Background: Palliative care (PC) improves the quality of life of patients with advanced cancer. Our aim was to describe PC referral among patients with advanced cancer, and associated outcomes in an academic medical centre.
Methods: We reviewed the medical records of 536 inpatients with cancer who had died in 2010. Our retrospective study compared patients who accessed PC services with those who did not. Statistical analysis was conducted using non-parametric tests due to non-normal distribution. We also conducted a multivariate analysis using a logistic regression model including age, gender, type of cancer and metastatic status.
Results: Out of 536 patients, 239 (45%) had PC referral. The most common cancer types were respiratory (22%) and gastrointestinal (19%). Patients with breast cancer (OR 23.76; CI 6.12 to 92.18) and gynaecological cancer (OR 7.64; CI 2.61 to 22.35) had greater PC access than patients with respiratory or haematological cancer. Patients referred to PC had significantly less chemotherapy in the last 2 weeks of life than non-referred patients, with 22 patients (9%) vs 59 (19%; p<0.001). PC-referred patients had significantly fewer admissions to intensive care units in the last month of life than non-referred patients, with 14 (6%) vs 58 (20%; p<0.001).
Conclusions: There was a large variation in access to PC according to the type of cancer. There is a need to improve collaboration between the PC service and the respiratory, cancer and haematology specialists. Further research will be required to determine the modality and the impact of this collaboration.
Introduction: To support general practitioners (GPs) in providing early palliative care to patients with cancer, chronic obstructive pulmonary disease or heart failure, the RADboud university medical centre indicators for PAlliative Care needs tool (RADPAC) and a training programme were developed to identify such patients and to facilitate anticipatory palliative care planning. We studied whether GPs, after 1 year of training, identified more palliative patients, and provided multidimensional and multidisciplinary care more often than untrained GPs.
METHODS: We performed a survey 1 year after GPs in the intervention group of an RCT were trained. With the help of a questionnaire, all 134 GPs were asked how many palliative patients they had identified, and whether anticipatory care was provided. We studied number of identified palliative patients, expected lifetime, contact frequency, whether multidimensional care was provided and which other disciplines were involved.
RESULTS: Trained GPs identified more palliative patients than did untrained GPs (median 3 vs 2; p 0.046) and more often provided multidimensional palliative care (p 0.024). In both groups, most identified patients had cancer.
CONCLUSIONS: RADPAC sensitises GPs in the identification of palliative patients. Trained GPs more often provided multidimensional palliative care. Further adaptation and evaluation of the tools and training are necessary to improve early palliative care for patients with organ failure.
In spite of a referral letter as an important document for communicating between physicians, whether it could also be useful as a source of information for patients has not yet established. We included cancer patients in palliative care setting, all of whom completed a standardized questionnaire regarding their opinion concerning the utility of a referral letter as a source of information and its requirements to achieve a better understanding. Completed questionnaires were received from 50 cancer patients. Ninety-four percent of participants agreed that a referral letter could be of great importance for procuring medical information to them. There was only minor divergence among the participants respecting age, gender, or education. Particular requirements were diagnosis, treatment plan, prognosis, list of drugs, and contact data of involved physicians. Additional important topics were laboratory values, alternatives to current therapy, side effects and supportive therapy, and advices regarding lifestyle and naturopathy. The majority of patients also concluded to accept technical terms in doctor's letters if a glossary supported their comprehension. The majority of patients prefer a concise description of medical information in a referral letter. This form of a letter would boost patients' involvement and help them transfer medical information to other therapists or relatives.
Background: There is extensive need for palliative care worldwide, but access to care remains inadequate, especially for non-cancer patients. Video consultations are a promising tool in the provision of home-based palliative care, but an overview of evidence solely on video consultations in palliative care is lacking.
Aim: To review and synthesize current evidence regarding the use of video consultations in general and specialized palliative care to various patient groups.
Design: A systematic integrative review with a narrative synthesis was undertaken in accordance with PRISMA (2009) guidelines. PROSPERO #: CRD42018095383
Data sources: PubMed, Embase, CINAHL, and PsychINFO were searched for primary research articles published between 2005 and 2018. In addition, reference lists of included articles were hand searched.
