Are We Listening?

This feature in each issue of the journal, will serve to indicate a main direction of thought about palliative care, somewhat as the compass and map offer guidance in the sport after which this section is titled.

Not just little adults: palliative care physician attitudes toward pediatric patients

BACKGROUND

Palliative care physicians are increasingly being asked to provide end-of-life (EOL) care for children. Yet very little is known about physicians' level of comfort and willingness to do so.

OBJECTIVES

This study assessed the attitudes of palliative care physicians toward providing care for pediatric patients and to describe the supports they desire in order to do so.

METHODS

An online questionnaire was e-mailed to all physicians in the Division of Palliative Care at the University of Toronto. The questionnaire explored perceptions, attitudes, and level of comfort caring for pediatric patients. Results are reported using frequencies, ratios, and other descriptive analyses.

RESULTS

Forty-four physicians of the 74 (59%) surveyed responded. On average, physicians cared for fewer than one child per each year of practice. Although the majority of respondents perceived their pediatric training to be inadequate, 70% were willing to provide care to children. Respondents felt at ease applying their knowledge and skills in some aspects of pediatric care (e.g., principles of pain and symptom management, communication about EOL issues) but less so in others (e.g., medication dosing, ethical issues unique to pediatrics). All respondents welcomed opportunities for additional training, but a third felt it was not essential. In particular, the most frequently expressed need was for mentorship by pediatric palliative care specialists.

CONCLUSIONS

Palliative physicians tend to be willing to care for children, but perceive their level of training to be insufficient. Although additional training is endorsed, physicians favored real-time support and mentorship from a pediatric expert.

Knowledge of and preference for advance care planning by adults with congenital heart disease

Congenital heart disease (CHD) is a chronic illness. Few adults with CHD are cured and those with disease of moderate or great complexity remain at risk of premature death. Current adult CHD guidelines recommend that providers encourage their patients to complete advance directives. We evaluated the prevalence of completed advance directives by and the preference for information about life expectancy of outpatients at a large adult CHD program. Two hundred patients with CHD (52% men, 35 ± 15 years old, range 18 to 79, 81% with disease of moderate or great complexity) completed a survey that assessed knowledge of advance directives and nature of and preferences for advance care planning. Only 5% of patients reported that they had completed advance directives; 56% had never heard of them. However, most patients (87%) reported that they would prefer to have an advance directive available if they were dealing with their own dying and were unable to speak for themselves. Patients who had formally identified substitute decision makers (n = 34) were typically older (47 ± 16 vs 33 ± 13 years, p <0.001) and more likely to have partners (30% vs 6%, p <0.001). Most patients (70%) reported that they wanted general information about the average life expectancy for patients with their heart condition. In conclusion, in contrast to recommendations from published guidelines, advance care planning documents are infrequently completed by outpatients. Health care providers caring for patients with CHD should educate their patients about advance directives and assist them in preparing formal end-of-life-planning documents.

Health system characteristics of quality care delivery: a comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada

BACKGROUND

A number of palliative care delivery models have been proposed to address the structural and process gaps in this care. However, the specific elements required to form competent systems are often vaguely described.

AIM

The purpose of this study was to explore whether a set of modifiable health system factors could be identified that are associated with population palliative care outcomes, including less acute care use and more home deaths.

DESIGN

A comparative case study evaluation was conducted of 'palliative care' in four health regions in Ontario, Canada. Regions were selected as exemplars of high and low acute care utilization patterns, representing both urban and rural settings. A theory-based approach to data collection was taken using the System Competency Model, comprised of structural features known to be essential indicators of palliative care system performance. Key informants in each region completed study instruments. Data were summarized using qualitative techniques and an exploratory factor pattern analysis was completed.

RESULTS

43 participants (10+ from each region) were recruited, representing clinical and administrative perspectives. Pattern analysis revealed six factors that discriminated between regions: overall palliative care planning and needs assessment; a common chart; standardized patient assessments; 24/7 palliative care team access; advanced practice nursing presence; and designated roles for the provision of palliative care services.

CONCLUSIONS

The four palliative care regional 'systems' examined using our model were found to be in different stages of development. This research further informs health system planners on important features to incorporate into evolving palliative care systems.

Palliative care and oncology: integration leads to better care

The timely integration of palliative care services into standard oncology care is essential to providing comprehensive individualized care for patients with advanced and incurable cancer and their families. Herein we discuss five important areas in which this integration is critical to optimize management, namely: symptom management, transitioning from disease-focused care to palliative care, discussing goals of care and advance care planning, community care, and psychosocial support for the patient and family.

Methylnaltrexone in the treatment of opioid-induced constipation in cancer patients receiving palliative care: willingness-to-pay and cost-benefit analysis

CONTEXT

When laxative regimens have failed, methylnaltrexone may be indicated for the relief of opioid-induced constipation (OIC) in patients with advanced illness receiving palliative care.

