Curriculum Studies in the Age of Covid-19

<h3>Context:</h3> Since 2015, the College of Family Physicians of Canada’s Certificates of Added Competence (CAC) program has included enhanced skill certification in Palliative Care (PC) to support the scope of Family Medicine services available to patients and communities. <h3>Objective:</h3> To describe the ways in which family physicians with a CAC in palliative care contribute within their communities, the factors that influence the models in which these physicians work, and the perceived impacts of this work. <h3>Study Design:</h3> Secondary unconstrained content analysis of qualitative data from a multiple case study on the role and impacts of family physicians with a CAC. <h3>Population:</h3> Six family medicine practices across Canada, between September 2018 and June 2019. <h3>Data Source:</h3> Interviews with PC and generalist physicians, trainees, and administrators, which included discussion of the PC role, associated with these cases. <h3>Outcome Measure:</h3> Qualitative descriptions of the models of care, factors influencing the way PC physicians work, and their impacts in the community. <h3>Results:</h3> Twenty-one participants (nine PC physicians, five generalist family physicians, two residents, five physicians with enhanced skills in other domains) contributed data. PC physicians enhanced the workforce to meet palliative care needs in communities. PC physicians worked in various models, ranging from maintaining and enhancing their own family practice through to working exclusively as a PC physician. In the latter case, PC physicians worked in a collaborative model with other physicians by providing consultations to other physicians, co-managing patients (shared care), or assuming care of the patient as the main provider (transfer of care). PC physicians intentionally built capacity among their colleagues, with some activities not being remunerated. Funding models and other structures favoured the PC physician taking over care. <h3>Conclusion:</h3> PC physicians with added competency facilitate comprehensive care of people until the end of life, through direct patient care models and by building capacity among others. Remuneration models should support system capacity and relationships that enable family physicians to provide primary palliative care, especially outside the transfer of care model.

Background:Since 2015, the College of Family Physicians of Canada has certified enhanced skills in palliative care (PC) with a certificate of added competence.Aim:This study aimed to describe the ways family physicians with enhanced skills in PC contribute within their communities, the factors that influence ways of practicing, and the perceived impacts.Design:Secondary analysis of data from a multiple case study on the role and impacts of family physicians with enhanced skills (i.e., PC physicians) was undertaken.Setting/Participants:Interviews were conducted in 2018 to 2019 with PC and generalist family physicians and residents associated with six family medicine practice cases across Canada. An unconstrained qualitative content analysis was performed.Results:Twenty-one participants (nine PC physicians, five generalist family physicians, two residents, and five physicians with enhanced skills in other domains) contributed data. PC physicians worked by enhancing their own family practice or as focused PC physicians. Roles included collaborating with other physicians through consultations, comanaging patients (shared care), or assuming care of the patient as the main provider (takeover). PC physicians increased capacity among their colleagues, with some patient care and education activities not being remunerated. Funding models and other structures were perceived as incentivizing the takeover model.Conclusion:Family physicians with enhanced skills in PC contribute to comprehensive care through the end of life. Remuneration should support system capacity and relationships that enable family physicians to provide primary PC especially outside the takeover model.

BackgroundRespiratory medicine (RM) and palliative care (PC) physicians’ management of chronic breathlessness in advanced chronic obstructive pulmonary disease (COPD), fibrotic interstitial lung disease (fILD) and lung cancer (LC), and the influence of practice guidelines was explored via an online survey.MethodsA voluntary, online survey was distributed to RM and PC physicians via society newsletter mailing lists.Results450 evaluable questionnaires (348 (77%) RM and 102 (23%) PC) were analysed. Significantly more PC physicians indicated routine use (often/always) of opioids across conditions (COPD: 92% vs. 39%, fILD: 83% vs. 36%, LC: 95% vs. 76%; all p < 0.001) and significantly more PC physicians indicated routine use of benzodiazepines for COPD (33% vs. 10%) and fILD (25% vs. 12%) (both p < 0.001). Significantly more RM physicians reported routine use of a breathlessness score (62% vs. 13%, p < 0.001) and prioritised exercise training/rehabilitation for COPD (49% vs. 7%) and fILD (30% vs. 18%) (both p < 0.001). Overall, 40% of all respondents reported reading non-cancer palliative care guidelines (either carefully or looked at them briefly). Respondents who reported reading these guidelines were more likely to: routinely use a breathlessness score (χ2 = 13.8; p < 0.001), use opioids (χ2 = 12.58, p < 0.001) and refer to pulmonary rehabilitation (χ2 = 6.41, p = 0.011) in COPD; use antidepressants (χ2 = 6.25; p = 0.044) and refer to PC (χ2 = 5.83; p = 0.016) in fILD; and use a handheld fan in COPD (χ2 = 8.75, p = 0.003), fILD (χ2 = 4.85, p = 0.028) and LC (χ2 = 5.63; p = 0.018).ConclusionsThese findings suggest a need for improved dissemination and uptake of jointly developed breathlessness management guidelines in order to encourage appropriate use of existing, evidence-based therapies. The lack of opioid use by RM, and continued benzodiazepine use in PC, suggest that a wider range of acceptable therapies need to be developed and trialled.