Results: The search resulted in 813 articles; 39 articles were included in the review, consisting of mixed methods (n = 14), qualitative (n = 10), quantitative (n = 10), and case studies (n = 5). The studies mainly focused on specialized palliative care to adult patients with cancer in high income countries. Through data analysis, six themes addressing advantages/disadvantages and facilitators/barriers were identified: (1) Redesign of care, (2) Communication, (3) User perceptions, (4) Technology, (5) Privacy issues, and (6) Economic implications.
Conclusion: Using video technology in palliative care has both advantages and disadvantages. However, evidence beyond the focus on specialized palliative care and patients with cancer is limited. Future research should focus on how and when video consultations might replace in-person specialized palliative care and video consultations in general palliative care, in low and middle income countries; and involve patients with a non-cancer diagnosis.
Pediatric phase I clinical oncology trials represent a unique cohort of patients who have not responded to standard therapies and remain highly vulnerable to treatment toxicity and/or disease burden. Incorporating a palliative care consultation into the care plan for those with relapsed/refractory cancer where chance of cure is limited is generally recommended. A retrospective chart review of pediatric phase I trials revealed that palliative care was consulted in <20% of patients, most often for symptom management. Efforts to increase the use of palliative services in this population may enhance quality of life for children and families enrolled in phase I studies.
BACKGROUND: The American Academy of Pediatrics recommends palliative care for children at the diagnosis of serious illness. Yet few children who die receive specialty palliative care consultation, and when it is provided, palliative care consultation tends to occur after >75% of the time from diagnosis until death. Focusing on the timing of palliative consultation in relation to the date of diagnosis, we evaluated factors predicting earlier receipt of pediatric palliative care in a cohort of decedents.
METHODS: We retrospectively identified patients diagnosed with a life-limiting disease who died at our hospital in 2015-2017 after at least 1 inpatient palliative medicine consultation. Our primary outcome was time from palliative-qualifying diagnosis to earliest receipt of specialty palliative care. A survival analysis was used to describe factors associated with earlier receipt of palliative care.
RESULTS: The analysis included 180 patients (median age at diagnosis <1 month [interquartile range (IQR): 0-77]). The median time to first palliative consultation was 7 days after diagnosis (IQR: 2-63), compared with a median of 50 days between diagnosis and death (IQR: 7-210). On the multivariable analysis, palliative consultation occurred earlier for patients who had cardiovascular diagnoses, had private insurance, and were of African American race.
CONCLUSIONS: In a cohort of decedents at our institution, palliative consultation occurred much earlier than has been previously reported. We also identify factors associated with delayed receipt of palliative care among children who are dying that reveal further opportunities to improve access to specialty palliative care.
BACKGROUND: The World Health Organisation (WHO) endorses integrated palliative care which has a significant impact on quality of life and satisfaction with care. Effective integration between hospices, palliative care services, hospitals and primary care services are required to support patients with palliative care needs. Studies have indicated that little is known about which aspects are regarded as most important and should be priorities for international implementation. The Integrated Palliative Care in cancer and chronic conditions (InSup-C) project, aimed to investigate integrated practices in Europe and to formulate requirements for effective palliative care integration. It aimed to develop recommendations, and to agree priorities, for integrated palliative care linked to the InSuP-C project.
METHODS: Transparent expert consultation was adopted at the approach used. Data were collected in two phases: 1) international transparent expert consultation using face-to-face roundtable discussions at a one day workshop in Brussels, and 2) via subsequent online cross-sectional survey where items were rated to indicate degree of agreement on their importance and ranked to indicate priority for implementation. Workshop discussions used content analysis to develop a list of 23 recommendations, which formed the survey questionnaire. Survey analysis used descriptive statistics and qualitative content analysis of open responses.
RESULTS: Thirty-six international experts in palliative care and cancer care, including senior clinicians, researchers, leaders of relevant international organisations and funders, were invited to a face-to-face workshop. Data were collected from 33 (19 men, 14 women), 3 declined. They mostly came from European countries (31), USA (1) and Australia (1). Twenty one of them also completed the subsequent online survey (response rate 63%). We generated 23 written statements that were grouped into the organisational constructs: macro (10), meso (6) and micro (7) levels of integration of palliative care. Highest priority recommendations refer to education, leadership and policy-making, medium priority recommendations focused on funding and relationship-building, and lower priority recommendations related to improving systems and infrastructure.