OBJECTIVES

A cost-benefit analysis (CBA), based on a willingness-to-pay (WTP) approach, was performed to determine if methylnaltrexone should be added to the formulary list of drugs being reimbursed by third-party payers in Canada for the treatment of cancer patients in palliative care suffering from OIC.

METHODS

The WTP study had two components: a decision board explaining treatment options (Component A) and a questionnaire to measure individual WTP using a bidding game approach (Component B). Component A had two options: Option 1 (laxatives only) and Option 2 (laxatives+methylnaltrexone injection). Only participants choosing Option 2 were invited to complete Component B. The results of the WTP survey were then incorporated into a CBA. Within a hypothetical cohort, additional monthly premiums that individuals were willing to pay for methylnaltrexone were compared with the monthly costs to the insurer for providing methylnaltrexone to all patients who would potentially be using it.

RESULTS

Four hundred one Canadians, of age 18 years and older, were surveyed and yielded a WTP in additional monthly insurance premiums of Canadian dollar (CAD) $8.65 (95% confidence interval: CAD$6.17-CAD$11.13). The CBA resulted in additional CAD$89,307 with a cost of CAD$139,840 and benefits of CAD$229,147. A set of 10,000 Monte Carlo simulations resulted in average CBA savings of CAD$145,011 with a 99.86% probability of dominance.

CONCLUSION

The present CBA provides pharmacoeconomic evidence for the adoption of methylnaltrexone for treating OIC in terminally ill cancer patients.

Resource use and costs of end-of-Life/palliative care: Ontario adult cancer patients dying during 2002 and 2003

The objective of this study is to estimate the direct medical cost of end-of-life and palliative (EOL/PAL) care for cancer patients during the last six months of their lives--or, during the period from diagnosis to death, if briefer--in 2002 and 2003, in Ontario, Canada. A linkage of cancer registry and administrative data is used to determine the costs of health care resources used during the EOL/PAL care period. Costs are analyzed by cancer diagnosis, location of death, and type of service. The total Ontario Ministry of Health-funded cost of EOL/PAL care for cancer patients is estimated to be about CAD$544 million per year, with an average per patient cost of about $25,000 in 2002-2003. Our results suggest that acute care consumes 75 percent of EOL/PAL funding and that only a small proportion of health care services used by EOL/PAL care cancer patients is likely to be formal palliative care.

Consensus recommendations for the management of constipation in patients with advanced, progressive illness

Constipation is a highly prevalent and distressing symptom in patients with advanced, progressive illnesses. Although opioids are one of the most common causes of constipation in patients with advanced, progressive illness, it is important to note that there are many other potential etiologies and combinations of causes that should be taken into consideration when making treatment decisions. Management approaches involve a combination of good assessment techniques, preventive regimens, appropriate pharmacological treatment of established constipation, and frequent monitoring. In this vulnerable patient population, maintenance of comfort and respect for individual preferences and sensitivities should be overriding considerations when making clinical decisions. This consensus document was developed by a multidisciplinary group of leading Canadian palliative care specialists in an effort to define best practices in palliative constipation management that will be relevant and useful to health care professionals. Although a wide range of options exists to help treat constipation and prevent its development or recurrence, there is a limited body of evidence evaluating pharmacological interventions. These recommendations are, therefore, based on the best of the available evidence, combined with expert opinion derived from experience in clinical practice. This underscores the need for further clinical evaluation of the available agents to create a robust, evidence-based foundation for treatment decisions in the management of constipation in patients with advanced, progressive illness.

Factors Associated with End-of-Life Health Service Use in Patients Dying of Cancer

This study describes acute care hospital death, physician house calls and home care near the end of life among patients who died of cancer and the factors that are associated with these events and services. It is a population-based retrospective study that uses linked administrative healthcare data. The cohort includes all patients who died of cancer between 2000 and 2004 in Ontario, Canada.Fifty-five per cent of patients died in acute care hospital, 68% received home care in the last 6 months of life and 24% received at least one physician house call in the last 2 weeks of life. Increased age was associated with a decreased likelihood of each event or service. Women were less likely to die in acute care and more likely to receive home care. Residents in low-income neighbourhoods were less likely to receive house calls or home care. Patients who received home care or house calls were less likely to die in acute care.Our observations add to those in the literature, suggesting a need to increase the use of supportive care services at the end of life in hopes of decreasing the need for acute care. They also serve as a baseline for future comparison, which is of particular interest since new government policies directed at end-of-life care were recently introduced.

Healthcare integration: the study of the toronto central regional hospice palliative care "system" and its integration challenges

The Ontario Ministry of Health and Long-Term Care's End-of-Life strategy did not result in integrated hospice palliative care (HPC) systems. Consequently, HPC has evolved differently across the 14 local health integration networks. In the Toronto Central Local Health Integration Network, the HPC sector lacks foundational systems integration elements: infrastructure and tools that can ensure optimal access and delivery; centralized data capture and management resources to support delivery and planning; and central planning and performance authority that will further improvements in systems delivery, planning and accountability. The sector has been able to function because of inter-organizational initiatives and system linkage tools.

