Ghaedi B, Dhuper M, Hackbusch R. A mixed-methods pilot study of 'LIFEView' audiovisual technology: Virtual travel to support well-being and quality of life in palliative and end-of-life care patients. Palliat Med 2020; 34:954-965. [PMID: 32383629 PMCID: PMC7336530 DOI: 10.1177/0269216320918514] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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 There is evidence that psychosocial and spiritual interventions of short duration, such as reminiscence therapy, provide positive impacts on quality of life and emotional and existential well-being in adults receiving palliative care. AIM To determine (1) the feasibility of integrating 'LIFEView', a video-based software with >1600 videos of world destinations, in palliative care settings, and (2) positive, neutral or harmful effects of using 'LIFEView' videos. DESIGN A mixed-methods pre-post intervention pilot study was conducted to collect feasibility and preliminary data on physical and psychological symptoms, physiological indicators, spiritual well-being and aspects of quality of life. SETTING/PARTICIPANTS Adult patients on an inpatient palliative care unit or receiving care from a community palliative care consultation team who were capable of providing consent and completing the outcome measures were eligible participants. RESULTS Overall, 27/41 (66%) participants took part in the study. Feasibility criteria, including participant acceptability, low participant burden, tool completion rate and retention rate, were fulfilled, though challenges were experienced with recruitment. Modest improvements, though non-significant, were shown on preliminary data collected on physical and psychological symptoms using the Edmonton Symptom Assessment System-revised, spiritual well-being assessed by the 12-item Functional Assessment of Chronic Illness Therapy - Spiritual Well-Being scale and physiological measurements. Qualitative analysis revealed five themes: motivations for using 'LIFEView', perceptions of the technology, reminiscence, 'LIFEView' as an adaptable technology and ongoing or future use. CONCLUSION A future adequately powered study to investigate the impacts of 'LIFEView' on patient well-being and quality of life appears to be feasible.
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Affiliation(s)
- Monisha Kabir
- Bruyère Research Institute, Ottawa, ON, Canada.,Telfer School of Management, University of Ottawa, Ottawa, ON, Canada
| | - Jill L Rice
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada
| | - Shirley H Bush
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada
| | - Peter G Lawlor
- Bruyère Research Institute, Ottawa, ON, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Continuing Care, Ottawa, ON, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Pamela A Grassau
- Bruyère Research Institute, Ottawa, ON, Canada.,School of Social Work, Carleton University, Ottawa, ON, Canada
| | - Bahareh Ghaedi
- Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Abstract
Delirium is a prevalent acute neurocognitive condition in patients with progressive life-limiting illness. Delirium remains underdetected; a systematic approach to screening is essential. Delirium at the end of life requires a comprehensive assessment. Consider the potential for reversibility, illness trajectory, patient preference, and goals of care before proceeding with investigations and interventions. Management should be interdisciplinary, and nonpharmacologic therapy is fundamental. For patients with refractory and severe agitation or perceptual disturbance, judicious use of medication may also be required. Carers and family should be seen as partners in care and be involved in shared decision making about care.
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Affiliation(s)
- Meera Agar
- IMPACCT (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation) Faculty of Health, University of Technology Sydney, Building 10, Level 3, 235 Jones Street, Ultimo, New South Wales 2007, Australia.
| | - Shirley H Bush
- The Ottawa Hospital, General Campus, 501 Smyth Road, Box 206, Ottawa, ON K1H 8L6, Canada; Bruyère Research Institute, 85 Primrose Ave, Ottawa, ON K1R 6M1, Canada; Ottawa Hospital Research Institute, 053 Carling Ave, Ottawa, ON K1Y 4E9, Canada; Palliative Care, Bruyère Continuing Care, The Ottawa Hospital, 43, Bruyère Street, Ottawa, Ontario K1N 5C8, Canada
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Hagarty AM, Bush SH, Talarico R, Lapenskie J, Tanuseputro P. Severe pain at the end of life: a population-level observational study. BMC Palliat Care 2020; 19:60. [PMID: 32354364 PMCID: PMC7193354 DOI: 10.1186/s12904-020-00569-2] [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] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pain is a prevalent symptom at the end of life and negatively impacts quality of life. Despite this, little population level data exist that describe pain frequency and associated factors at the end of life. The purpose of this study was to explore the prevalence of clinically significant pain at the end of life and identify predictors of increased pain. METHODS Retrospective population-level cohort study of all decedents in Ontario, Canada, from April 1, 2011 to March 31, 2015 who received a home care assessment in the last 30 days of life (n = 20,349). Severe daily pain in the last 30 days of life using linked Ontario health administrative databases. Severe pain is defined using a validated pain scale combining pain frequency and intensity: daily pain of severe intensity. RESULTS Severe daily pain was reported in 17.2% of 20,349 decedents. Increased risk of severe daily pain was observed in decedents who were female, younger and functionally impaired. Those who were cognitively impaired had a lower risk of reporting pain. Disease trajectory impacted pain; those who died of a terminal illness (i.e. cancer) were more likely to experience pain than those with frailty (odds ratio 1.66). CONCLUSION Pain is a common fear of those contemplating end of life, but severe pain is reported in less than 1 in 5 of our population in the last month of life. Certain subpopulations may be more likely to report severe pain at the end of life and may benefit from earlier palliative care referral and intervention.