CONCLUSIONS: Our findings suggest that amongst a group of international experts there was overall good agreement on the importance of recommendations for integrated palliative care. Understanding expert's priorities is important and can guide practice, policymaking and future research.
OBJECTIVES: To compare characteristics and needs of inpatients with neurologic disease to those with cancer referred for palliative care (PC) consultation.
METHODS: This prospective cohort study used data collected by the Palliative Care Quality Network from January 2013 until December 2016. We compared demographics, reasons for consultation, discharge disposition, Palliative Performance Scale (PPS) score, and outcomes of care among patients with a primary diagnosis of neurologic disease vs cancer.
RESULTS: The most common reason for PC consultation in all patients was assistance with goals of care and advanced care planning. PC consultation was less often requested for pain and symptom management in patients with neurologic disease compared to patients with cancer (13.7% vs 43%, odds ratio 0.3) and more often for assistance with transition to comfort measures only and withdrawal of life-sustaining treatment (19.1% vs 7.1%, odds ratio 1.3). Patients with cancer had higher PPS scores (42.1% vs 23.4%) and were more likely to be discharged home from the hospital, while patients with neurologic disease were more likely to die in hospital.
CONCLUSIONS: Patients with neurologic disease as a reason for PC consultation are more in need of end-of-life care planning and more likely to die in the hospital than those with cancer, suggesting that targeted approaches may best address the needs of each patient population. Our results can direct further research and education in neuropalliative care.
Background: Palliative care (pc) consultation has been associated with less aggressive care at end of life in a number of malignancies, but the effect of the consultation timing has not yet been fully characterized. For patients with unresectable pancreatic cancer (upcc), aggressive and resource-intensive treatment at the end of life can be costly, but not necessarily of better quality. In the present study, we investigated the association, if any, between the timing of specialist pc consultation and indicators of aggressive care at end of life in patients with upcc.
Methods: This retrospective cohort study examined the potential effect of the timing of specialist pc consultation on key indicators of aggressive care at end of life in all patients diagnosed with upcc in Nova Scotia between 1 January 2010 and 31 December 2015. Statistical analysis included univariable and multivariable logistic regression.
Results: In the 365 patients identified for inclusion in the study, specialist pc consultation was found to be associated with decreased odds of experiencing an indicator of aggressive care at end of life; however, the timing of the consultation was not significant. Residency in an urban area was associated with decreased odds of experiencing an indicator of aggressive care at end of life. We observed no association between experiencing an indicator of aggressive care at end of life and consultation with medical oncology or radiation oncology.
Conclusions: Regardless of timing, specialist pc consultation was associated with decreased odds of experiencing an indicator of aggressive care at end of life. That finding provides further evidence to support the integral role of pc in managing patients with a life-limiting malignancy.
BACKGROUND: The work of specialized palliative care (SPC) teams is often challenged by substantial amounts of time spent driving to and from patients' homes and long distances between the patients and the hospitals.
OBJECTIVE: Video consultations may be a solution for real-time SPC at home. The aim of this study was to explore the use of video consultations, experienced by patients and their relatives, as part of SPC at home.
METHODS: This explorative and qualitative study included palliative care patients in different stages and relatives to use video consultations as a part of their SPC between October 2016 and March 2017. Data collection took place in the patients' homes and consisted of participant observations followed by semistructured interviews. Inclusion criteria consisted of patients with the need for SPC, aged more than 18 years, who agreed to participate, and relatives wanting to participate in the video consultations. Data were analyzed with Giorgi's descriptive phenomenological methodology.
RESULTS: A number of patients (n=11) and relatives (n=3) were included and, in total, 86 video consultations were conducted. Patients participating varied in time from 1 month to 6 months, and the number of video consultations per patient varied from 3 to 18. The use of video consultations led to a situation where patients, despite life-threatening illnesses and technical difficulties, took an active role. In addition, relatives were able to join on equal terms, which increased active involvement. The patients had different opinions on when to initiate the use of video consultations in SPC; it was experienced as optional at the initiating stage as well as the final stage of illness. If the video consultations included multiple participants from the SPC team, the use of video consultations could be difficult to complete without interruptions.
CONCLUSIONS: Video consultations in SPC for home-based patients are feasible and facilitate a strengthened involvement and communication between patients, relatives, and SPC team members.