Women experience higher levels of fatigue than men at the end of life: a longitudinal home palliative care study

Few studies have evaluated sex differences in the prevalence, severity, and correlates of fatigue at the end of life. The Brief Fatigue Inventory, McGill Quality of Life (MQOL) Questionnaire, and Karnofsky Performance Scale were administered at two-week intervals to 102 patients in a home palliative program. Outcomes in the sample and a regional palliative database (n=3,096) were analyzed. Cancer was the diagnosis in 96% of patients enrolled. Prevalence (P=0.0091) and severity of fatigue (P<0.001) were higher in women at entry and in a repeated measures analysis over time (severity, P=0.0048). Performance status did not explain this difference. MQOL scores were inversely correlated to fatigue (Spearman coefficient=-0.48, P<0.0001), but did not differ by sex. There was no difference in fatigue interference with MQOL in women and men. Although depression was higher in women (P=0.042) and related to fatigue at entry, it did not explain the sex difference in fatigue scores. Of the sociodemographic variables examined, neither education nor living situation contributed to the fatigue difference. This study shows a sex effect in the fatigue experienced by patients with advanced illnesses, which is not explained by baseline differences in performance, depression, MQOL, education, or living situation. That fatigue interference with MQOL is the same for men and women suggests that higher fatigue scores in women reflect not only a difference in the dimension of fatigue severity, but are also relevant in relation to impact on QOL. Assessment of fatigue should include the dimension of QOL important for both women and men.

Models, standards, guidelines

This article reviews the current illness experience for elders, highlights key issues that cause suffering and affect the quality of life of elders in our society, and reviews the definition and the process for providing palliative care. A consensus-building process is described, which any hospice or palliative care organization can use to adapt existing consensus and evidence-based models, standards of practice, and preferred practice guidelines and engage all staff and stakeholders in the development of an organizational model to guide day-to-day practices and improve the quality of all its activities.

Discussion of death and dying in surgical textbooks

BACKGROUND

Quality end-of-life care is an increasing concern for the public and the medical profession. Surgical textbooks could serve as an important educational and reference resource to improve this care.

METHODS

Four general surgical textbooks were scored for helpful information on death and dying for eight surgical diseases. For each disease, nine content domains related to care of the dying patient were evaluated. Three texts included a chapter on cancer that was evaluated separately.

RESULTS

Disease epidemiology, prognosis/prevention, progression, and medical interventions were generally well discussed in all textbooks. However, little helpful information was provided with regards to breaking bad news/advanced care planning, mode of death, treatment decision-making, effect on family/surgeon, and symptom management. Cancer chapters also addressed only a few of these concerns.

CONCLUSION

Death and the dying patient are sufficiently frequent in surgical practice that it would be appropriate to increase the amount of information provided.

The principles of palliative radiotherapy: a palliative care physician's perspective

The relationship between oncology and palliative care is an evolving one. As one debates the processes of palliative radiotherapy, it is important to realize that "palliation" and "palliative care" are not synonymous. We need to explore the definition of palliative care, the myths surrounding palliative care and dying, the need for optimizing pain management and, finally, access to palliative radiotherapy and palliative care.

Special issues in pain control during terminal illness

Pain control is still a prime concern in managing patients with terminal illnesses, such as AIDS and cancer. I review some special issues that confront family physicians providing such care. Issues include common blocks to good pain management, understanding different types of pain, and the appropriate use of adjunct analgesic drugs and therapies.

Managing chronic pain in family practice

Pain is common in family practice. In dealing with chronic pain, both the family physician and the patient often have problems in defining and in understanding the origin of chronic pain and in providing effective pain relief. This article explores a practical, holistic approach to understanding and managing chronic pain.

Understanding Dying Patients and Their Families: Using the family FIRO model

Caring for dying patients and their families presents unique opportunities and challenges for the family physician. The family FIRO model provides a simple way of assessing families and providing appropriate, individualized care. This article outlines the model, discusses the care of dying patients and their families from the FIRO perspective, and provides a guideline for the family physician. A framework is suggested for teaching residents to support families.

Mouse myeloma. A model for studies of cell kinetics

The mouse plasma cell tumor Adj PC-5 grows slowly due to a large loss of cells from the growth fraction into nonprolifeative, end-stage cells. All tumor cells with the capacity to form a colony appear to be in cell cycle. Marked tumor specificity of several alkylating agents could not be explaned by differences in the porliferative state of myeloma and normal marrow cells. The sensitivity of different mouse myelomas to an alkylating agent varies considerably. The factors determining whether a mouse myeloma is sensitive to an alkylating agent are probably related to structure of the agent and intrinsic properties of the cell, rather than to the agent's mechanism of action.