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Affiliation(s)
- A Meaghen Hagarty
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada
| | - Robert Talarico
- Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada.,ICES, Population Health and Primary Care, Ottawa, Ontario, Canada
| | - Julie Lapenskie
- Bruyère Research Institute, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada
| | - Peter Tanuseputro
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada. .,Bruyère Research Institute, Ottawa, Ontario, Canada. .,Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y4E9, Canada. .,ICES, Population Health and Primary Care, Ottawa, Ontario, Canada.
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Hosie A, Phillips J, Lam L, Kochovska S, Noble B, Brassil M, Kurrle S, Cumming A, Caplan GA, Chye R, Ely EW, Lawlor PG, Bush SH, Davis JM, Lovell M, Parr C, Williams S, Hauser K, McArdle S, Jacquier K, Phillipson C, Kuwahata L, Kerfoot J, Brown L, Fazekas B, Cheah SL, Edwards L, Green A, Hunt J, Attwood R, Assen T, Garcia M, Wilcock J, Agar M. A Multicomponent Nonpharmacological Intervention to Prevent Delirium for Hospitalized People with Advanced Cancer: A Phase II Cluster Randomized Waitlist Controlled Trial (The PRESERVE Pilot Study). J Palliat Med 2020; 23:1314-1322. [PMID: 32343634 DOI: 10.1089/jpm.2019.0632] [Citation(s) in RCA: 16] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Delirium is a common debilitating complication of advanced cancer. Objective: To determine if a multicomponent nonpharmacological delirium prevention intervention was feasible for adult patients with advanced cancer, before a phase III (efficacy) trial. Design: Phase II (feasibility) cluster randomized controlled trial. All sites implemented delirium screening and diagnostic assessment. Strategies within sleep, vision and hearing, hydration, orientation, mobility, and family domains were delivered to enrolled patients at intervention site admission days 1-7. Control sites then implemented the intervention ("waitlist sites"). Setting: Four Australian palliative care units. Measurements: The primary outcome was adherence, with an a priori endpoint of at least 60% patients achieving full adherence. Secondary outcomes were interdisciplinary care delivery, delirium measures, and adverse events, analyzed descriptively and inferentially. Results: Sixty-five enrolled patients (25 control, 20 intervention, and 20 waitlist) had 98% delirium screens and 75% diagnostic assessments completed. Nurses (67%), physicians (16%), allied health (8.4%), family (7%), patients (1%), and volunteers (0.5%) delivered the intervention. There was full adherence for 5% patients at intervention sites, partial for 25%. Both full and partial adherence were higher at waitlist sites: 25% and 45%, respectively. One-third of control site patients (32%) became delirious within seven days of admission compared to one-fifth (20%) at both intervention and waitlist sites (p = 0.5). Mean (standard deviation) Delirium Rating Scale-Revised-1998 scores were 16.8 + 12.0 control sites versus 18.4 + 8.2 (p = 0.6) intervention and 18.7 + 7.8 (p = 0.5) waitlist sites. The intervention caused no adverse events. Conclusion: The intervention requires modification for optimal adherence in a phase III trial.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia.,St. Vincent's Health Network Sydney, Darlinghurst, New South Wales, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jane Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Lawrence Lam
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Beverly Noble
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Meg Brassil
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Susan Kurrle
- Northern Clinical School, Hornsby Ku-ring-gai Health Service, University of Sydney, Hornsby, New South Wales, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Gideon A Caplan
- Prince of Wales Hospital, Geriatric Medicine, Randwick, New South Wales, Australia.,UNSW Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Richard Chye
- St. Vincent's Health Network Sydney, Darlinghurst, New South Wales, Australia.,UNSW Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University, Nashville, Tennessee, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jan Maree Davis
- Department of Palliative Care, Calvary Health Care Kogarah, Kogarah, New South Wales, Australia
| | - Melanie Lovell
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Cynthia Parr
- HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Sally Williams
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Katherine Hauser
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Susan McArdle
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Karen Jacquier
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Carl Phillipson
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | | | | | - Linda Brown
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Seong Leang Cheah
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Layla Edwards
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Anna Green
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jane Hunt
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Robyn Attwood
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Teresa Assen
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Maja Garcia
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Julie Wilcock
- Ingham Institute, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Meera Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Ingham Institute, Liverpool Hospital, Liverpool, New South Wales, Australia
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Bush SH, Gratton V, Kabir M, Enright P, Grassau PA, Rice J, Hall P. Building a Medical Undergraduate Palliative Care Curriculum: Lessons Learned. J Palliat Care 2020; 36:29-37. [PMID: 32284024 DOI: 10.1177/0825859720916565] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Previous literature demonstrates that current palliative care training is in need of improvement for medical students in global, European and Canadian contexts. The training of medical undergraduates is key to ensure that the ongoing and increasing need for enhanced access to palliative care across all settings and communities is met. We describe building a comprehensive palliative and end-of-life care curriculum for medical undergraduates at our university. As with recent European and US studies, we found that the process of university curriculum renewal provided a critical opportunity to integrate palliative care content, but needed a local palliative care champion already in place as an energetic and tireless advocate. The development and integration of a substantive bilingual (English and French) palliative and end-of-life care curriculum over the 4-year medical undergraduate program at our university has occurred over the course of 14 years, and required multiple steps and initiatives. Subsequent to the development of the curriculum, there has been a 13-fold increase in students selecting our palliative care clinical rotations. Critical lessons learned speak to the importance of having a team vision, interprofessional collaboration with a focus on vision, plans and implementation, and flexibility to actively respond and further integrate new educational opportunities within the curriculum. Future directions for our palliative care curriculum include shifting to a competency-based training and evaluation paradigm. Our findings and lessons learned may help others who are working to develop a comprehensive undergraduate medical education curriculum.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Canada.,152971Bruyère Research Institute, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Continuing Care, Ottawa, Canada
| | - Valérie Gratton
- Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Canada.,Institut du Savoir Montfort, Ottawa, Canada.,Hôpital Montfort, Ottawa, Canada
| | | | - Paula Enright
- Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Canada
| | - Pamela A Grassau
- Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Canada.,152971Bruyère Research Institute, Ottawa, Canada.,School of Social Work, Carleton University, Ottawa, Canada
| | - Jill Rice
- Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Canada.,152971Bruyère Research Institute, Ottawa, Canada.,Ottawa Hospital Research Institute, Ottawa, Canada.,Bruyère Continuing Care, Ottawa, Canada
| | - Pippa Hall
- Division of Palliative Care, Department of Medicine, 6363University of Ottawa, Ottawa, Canada
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Barnes CJ, Webber C, Bush SH, McNamara-Kilian M, Brodeur J, Marchington K, Sabri E, Lawlor PG. Rating Delirium Severity Using the Nursing Delirium Screening Scale: A Validation Study in Patients in Palliative Care. J Pain Symptom Manage 2019; 58:e4-e7. [PMID: 31283968 DOI: 10.1016/j.jpainsymman.2019.06.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 06/28/2019] [Indexed: 02/05/2023]
Affiliation(s)
- Christopher J Barnes
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada.