OBJECTIVE: Delays in specialized palliative care (PC) consultation in end-stage liver disease (ESLD) patients may be explained by clinician attitudes toward PC. Our aim is to assess the attitudes of hepatology and liver transplant (HLT) and PC clinicians toward PC consultation and consultant roles in ESLD patient care.
METHODS: Clinician members of HLT and PC professional societies were surveyed. Using a five-point Likert scale, they rated their comfort level toward various PC consultant roles and their agreement with triggers for and reasons to defer PC consultation. Change in attitudes toward PC consultation resulting from liver transplant (LT) eligibility was evaluated.
RESULTS: A total of 311 HLT (6.2%) and 379 PC (8.1%) clinicians completed the survey. The vast majority of HLT clinicians (>80%) were comfortable if PC consultants palliate symptoms, provide support, or facilitate advance care planning in LT-ineligible patients. LT eligibility reduced HLT clinician comfort toward all PC consultant roles, except supportive care. A vast majority of PC clinicians (>90%) were comfortable assuming all PC roles, except pain management without opioids (43-51%). About 80% of HLT clinicians agree with PC consultation in LT-ineligible patients with decompensated cirrhosis or hepatocellular carcinoma (HCC), compared to 20-30% if LT ineligible. Common justifications for deferring PC consultation included mild disease, LT eligibility, unavailability of PC specialists, and lack of addressable palliative issues.
CONCLUSIONS: Barriers to specialized PC consultation in ESLD include HLT clinician discomfort with PC consultant roles, patients' LT eligibility, perception that PC is end-of-life care, unclear triggers for PC consultation, and concern about opioid-based pain palliation.
BACKGROUND: Earlier palliative care consultation is associated with less intensive medical care and improved quality outcomes for patients with cancer. However, there are limited data about how the timing of palliative care affects utilization among noncancer patients exposed to palliative care consultation.
OBJECTIVE: Comparison of health care utilization for hospice decedents who received early versus late palliative care.
DESIGN: A retrospective cohort study utilizing hospital and hospice administrative databases.
SETTING/SUBJECTS: Patients with cancer and noncancer diagnoses who received specialty palliative care consultation before dying at a local hospice.
MEASUREMENTS: Comparing early (>90 days before death) versus late (<90 days before death) palliative care, outcome measures included intensive care unit (ICU) utilization and hospice length of stay (LOS).
RESULTS: Of 233 hospice decedents in 2014 who had palliative care referrals, 36 (15.4%) had early and 197 (84.5%) had late referrals. Nearly half of the patients had a noncancer hospice diagnosis. Only 6% of the early group used the ICU in the last month of life, whereas 56% of the late group did. Patients receiving early palliative care had a longer median hospice LOS than those with late palliative care (138 days vs. 8 days).
CONCLUSIONS: Early palliative care appears to reduce intensive medical care and increase hospice LOS for patients with a variety of end-stage diseases.
Background: The impact of specialty pediatric palliative care (PPC) on intensive care unit (ICU) length of stay for children is unclear.
Objective: To estimate the impact of PPC consultation by analyzing ICU stay as a dynamic outcome over the course of hospitalization.
Patients and Methods: Retrospective cohort study of children hospitalized with diagnoses suggested as referral triggers for PPC at a large academic children's hospital. We assessed ICU stay according to PPC consultation and, using a patient-day analysis, applied multivariable mixed effects logistic regression to predict the odds of being in the ICU on a given day.
Results: The analytic sample included 777 admissions (11,954 hospital days), of which 100 admissions (13%) included PPC consultation. Principal patient demographics were age 8 ± 6 years, 55% male sex, 71% white race, and 52% commercial insurance. Cardiac diagnoses were most frequent (29%) followed by gastrointestinal (22%) and malignant (20%) conditions. Although total ICU stay was longer for admissions, including PPC consultation (compared to admissions where PPC was not consulted), the odds of being in the ICU on a given day were reduced by 79% after PPC consultation (odds ratio [OR] = 0.21; 95% confidence interval [CI]: 0.13–0.34; p < 0.001) for children with cancer and 85% (OR = 0.15; 95% CI: 0.08–0.26; p < 0.001) for children with nononcologic conditions.