Existential pain—an entity, a provocation, or a challenge?

A Nationwide Survey of Japanese Palliative Care Physicians' Practice of Corticosteroid Treatment for Dyspnea in Patients With Cancer

Palliative care and end stage liver disease: A survey study comparing perspectives of hepatology and palliative care physicians and clinical scenarios that could require palliative care intervention

At our institution's cancer palliative care (PC) clinic, new referrals from oncologists were scheduled for consultation and ongoing follow-up by PC physicians without input from the patients' family physicians (FPs). FPs reported that they felt out of the loop. We implemented a quality improvement (QI) initiative aimed at systematically facilitating care coordination between FPs and PC physicians. A coordination toolkit was sent from the PC physician to the FP whenever the PC physician received a consultation request from an oncologist. The toolkit included an introduction to the PC physician team; an opportunity for the FP to choose how best to collaborate with PC physicians to meet the patient's PC needs; and contact information for access to 24/7 PC physician support. Responses from FPs regarding their preferred level of engagement with PC determined further care planning in the clinic. We measured feasibility, response rate, and qualitative surveys of FPs about the usefulness of the intervention. Two hundred fourteen new consultations were eligible for a standardized letter over the 6-month implementation period. Feasibility for sending the toolkit was 90.0% and response rate for collaborative care preference from FPs was 86.0%, with median response time of 3-4 days. 78.9% of FPs indicated they would prefer ongoing consultative care by the PC physician, while 18.6% indicated that PC physician consultation was not needed, or that the FP would provide primary PC after a one-time PC physician consultation. We successfully implemented a QI initiative to improve care coordination between FPs and PC physicians for patients with cancer. The coordination toolkit can protect the patient-FP primary PC relationship and optimize specialist PC resource utilization for complex patients.

Background: The 12-months “surprise” question (12-SQ) for estimating prognosis and the need for integrating palliative care (PC) services has not yet been investigated for neurological patients.Objective: Test the value of the 12-SQ on a sample of neurorehabilitation patients.Methods: All patients newly registered in the Department of Neurorehabilitation, Dr. Becker Rhein-Sieg-Clinic (8/2016-03/2017) were asked to participate. The treating neurorehabilitation physicians (NP) and an external consulting PC physician (PCP) independently estimated patients' prognosis using the 12-SQ; while symptom burden was independently assessed using the standardized palliative outcome measurement HOPE-SP-CL, a set of additional neurological issues, and ECOG. Follow-up with consenting patients 12 months later was via telephone. Descriptive and inferential statistics were utilized in data analysis.Results: Of 634 patients, 279 (44%) patients (male: 57.7%, female: 42.3%; mean age: 63 ± 14) (or, alternatively, their legal representative) consented and were assessed at baseline. Per patient NP and PCP both answered the 12-SQ with “Yes” (164), with “No” (42), or had different opinions (73). The “No” group displayed the highest symptom burden on all three measures for both disciplines. Overall, PCP scored higher (i.e., worse) than NP on all measures used. Follow-up was possible for 236 (drop-out: 15.4%) patients (deceased: 34 (14.4%), alive: 202 (85.6%)). Baseline scores on all measures were higher for deceased patients compared to those still living. Prognostic characteristics were: sensitivity: NP 50%, PCP 67.6%; specificity: NP 86.1%, PCP 70.3%, p < 0.001; positive predictive value: NP 37.8%, PCP 27.7%; negative predictive value: NP 91.1%, PCP 92.8%; area under the curve: NP 0.68, PCP 0.69; success rate: NP 80.9%, PCP 69.9%, p = 0.002. Regression analysis indicated that age, dysphagia and overburdening of family (NP answering the 12-SQ), dysphagia and rehabilitation phase (PCP answering the 12-SQ) were associated with increased likelihood of dying within 12 months. Without the 12-SQ as relevant predictor, age, dysphagia and ECOG were significant predictors (NP and PCP).Conclusion: Combining the 12-SQ with a measurement assessing PC and neurological issues could potentially improve the 12-SQ's predictive performance of 12-month survival and help to identify when to initiate the PC approach. Clinical experiences influence assessment and prognosis estimation.