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada; Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Jennifer Brodeur
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada
| | - Katie Marchington
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Canada; Department of Psychosocial Oncology and Palliative Care, University Health Network, Toronto, Canada
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Peter G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Canada; Palliative Care, Bruyère Continuing Care, Ottawa, Canada; Bruyère Research Institute, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
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Bush SH, Roze des Ordons A, Chary S, Boyle AB. The Development and Validation of Updated Palliative and End-of-Life Care Competencies for Medical Undergraduates in Canada. J Palliat Med 2019; 22:1498-1500. [PMID: 31486699 DOI: 10.1089/jpm.2019.0160] [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: 11/13/2022] Open
Abstract
In 2008, a Canadian strategy called the "Educating Future Physicians in Palliative and End-of-Life Care" (EFPPEC) project published national medical undergraduate competencies for palliative and end-of-life care. Since that time, there have been several changes in the practice environment. To formally incorporate these changes and also update the competencies for EFPPEC, an EFPPEC update project team was established in 2017. The EFPPEC update document in English was finalized in June 2018, and subsequent minor amendments to the French version were completed in January 2019. This report describes the process and also shares the new updated EFPPEC competencies with the wider palliative care community.
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Affiliation(s)
- Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Amanda Roze des Ordons
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Anesthesiology, University of Calgary, Calgary, Alberta, Canada
| | - Srini Chary
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Division of Palliative Medicine, Department of Oncology, University of Calgary, Calgary, Alberta, Canada.,Pallium Canada, Ottawa, Ontario, Canada
| | - Anne B Boyle
- Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Ontario, Canada
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Hosie A, Siddiqi N, Featherstone I, Johnson M, Lawlor PG, Bush SH, Amgarth-Duff I, Edwards L, Cheah SL, Phillips J, Agar M. Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review. Palliat Med 2019; 33:878-899. [PMID: 31250725 DOI: 10.1177/0269216319853487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 12/25/2022]
Abstract
BACKGROUND Delirium is common, distressing, serious and under-researched in specialist palliative care settings. OBJECTIVES To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. DESIGN Systematic review (PROSPERO 2017 CRD42017062178). DATA SOURCES Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. RESULTS The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall. CONCLUSION Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.
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Affiliation(s)
- Annmarie Hosie
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | | | | | - Peter G Lawlor
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Layla Edwards
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Jane Phillips
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meera Agar
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
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Watt CL, Momoli F, Ansari MT, Sikora L, Bush SH, Hosie A, Kabir M, Rosenberg E, Kanji S, Lawlor PG. The incidence and prevalence of delirium across palliative care settings: A systematic review. Palliat Med 2019; 33:865-877. [PMID: 31184538 PMCID: PMC6691600 DOI: 10.1177/0269216319854944] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [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: 12/24/2022]
Abstract
BACKGROUND Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed. AIM Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings. DESIGN This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment. DATA SOURCES Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included. RESULTS Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used. CONCLUSION Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
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Affiliation(s)
- Christine L Watt
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada
| | - Franco Momoli
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,4 Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mohammed T Ansari
- 5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- 6 Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H Bush
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Annmarie Hosie
- 8 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Erin Rosenberg
- 9 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,10 Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
| | - Salmaan Kanji
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,11 Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada.,12 Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter G Lawlor
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
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Boland JW, Lawlor PG, Bush SH. Delirium: non-pharmacological and pharmacological management. BMJ Support Palliat Care 2019; 9:482-484. [PMID: 31366592 DOI: 10.1136/bmjspcare-2019-001966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/17/2019] [Indexed: 11/03/2022]
Affiliation(s)
- Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK .,Care Plus Group and St Andrew's Hospice, North East Lincolnshire, UK