Conclusions: Among children hospitalized with a diagnosis deemed eligible for specialty PPC, the likelihood of being in the ICU on a given day was strongly reduced after PPC consultation, supporting the value of PPC.
Formal communication of end-of-life preferences is crucial among patients with metastatic cancer. Our objective is to describe the prevalence of advance directives (AD) and do-not-resuscitate (DNR) orders among stage IV cancer patients with acute care surgery consultations, and the associated outcomes. This is a single institution retrospective review over an eight-year period. Two hundred and three patients were identified; mean age was 55.3 ± 11.4 years and 48.8 per cent were male. Fifty (24.6%) patients underwent exploratory surgery. Nineteen (10.6%) patients had another type of surgery. Twenty-one (10.3%) patients had a DNR order, and none had an AD on-admission. Fifty-four (26.6%) patients had a DNR order placed and four (2%) patients completed an AD postadmission. DNR postadmission was associated with the highest mortality at 42.6 per cent compared with 14.3 per cent for DNR on-admission and 1.56 per cent for full-code patients (P < 0.001). Compared with patients that remained full-code and those with DNR on-admission, DNR postadmission was associated with longer length of stay (19.6 days; P < 0.001) and ICU length of stay (7.72 days; P < 0.001). The prevalence of AD and DNR orders among stage IV cancer patients is low. The higher in-hospital mortality of patients with DNR postadmission reflects the use of DNR orders during clinical decline.
BACKGROUND: Hospital-based palliative care consultation is consistently associated with reduced hospitalization costs and more importantly with improved patient quality of life. As healthcare systems move toward value-based purchasing rather than fee-for-service models, understanding how palliative care consultation is associated with value-based purchasing metrics can provide evidence for expanded health system support for a greater palliative care presence.
AIM: To understand how a palliative care consultation impacts rates of patient readmission and hospital-acquired infections associated with value-based purchasing metrics.
DESIGN: Retrospective propensity-matched case-control study evaluating the impact of palliative care consultation on hospital charges, hospital and intensive care unit length of stay, readmission rates, and rates of hospital-acquired conditions.
SETTING/PARTICIPANTS: All adult patients admitted to a two hospital healthcare system over a 2-year period from 1 April 2015 to 31 March 2017. The palliative care team involved three physicians, five advanced practice providers, a social worker, and a chaplain during the study period.
RESULTS: A total of 3415 patients receiving a palliative consult were propensity matched to 25,028 controls. Compared to controls, cases had decreased charges per day and decreased rates of 7-, 30-, and 90-day readmissions.
CONCLUSION: Through value-based purchasing, hospitals have 3% of their Medicare reimbursements at risk based on readmission rates. By clarifying prognosis and patient goals, palliative care consultation reduces readmission rates. Hospital systems may want to invest in larger palliative care programs as part of their efforts to reduce hospital readmissions.
BACKGROUND: Chronic kidney disease palliative care guidelines would benefit from more diverse and objectively defined health status measures.
AIM: The aim is to identify high-risk patients from administrative data and facilitate timely and uniform palliative care involvement.
DESIGN: It is a retrospective cohort study.
SETTING/PARTICIPANTS: In total, 45,368 Veterans, with chronic kidney disease Stage 3, 4, or 5, were monitored for up to 6 years and categorized into three groups, based on whether they died, started dialysis, or avoided both outcomes.
RESULTS: Patient's appointment utilization was a significant predictor for both outcomes. It separated individuals into low, medium, and high appointment utilizers. Among the low appointment utilizers, the risk of death did not change significantly, while the risk of dialysis increased. Medium appointment utilizers had a stable risk of death and a decreasing risk of dialysis. Significant appointment utilization (above 31 visits during the baseline year) helped high-risk patients avoid both outcomes of interest-death and dialysis.
CONCLUSION: Our model could justify the creation of a novel palliative care introduction trigger, as patients with medium demand for care may benefit from additional palliative care evaluation. The trigger could facilitate the uniformization of conservative treatment preparations. It could prompt messages to a managing physician when a patient crosses the threshold between low and medium appointment utilization. It may also aid in system-level policy development. Furthermore, our results highlight the benefit of significant appointment utilization among high-risk patients.