The Current Practice of Oxygen Therapy for Dyspnea in Terminally Ill Cancer Patients: A Nationwide Survey of Japanese Palliative Care Physicians

107 Background: Integration of palliative care in the outpatient oncology clinic improves the quality of care for patients with advanced cancer. While models of outpatient palliative care (PC) in the academic oncology clinic have been demonstrated, the feasibility of PC in a private practice oncology clinic has not been established. Methods: In 2014 our 8 office oncology practice composed of 30 physicians and 10 advanced practice providers hired a full-time PC physician. Our questions included: 1) Would the PC physician be valued by the oncologists in the practice; 2) Would internal referrals and follow-up encounters provide sufficient activity for PC physician employment; 3) Would the revenue received for patient encounters offset the cost to the practice of the PC physicians? We emailed a survey to providers; we tallied data on patient encounters; and we reviewed the actual dollar amount of reimbursements received from payers for PC evaluation and management codes for a 1 year period. Results: In our second full year, a single palliative care physician saw 487 initial consultations and 1273 follow-up encounters for a total of 1760 encounters. The collected revenue for these encounters covered 102% of the palliative care physician’s combined salary and overhead. This data enabled the additional hiring of a second PC physician in 2016. Of 36 providers surveyed, 24 (67%) completed our 10 question survey. On a 1-5 point scale, when asked to rank the positive influence of the palliative care program on the culture of patient care in the practice, the aggregate score was 4.96. When asked questions on how helpful the palliative care program was to the providers in managing a variety of patient concerns, all items scored between 4.5 and 5. A question on how helpful the PC physicians were as a curbside resource received an aggregate score of 5.0. Conclusions: Based on referral numbers and surveyed attitudes, PC physicians were readily accepted into the fabric of a community based oncology practice. Analysis of financial data demonstrates that the PC physician can cover a substantial part of their salary requirement through billing for patient encounters.

Spiritual Care Training for Palliative Care Fellows (QI726)

The aim of this study was to explore palliative home care physicians' experiences regarding end-of-life breakpoint communication (BPC). This is a qualitative study where focus group interviews were conducted and analysed using qualitative content analysis. The results show that the participants saw themselves as being responsible for accomplishing BPC, and they were convinced that it should be regarded as a process of communication initiated at an early stage, i.e. proactively. However, BPC was often conducted as a reaction to the patient's sudden deterioration or sometimes not at all. The barriers to achieving proactive BPC included physicians' uncertainty regarding the timing of BPC, primarily due to difficulties in prognostication in terms of time of death, and uncertainty as to what BPC should include and how it should best be approached. Furthermore, there was insufficient documentation regarding previous BPC, which impeded proactive BPC. Although our study shows that physicians are ambitious when it comes to the communication of information to patients and families, there is a need for further training in how to conduct BPC and when to initiate the BPC process. Furthermore, there should be documentation that different professionals can access as this would appear to facilitate a proactive BPC process.

We examined the delivery of physician palliative care (PC) services and its association with aggressive end-of-life care (EOLC) in patients with gastrointestinal (GI) cancer in Ontario, Canada. All patients with primary cause of death from esophageal, gastric, colon, and anorectal cancer from January 2003 to December 2013 were identified. PC services within 2years of death were classified: (1) any PC; (2) timing of first PC (≤ 7, 8-90, 91-180, and 181-730days before death); and (3) intensity of PC measured by number of days used (1st-25th, 26th-50th, 51st-75th, and 76th-100th percentiles). Aggressive EOLC was defined as any of the following: chemotherapy, emergency department visits, hospital or intensive care unit (ICU) admissions (all ≤ 30days of death), and death in hospital and in the ICU; these were combined as a composite outcome (any aggressive EOLC). The cohort included 34,630 patients, of whom 74% had at least one PC service. Timing of the first PC service varied: ≤ 7 (12%), 8-90 (42%), 91-180 (16%), and 181-730 (30%) days before death. Compared with patients not receiving PC, any PC was associated with a reduction in any aggressive EOLC (risk ratio [RR] 0.75, 95% confidence interval [CI] 0.74-0.76); this association was similar regardless of timing of the first PC service. The most dramatic reduction in aggressive EOLC occurred in patients who received the greatest number of days of PC (RR 0.65, 95% CI 0.63-0.67). The majority of patients received PC within 2years of death. A larger number of days of PC was associated with a greater reduction in aggressive EOLC.

Objectives: The field of pediatric palliative care (PPC) has grown in the last few years because of increased awareness of the unique requirements of children at the terminal stage. In this study, we aimed to analyze the willingness and confidence of adult palliative care physicians in Saudi Arabia who provide palliative care services to children in need. Methods: This study employed a cross-sectional design to collect data from a large sample of palliative care physicians in Saudi Arabia. This study included palliative care physicians with a Saudi license who worked in Saudi Arabia and cared for patients with palliative needs. Results: According to this study, palliative care physicians in Saudi Arabia felt unprepared to provide PPC while maintaining a good attitude toward the practice. Most palliative care physicians believed that their training was insufficient because they had little experience in this field. In addition, they are less comfortable managing pain and symptoms than interacting with families of palliative children. Conclusions: In Saudi Arabia, palliative care physicians are eager to offer PPC; however, they need requisite resources and training. In addition, we found that palliative care physicians and their patients would benefit from further support and assistance from a PPC team.

1436P - Survey on Models of Integration of Oncology and Palliative Care (PC) in Italian Oncology Units Esmo Designated Centers