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Continuing Care, Ottowa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Bruyère Research Institute and Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Bruyère Continuing Care, Ottowa, Ontario, Canada
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Boland JW, Kabir M, Bush SH, Spiller JA, Johnson MJ, Agar M, Lawlor P. Delirium management by palliative medicine specialists: a survey from the association for palliative medicine of Great Britain and Ireland. BMJ Support Palliat Care 2019; 12:73-80. [PMID: 30837278 DOI: 10.1136/bmjspcare-2018-001586] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [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: 06/11/2018] [Revised: 11/21/2018] [Accepted: 02/11/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Delirium is common in palliative care settings. Management includes detection, treatment of cause(s), non-pharmacological interventions and family support; strategies which are supported with varying levels of evidence. Emerging evidence suggests that antipsychotic use should be minimised in managing mild to moderate severity delirium, but the integration of this evidence into clinical practice is unknown. METHODS A 21-question online anonymous survey was emailed to Association for Palliative Medicine members in current clinical practice (n=859), asking about delirium assessment, management and research priorities. RESULTS Response rate was 39%: 70% of respondents were palliative medicine consultants. Delirium guidelines were used by some: 42% used local guidelines but 38% used none. On inpatient admission, 59% never use a delirium screening tool. Respondents would use non-pharmacological interventions to manage delirium, either alone (39%) or with an antipsychotic (58%). Most respondents (91%) would prescribe an antipsychotic and 6% a benzodiazepine, for distressing hallucinations unresponsive to non-pharmacological measures. Inpatient (57%) and community teams (60%) do not formally support family carers. Research priorities were delirium prevention, management and prediction of reversibility. CONCLUSION This survey of UK and Irish Palliative Medicine specialists shows that delirium screening at inpatient admission is suboptimal. Most specialists continue to use antipsychotics in combination with non-pharmacological interventions to manage delirium. More support for family carers should be routinely provided by clinical teams. Further rigorously designed clinical trials are urgently needed in view of management variability, emerging evidence and perceived priorities for research.
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Affiliation(s)
- Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Monisha Kabir
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Continuing Care, Ottawa, Ontario, Canada
| | - Juliet Anne Spiller
- Palliative Medicine, Marie Curie Hospice, Edinburgh, UK.,IMPACCT (Improving Palliative, Chronic and Aged Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Meera Agar
- IMPACCT (Improving Palliative, Chronic and Aged Care through Clinical Research and Translation), Faculty of Health, University of Technology, Sydney, Australia
| | - Peter Lawlor
- Division of Palliative Care, Bruyère Research Institute; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Continuing Care, Ottawa, Ontario, Canada
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Lawlor PG, Rutkowski NA, MacDonald AR, Ansari MT, Sikora L, Momoli F, Kanji S, Wright DK, Rosenberg E, Hosie A, Pereira JL, Meagher D, Rice J, Scott J, Bush SH. A Scoping Review to Map Empirical Evidence Regarding Key Domains and Questions in the Clinical Pathway of Delirium in Palliative Care. J Pain Symptom Manage 2019; 57:661-681.e12. [PMID: 30550832 DOI: 10.1016/j.jpainsymman.2018.12.002] [Citation(s) in RCA: 19] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/03/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
CONTEXT Based on the clinical care pathway of delirium in palliative care (PC), a published analytic framework (AF) formulated research questions in key domains and recommended a scoping review to identify evidence gaps. OBJECTIVES To produce a literature map for key domains of the published AF: screening, prognosis and diagnosis, management, and the health-related outcomes. METHODS A standard scoping review framework was used by an interdisciplinary study team of nurse- and physician-delirium researchers, an information specialist, and review methodologists to conduct the review. Knowledge user engagement provided context in refining 19 AF questions. A peer-reviewed search strategy identified citations in Medline, PsycINFO, Embase, and CINAHL databases between 1980 and 2018. Two reviewers independently screened records for inclusion using explicit study eligibility criteria for the population, design, delirium diagnosis, and investigational intent. RESULTS Of 104 studies reporting empirical data and meeting eligibility criteria, most were conducted in patients with cancer (73.1%) and in inpatient PC units (52%). The most frequent study design was a one or more group, nonrandomized trial or cohort (67.3%). Evidence gaps were identified: delirium risk prediction; comparative effectiveness and harms of prevention, variability in delirium management across PC settings, advanced directive and substitute decision-maker input, and transition of care location; and estimating delirium reversibility. Future rigorous primary studies are required to address these gaps and preliminary concerns regarding the quality of extant literature. CONCLUSION Substantial evidence gaps exist, providing opportunities for future research regarding the assessment, prognosis, and management of delirium in PC settings.