Aim: Pancreas cancer continues to carry a poor prognosis. Hospitalized patients with advanced chronic pancreatic illnesses increasingly receive palliative care due to its perceived clinical benefits. Meanwhile, a growing proportion of elderly patients are reportedly receiving life-sustaining procedures. Temporal trends in the utilization of life-sustaining procedures and palliative care consultation among dying patients with advanced chronic pancreatic illnesses in US hospitals were examined.
Methods and Materials: A serial, cross-sectional analysis was carried out using the National Inpatient Sample Database. Decedents 18 years and older with a principal diagnosis of pancreas cancer or other advanced chronic pancreatic illnesses from 2005 through 2014. The compound annual growth rates (CAGRs) and Cochrane-Armitage correction of 2 statistic were used. The receipt of life-sustaining systemic procedures, intra-abdominal local procedures and surgeries, and palliative care consultation were examined. Multilevel multivariate logistic regressions were performed to examine the association of various procedures with the utilization of palliative care consultation.
Results: Among 77 394 183 hospitalizations, 29 515 patients were examined. The CAGRs of systemic procedures, intra-abdominal procedures, surgeries, and palliative care were -4.19% (P = .008), 2.17%, -1.40%, and 14.03% (P < .001), respectively. The receipt of systemic procedures (odds ratio [OR] = 2.40, 95% confidence interval [CI], 2.08-2.74), local intra-abdominal procedures (OR = 1.46, 95% CI, 1.27-1.70), and surgeries (OR = 2.51, 95% CI, 2.07-3.05) was associated with palliative care consultation (Ps < .001).
Conclusions:Among adults with pancreatic cancer or other advanced chronic pancreatic illnesses in the US hospitals from 2005 to 2014, the utilization of life-sustaining systemic procedures decreased while the prevalence of palliative care consultation increased.
Notre travail s’appuie sur un constat : le médecin généraliste est désormais confronté à des patients atteints de pathologies longues et incurables, en phase de soins palliatifs. Or le généraliste n’est pas formé à leur prise en charge, différente de celle d’un autre patient : il ne s’agit plus d’aider sur le chemin de la guérison mais d’accompagner vers la mort.
Il s’agit donc de réfléchir à la posture du généraliste face à ce type de patient, lors d’un suivi au long cours. Quelles démarches doit-il adopter au sein du nouvel espace qu’est celui de la rencontre en soins palliatifs ?
Objective: The in-hosptial palliative care consultation (PCC) is emerging as a routine service in some medical center in China. The current study evaluated how physicians in primary care team and consultation team perceive the PCC service for the purpose of investigating the effectiveness of this consultation model in a general hospital.
Methods: In-hosptial palliative care consultations have been carried out at Peking Union Medical College Hosptial by a dedicated consultation team, and 37 consultations were completed in 2016. A questionnaire was designed for physicians in terms of its benefits to patients,their family as well as the primary care team. Physicians who applied for consultation in 2016 formally (requested from the department other than the Geriatrics) and informally (by rotating residents and unemployed visiting doctors in geriatric department) were invited to participate in the survey by scanning a two dimentional code on social networking platform.
Results: There were 103 physicians participated in the survey, including primary care physicians from the department of Internal Medicine (n=8), Gynaecology (n=16) and Surgery (n=13), rotating residents (n=30), visiting doctors (n=16) in Geriatric department, and PCC team members (n=20). 94.0% of the non-PCC physicians agreed that PCC relieved the suffering of patients; 89.2% thought PCC improved the quality of patients' life; there were 91.6%, 95.2%, 90.4% physicians who felt it relieved the anxiety of patients, of family members and of care providers, respectively. There were 96.4% physicians who felt it could ease the tension in physician-patient relationship; 97.6% felt it lower the risk for medical negligence, and 96.4% of doctors who applied for PPC felt satisfied with PCC service in terms of process and achieving objectives of consultation. More primary-team physician agree "PCC service helps the physicians better understand palliative care" than PCC members (97.6% vs. 80%, P<0.05), while both were interested in learning more on palliative medicine (100% vs. 96.4%, P>0.05).
Conclusion: Palliative care consultation service in a general hospital is efficacious and acclaimed.The primary care physicians and the PCC members hold positive attitudes to the benefits that the PCC services bring to patients, family members, and physicians themselves. PCC for terminal patients in a general hospital may serve as a good modle for promotion of palliative care in China.