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Affiliation(s)
- Peter G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | | | | | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
| | - Franco Momoli
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - David K Wright
- School of Nursing, Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Erin Rosenberg
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; The Ottawa Hospital, Department of Critical Care, Ottawa, Ontario, Canada
| | - Annmarie Hosie
- University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jose L Pereira
- Department of Family Medicine, University of Ottawa, Ontario, Canada; Division of Palliative Medicine, McMaster University, Ontario, Canada
| | - David Meagher
- University of Limerick School of Medicine, Limerick, Ireland
| | - Jill Rice
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Scott
- The Ottawa Hospital, Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyère Continuing Care, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
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Hosie A, Phillips J, Lam L, Kochovska S, Noble B, Brassil M, Kurrle SE, Cumming A, Caplan GA, Chye R, Le B, Ely EW, Lawlor PG, Bush SH, Davis JM, Lovell M, Brown L, Fazekas B, Cheah SL, Edwards L, Agar M. Multicomponent non-pharmacological intervention to prevent delirium for hospitalised people with advanced cancer: study protocol for a phase II cluster randomised controlled trial. BMJ Open 2019; 9:e026177. [PMID: 30696686 PMCID: PMC6352777 DOI: 10.1136/bmjopen-2018-026177] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Delirium is a significant medical complication for hospitalised patients. Up to one-third of delirium episodes are preventable in older inpatients through non-pharmacological strategies that support essential human needs, such as physical and cognitive activity, sleep, hydration, vision and hearing. We hypothesised that a multicomponent intervention similarly may decrease delirium incidence, and/or its duration and severity, in inpatients with advanced cancer. Prior to a phase III trial, we aimed to determine if a multicomponent non-pharmacological delirium prevention intervention is feasible and acceptable for this specific inpatient group. METHODS AND ANALYSIS The study is a phase II cluster randomised wait-listed controlled trial involving inpatients with advanced cancer at four Australian palliative care inpatient units. Intervention sites will introduce delirium screening, diagnostic assessment and a multicomponent delirium prevention intervention with six domains of care: preserving natural sleep; maintaining optimal vision and hearing; optimising hydration; promoting communication, orientation and cognition; optimising mobility; and promoting family partnership. Interdisciplinary teams will tailor intervention delivery to each site and to patient need. Control sites will first introduce only delirium screening and diagnosis, later implementing the intervention, modified according to initial results. The primary outcome is adherence to the intervention during the first seven days of admission, measured for 40 consecutively admitted eligible patients. Secondary outcomes relate to fidelity and feasibility, acceptability and sustainability of the study intervention, processes and measures in this patient population, using quantitative and qualitative measures. Delirium incidence and severity will be measured to inform power calculations for a future phase III trial. ETHICS AND DISSEMINATION Ethical approval was obtained for all four sites. Trial results, qualitative substudy findings and implementation of the intervention will be submitted for publication in peer-reviewed journals, and reported at conferences, to study sites and key peak bodies. TRIAL REGISTRATION NUMBER ACTRN12617001070325; Pre-results.
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Affiliation(s)
- Annmarie Hosie
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Lawrence Lam
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Beverly Noble
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meg Brassil
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Susan E Kurrle
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Healthcare, Sydney, New South Wales, Australia
| | - Gideon A Caplan
- Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
- University of New South Wales, Randwick, New South Wales, Australia
| | - Richard Chye
- Sacred Heart Health Service, St. Vincent’s Hospital, Darlinghurst, New South Wales, Australia
| | - Brian Le
- Palliative and Supportive Services, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - E Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center at Vanderbilt University, and the Tennessee Valley Veteran’s Affairs Geriatric Research Education Clinical Center (GRECC), Nashville TN USA, Nashville, Tennessee, USA
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Jan Maree Davis
- Palliative Care, Calvary Health Care Kogarah, Sydney, New South Wales, Australia
| | - Melanie Lovell
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
- Hornsby Ku-ring-gai Health Service, Northern Clinical School, University of Sydney, Hornsby, New South Wales, Australia
- HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Linda Brown
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Seong Leang Cheah
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Layla Edwards
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Meera Agar
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, University of Technology Sydney, Sydney, New South Wales, Australia
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Bush SH, Lawlor PG, Ryan K, Centeno C, Lucchesi M, Kanji S, Siddiqi N, Morandi A, Davis DHJ, Laurent M, Schofield N, Barallat E, Ripamonti CI. Delirium in adult cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2018; 29:iv143-iv165. [PMID: 29992308 DOI: 10.1093/annonc/mdy147] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Affiliation(s)
- S H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - P G Lawlor
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa
- Ottawa Hospital Research Institute, Ottawa
- Bruyère Research Institute, Ottawa
- Bruyère Continuing Care, Ottawa, Canada
| | - K Ryan
- Department of Palliative Medicine, Mater Misericordiae University Hospital, Dublin
- St Francis Hospice, Dublin
- School of Medicine, University College, Dublin, Ireland
| | - C Centeno
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona
- Palliative Medicine Group, Oncology Area, Navarra Institute for Health Research IdiSNA, Pamplona
- ATLANTES Research Program, Institute for Culture and Society (ICS), University of Navarra, Pamplona, Spain
| | - M Lucchesi
- Division of Thoracic Oncology, Cardio-Thoracic Department, University Hospital of Pisa, Pisa, Italy
| | - S Kanji
- Ottawa Hospital Research Institute, Ottawa
- Department of Pharmacy, The Ottawa Hospital, Ottawa, Canada
| | - N Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - A Morandi
- Department of Rehabilitation, Aged Care Unit, Ancelle Hospital, Cremona, Italy
| | - D H J Davis
- MRC Unit for Lifelong Health and Ageing at University College London, London, UK
| | - M Laurent
- Internal Medicine and Geriatric Department, APHP, Henri-Mondor Hospital, Créteil
- University Paris Est (UPE), UPEC A-TVB DHU, CEpiA (Clinical Epidemiology and Aging) Unit EA 7376, Créteil, France
| | | | - E Barallat
- Faculty of Nursing, Department of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
| | - C I Ripamonti
- Department of Onco-Haematology Fondazione IRCCS, Istituto Nazionale dei Tumori, Milano, Italy
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Featherstone I, Johnson M, Jones L, Coppo E, Hosie A, Bush SH, Siddiqi N, Taylor J, Teodorczuk A. 16 Delirium care of hospice patients: a qualitative interview study with staff and volunteers. BMJ Support Palliat Care 2018. [DOI: 10.1136/bmjspcare-2018-mariecurie.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
IntroductionDelirium is a distressing condition which is commonly experienced by hospice patients. Although delirium can be prevented by around one-third in hospital inpatients (Siddiqi et al. 2016) there has been little research into effective strategies to prevent and manage delirium in hospices. Greater insight into the current practice attitudes and understanding of hospice staff and volunteers would inform the development of interventions that are tailored to improve delirium care in hospices.AimTo explore the understanding attitudes and practice of hospice staff and volunteers regarding the care of patients with delirium.Methods36 qualitative semi-structured interviews were conducted at two hospices. Participants were purposively sampled to include different disciplines (9 health care assistants, 8 nurses, 5 doctors, 4 volunteers, 3 board members, 2 allied health professionals, 2 managers, 2 domestic workers and 2 fundraisers). A topic guide and case vignettes prompted participants to describe their experiences in relation to delirium prevention recognition assessment and management. Three researchers are conducting thematic analysis to identify analyse and interpret themes from the interview data.ResultsProvisional results include themes of: ‘Supporting the distressing experience of delirium’; ‘Management strategies’ and ‘The burden of delirium care.’ Gaps in current practice relate to delirium prevention recognition and screening. Potential facilitators for developing interventions in hospices include education flexibility in staffing the role of volunteers and a supportive staff culture.ConclusionThis study will provide important insights into staff and volunteers’ current practice which will inform the development of a targeted intervention to improve delirium care in hospices.Reference. Siddiqi N, Harrison J, Clegg A, Teale E, Young J, Taylor J, Simpkins S. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews2016;(3). Art. No.: CD005563. doi:10.1002/14651858.CD005563.pub3
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Nekolaichuk C, Huot A, Gratton V, Bush SH, Tarumi Y, Watanabe SM. Development of a French Version of the Edmonton Symptom Assessment System-Revised: A Pilot Study of Palliative Care Patients' Perspectives. J Palliat Med 2017; 20:966-976. [DOI: 10.1089/jpm.2016.0510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Affiliation(s)
- Cheryl Nekolaichuk
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
- Tertiary Palliative Care Unit, Grey Nuns Community Hospital, Edmonton, Alberta, Canada
- Palliative Institute, Covenant Health, Edmonton, Alberta, Canada
| | - Ann Huot
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
- Department of Symptom Control and Palliative Care, Cross Cancer Institute, Edmonton, Alberta, Canada
| | - Valérie Gratton
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Montfort Hospital, Ottawa, Ontario, Canada
| | - Shirley H. Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
- Palliative Care Unit, Élisabeth Bruyère Hospital, Ottawa, Ontario, Canada
| | - Yoko Tarumi
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
- Palliative Care Consult Service, Royal Alexandria Hospital, Edmonton, Alberta, Canada
| | - Sharon M. Watanabe
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, Alberta, Canada
- Department of Symptom Control and Palliative Care, Cross Cancer Institute, Edmonton, Alberta, Canada
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Bush SH, Marchington KL, Agar M, Davis DHJ, Sikora L, Tsang TWY. Quality of clinical practice guidelines in delirium: a systematic appraisal. BMJ Open 2017; 7:e013809. [PMID: 28283488 PMCID: PMC5353343 DOI: 10.1136/bmjopen-2016-013809] [Citation(s) in RCA: 30] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 01/13/2017] [Accepted: 02/20/2017] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To determine the accessibility and currency of delirium guidelines, guideline summary papers and evaluation studies, and critically appraise guideline quality. DESIGN Systematic literature search for formal guidelines (in English or French) with focus on delirium assessment and/or management in adults (≥18 years), guideline summary papers and evaluation studies.Full appraisal of delirium guidelines published between 2008 and 2013 and obtaining a 'Rigour of Development' domain screening score cut-off of >40% using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument. DATA SOURCES Multiple bibliographic databases, guideline organisation databases, complemented by a grey literature search. RESULTS 3327 database citations and 83 grey literature links were identified. A total of 118 retrieved delirium guidelines and related documents underwent full-text screening. A final 21 delirium guidelines (with 10 being >5 years old), 12 guideline summary papers and 3 evaluation studies were included. For 11 delirium guidelines published between 2008 and 2013, the screening AGREE II 'Rigour' scores ranged from 3% to 91%, with seven meeting the cut-off score of >40%. Overall, the highest rating AGREE II domains were 'Scope and Purpose' (mean 80.1%, range 64-100%) and 'Clarity and Presentation' (mean 76.7%, range 38-97%). The lowest rating domains were 'Applicability' (mean 48.7%, range 8-81%) and 'Editorial Independence' (mean 53%, range 2-90%). The three highest rating guidelines in the 'Applicability' domain incorporated monitoring criteria or audit and costing templates, and/or implementation strategies. CONCLUSIONS Delirium guidelines are best sourced by a systematic grey literature search. Delirium guideline quality varied across all six AGREE II domains, demonstrating the importance of using a formal appraisal tool prior to guideline adaptation and implementation into clinical settings. Adding more knowledge translation resources to guidelines may improve their practical application and effective monitoring. More delirium guideline evaluation studies are needed to determine their effect on clinical practice.
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Affiliation(s)
- Shirley H Bush
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Katie L Marchington
- Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Meera Agar
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| | - Lindsey Sikora
- Health Sciences Library, University of Ottawa, Ottawa, Ontario, Canada
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Bush SH. I Don't Want to Die an Old Person. J Palliat Med 2016; 20:432. [PMID: 27870607 DOI: 10.1089/jpm.2016.0474] [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] [Indexed: 11/13/2022] Open
Affiliation(s)
- Shirley H Bush
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa , Ottawa, Ontario, Canada .,2 Bruyère Research Institute , Ottawa, Ontario, Canada .,3 The Ottawa Hospital Research Institute , Ottawa, Ontario, Canada .,4 Bruyère Continuing Care , Ottawa, Ontario, Canada
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Matsuo K, Takazawa Y, Ross MS, Elishaev E, Podzielinski I, Yunokawa M, Sheridan TB, Bush SH, Klobocista MM, Blake EA, Takano T, Matsuzaki S, Baba T, Satoh S, Shida M, Nishikawa T, Ikeda Y, Adachi S, Yokoyama T, Takekuma M, Fujiwara K, Hazama Y, Kadogami D, Moffitt MN, Takeuchi S, Nishimura M, Iwasaki K, Ushioda N, Johnson MS, Yoshida M, Hakam A, Li SW, Richmond AM, Machida H, Mhawech-Fauceglia P, Ueda Y, Yoshino K, Yamaguchi K, Oishi T, Kajiwara H, Hasegawa K, Yasuda M, Kawana K, Suda K, Miyake TM, Moriya T, Yuba Y, Morgan T, Fukagawa T, Wakatsuki A, Sugiyama T, Pejovic T, Nagano T, Shimoya K, Andoh M, Shiki Y, Enomoto T, Sasaki T, Fujiwara K, Mikami M, Shimada M, Konishi I, Kimura T, Post MD, Shahzad MM, Im DD, Yoshida H, Omatsu K, Ueland FR, Kelley JL, Karabakhtsian RG, Roman LD. Significance of histologic pattern of carcinoma and sarcoma components on survival outcomes of uterine carcinosarcoma. Ann Oncol 2016; 27:1257-66. [PMID: 27052653 DOI: 10.1093/annonc/mdw161] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [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: 12/07/2015] [Accepted: 03/29/2016] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND To examine the effect of the histology of carcinoma and sarcoma components on survival outcome of uterine carcinosarcoma. PATIENTS AND METHODS A multicenter retrospective study was conducted to examine uterine carcinosarcoma cases that underwent primary surgical staging. Archived slides were examined and histologic patterns were grouped based on carcinoma (low-grade versus high-grade) and sarcoma (homologous versus heterologous) components, correlating to clinico-pathological demographics and outcomes. RESULTS Among 1192 cases identified, 906 cases were evaluated for histologic patterns (carcinoma/sarcoma) with high-grade/homologous (40.8%) being the most common type followed by high-grade/heterologous (30.9%), low-grade/homologous (18.0%), and low-grade/heterologous (10.3%). On multivariate analysis, high-grade/heterologous (5-year rate, 34.0%, P = 0.024) and high-grade/homologous (45.8%, P = 0.017) but not low-grade/heterologous (50.6%, P = 0.089) were independently associated with decreased progression-free survival (PFS) compared with low-grade/homologous (60.3%). In addition, older age, residual disease at surgery, large tumor, sarcoma dominance, deep myometrial invasion, lymphovascular space invasion, and advanced-stage disease were independently associated with decreased PFS (all, P < 0.01). Both postoperative chemotherapy (5-year rates, 48.6% versus 39.0%, P < 0.001) and radiotherapy (50.1% versus 44.1%, P = 0.007) were significantly associated with improved PFS in univariate analysis. However, on multivariate analysis, only postoperative chemotherapy remained an independent predictor for improved PFS [hazard ratio (HR) 0.34, 95% confidence interval (CI) 0.27-0.43, P < 0.001]. On univariate analysis, significant treatment benefits for PFS were seen with ifosfamide for low-grade carcinoma (82.0% versus 49.8%, P = 0.001), platinum for high-grade carcinoma (46.9% versus 32.4%, P = 0.034) and homologous sarcoma (53.1% versus 38.2%, P = 0.017), and anthracycline for heterologous sarcoma (66.2% versus 39.3%, P = 0.005). Conversely, platinum, taxane, and anthracycline for low-grade carcinoma, and anthracycline for homologous sarcoma had no effect on PFS compared with non-chemotherapy group (all, P > 0.05). On multivariate analysis, ifosfamide for low-grade/homologous (HR 0.21, 95% CI 0.07-0.63, P = 0.005), platinum for high-grade/homologous (HR 0.36, 95% CI 0.22-0.60, P < 0.001), and anthracycline for high-grade/heterologous (HR 0.30, 95% CI 0.14-0.62, P = 0.001) remained independent predictors for improved PFS. Analyses of 1096 metastatic sites showed that carcinoma components tended to spread lymphatically, while sarcoma components tended to spread loco-regionally (P < 0.001). CONCLUSION Characterization of histologic pattern provides valuable information in the management of uterine carcinosarcoma.
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Affiliation(s)
- K Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
| | - Y Takazawa
- Department of Pathology, Cancer Institute Hospital, Tokyo, Japan
| | - M S Ross
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology
| | - E Elishaev
- Department of Pathology, MaGee-Womens Hospital, University of Pittsburgh, Pittsburgh
| | - I Podzielinski
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, USA
| | - M Yunokawa
- Department of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | - T B Sheridan
- Department of Pathology, Mercy Medical Center, Baltimore
| | - S H Bush
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of South Florida, Tampa
| | - M M Klobocista
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Bronx
| | - E A Blake
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology; University of Colorado, Boulder, USA
| | - T Takano
- Department of Obstetrics and Gynecology, Tohoku University, Miyagi
| | - S Matsuzaki
- Department of Obstetrics and Gynecology, Osaka University, Osaka
| | - T Baba
- Department of Obstetrics and Gynecology, Kyoto University, Kyoto
| | - S Satoh
- Department of Obstetrics and Gynecology, Tottori University, Tottori
| | - M Shida
- Department of Obstetrics and Gynecology, Tokai University, Kanagawa
| | - T Nishikawa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama
| | - Y Ikeda
- Departments of Obstetrics and Gynecology, The University of Tokyo, Tokyo
| | - S Adachi
- Department of Obstetrics and Gynecology, Niigata University, Niigata
| | - T Yokoyama
- Department of Obstetrics and Gynecology, Osaka Rosai Hospital, Osaka
| | - M Takekuma
- Department of Obstetrics and Gynecology, Shizuoka Cancer Center, Shizuoka
| | - K Fujiwara
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama
| | - Y Hazama
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama
| | - D Kadogami
- Department of Obstetrics and Gynecology; Kitano Hospital, Osaka, Japan
| | - M N Moffitt
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Portland, USA
| | - S Takeuchi
- Department of Obstetrics and Gynecology, Iwate Medical University, Morioka
| | - M Nishimura
- Department of Obstetrics and Gynecology, Tokushima University, Tokushima
| | - K Iwasaki
- Department of Obstetrics and Gynecology, Aichi Medical University, Aichi
| | - N Ushioda
- Department of Gynecology, Cancer Institute Hospital, Tokyo
| | - M S Johnson
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, USA
| | - M Yoshida
- Departments of Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - A Hakam
- Department of Pathology, Moffitt Cancer Center, University of South Florida, Tampa
| | - S W Li
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Bronx
| | - A M Richmond
- Department of Pathology, University of Colorado, Boulder
| | - H Machida
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
| | - P Mhawech-Fauceglia
- Department of Pathology, University of Southern California, Los Angeles, USA
| | - Y Ueda
- Department of Obstetrics and Gynecology, Osaka University, Osaka
| | - K Yoshino
- Department of Obstetrics and Gynecology, Osaka University, Osaka
| | - K Yamaguchi
- Department of Obstetrics and Gynecology, Kyoto University, Kyoto
| | - T Oishi
- Department of Obstetrics and Gynecology, Tottori University, Tottori
| | - H Kajiwara
- Department of Pathology, Tokai University, Kanagawa
| | - K Hasegawa
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama
| | - M Yasuda
- Department of Pathology, Saitama Medical University International Medical Center, Saitama
| | - K Kawana
- Departments of Obstetrics and Gynecology, The University of Tokyo, Tokyo
| | - K Suda
- Department of Obstetrics and Gynecology, Niigata University, Niigata
| | - T M Miyake
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama
| | - T Moriya
- Department of Pathology, Kawasaki Medical School, Okayama
| | - Y Yuba
- Department of Pathology, Kitano Hospital, Osaka, Japan
| | - T Morgan
- Department of Pathology, Oregon Health & Science University, Portland, USA
| | - T Fukagawa
- Department of Pathology, Iwate Medical University, Morioka
| | - A Wakatsuki
- Department of Obstetrics and Gynecology, Aichi Medical University, Aichi
| | - T Sugiyama
- Department of Obstetrics and Gynecology, Iwate Medical University, Morioka
| | - T Pejovic
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Portland, USA
| | - T Nagano
- Department of Obstetrics and Gynecology; Kitano Hospital, Osaka, Japan
| | - K Shimoya
- Department of Obstetrics and Gynecology, Kawasaki Medical School, Okayama
| | - M Andoh
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama
| | - Y Shiki
- Department of Obstetrics and Gynecology, Osaka Rosai Hospital, Osaka
| | - T Enomoto
- Department of Obstetrics and Gynecology, Niigata University, Niigata
| | - T Sasaki
- Department of Pathology, The University of Tokyo, Tokyo, Japan
| | - K Fujiwara
- Department of Gynecologic Oncology, Saitama Medical University International Medical Center, Saitama
| | - M Mikami
- Department of Obstetrics and Gynecology, Tokai University, Kanagawa
| | - M Shimada
- Department of Obstetrics and Gynecology, Tottori University, Tottori
| | - I Konishi
- Department of Obstetrics and Gynecology, Kyoto University, Kyoto
| | - T Kimura
- Department of Obstetrics and Gynecology, Osaka University, Osaka
| | - M D Post
- Department of Pathology, University of Colorado, Boulder
| | - M M Shahzad
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of South Florida, Tampa
| | - D D Im
- Department of Gynecology, Mercy Medical Center, Baltimore
| | - H Yoshida
- Departments of Pathology, National Cancer Center Hospital, Tokyo, Japan
| | - K Omatsu
- Department of Gynecology, Cancer Institute Hospital, Tokyo
| | - F R Ueland
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Kentucky, Lexington, USA
| | - J L Kelley
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology
| | - R G Karabakhtsian
- Department of Pathology, University of Kentucky, Lexington Department of Pathology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, USA
| | - L D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, Los Angeles, USA
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