Mechanical Insufflation-Exsufflation: A Strategy in Oncological Palliative Care

The effect of early and systematic integration of palliative care in oncology on quality of life and health care use near the end of life: A randomised controlled trial

252 Background: Despite a strong evidence base and increasing calls for integration, oncologists find it difficult to deliver primary palliative care concurrent with standard oncology care. Solutions that promote practical integration of palliative care in oncology are needed. In an AHRQ-funded pilot, ASCO and the American Academy of Hospice and Palliative Medicine are developing the Virtual Learning Collaborative (VLC) to develop and test a scalable model for quality improvement and dissemination of best practices in palliative care within the oncology setting. Methods: The VLC will be a web-based learning and collaboration system built upon existing ASCO technology resources. We will select at least 25 oncology practices to participate in regular, facilitated learning sessions, collaborative discussions, and sharing of best practices. The VLC will equip each practice with the knowledge, tools, and coaching to select, test, and adopt a quality improvement intervention relevant to their own palliative care needs. Development of the VLC is ongoing; oncology practices begin participation in Spring 2014. Results: We will assess the VLC using protocol-driven evaluation methods common to technology development, quality improvement, implementation science, and educational initiatives. VLC usability, feasibility, and acceptability will be assessed through surveys of participating practices and focus groups. Longitudinal changes in conformance to palliative care metrics will be assessed using ASCO’s Quality Oncology Practice Initiative (QOPI) system. We will use mixed qualitative and quantitative evaluation methods to assess ongoing changes in clinician knowledge and self-efficacy in applying palliative care principles. Conclusions: We aim to develop and test a novel method for facilitating quality improvement and palliative care learning in oncology. Through this pilot, we will refine the VLC for implementation in the greater oncology community. Ultimately, this effort supports other ASCO and AAHPM quality improvement initiatives focused on clinician education and dissemination of best practices.

Background:Palliative care is a specialized approach to symptom management that focuses on supporting patients’ physical and psychological quality of life throughout the disease course. In oncology, palliative care has been increasing in utilization. The evidence base for such care is also growing through the use of randomized controlled trials (RCTs). In this review, we aim to integrate the findings from 4 meta-analyses of palliative oncology care RCTs to examine the impact of palliative care on physical and psychological quality of life and survival.Method:We considered 4 meta-analyses of palliative oncology care RCTs, which each used slightly different methodologies and analyses. Two of the meta-analyses included both outpatient and inpatient populations, whereas the remaining meta-analyses focused specifically on outpatient palliative oncology care.Results:All 4 meta-analyses reported a robust quality of life advantage for patients randomized to receive palliative care. Two meta-analyses identified a survival advantage, whereas the other 2 detected no survival differences. In 1 meta-analysis that examined high-quality RCTs of outpatient palliative oncology care, it was found that an increased survival probability for palliative care, compared with standard of care, was confined to 6- to 18-month follow-up.Conclusions:There is a growing evidence base for palliative oncology care, as highlighted by the 4 meta-analyses considered. Such care successfully improves both physical and psychological quality of life for patients with serious illnesses, especially cancer. Clinicians should educate patients and their caregivers about the findings of these meta-analyses. Finally, governmental policies should focus on increasing palliative care access.

20 Background: PC and oncology teams can most effectively improve patient experience during cancer when the specialties improve care processes together through collaborative QI activities. To support collaboration ASCO, the American Academy of Hospice and Palliative Medicine, and Duke University developed a partnership to pilot the ASCO VLC. This pilot will develop and test a scalable model for quality improvement and dissemination of best practices, focused on improving palliative care in oncology. Methods: The ASCO VLC integrates lessons learned through the Breakthrough Series, ASCO Quality Training Program, and others. An Advisory Committee representing expertise in medical oncology, palliative care, geriatrics, nursing, social work, survivorship, health services research, and quality improvement oversees the pilot project. Content in the VLC website was refined based on feedback gathered through a needs assessment survey of pilot participants. Results: The online collaborative and learning platform went live in June 2014. The site houses live and recorded educational sessions covering PC and QI topics, includes discussion boards to foster interactions between practices, supports sharing of tools and resources, and allows practices to submit their problems and aims statements, and results of their work for peer review and feedback. 24 practices were recruited to participate; 73% from community/private practice sites. In response to the needs assessment, 85% of participants responded with a high sense of comfort with PC; yet, only 33% had similar comfort with QI. When asked to rank their top preference, respondents were most interested in learning about pain and symptom management (44%), or advance care planning (22%). Ongoing mixed qualitative and quantitative assessments through Spring 2015 will assess feasibility and acceptability of the ASCO VLC model. Conclusions: We are creating an online virtual learning collaborative as a sustainable infrastructure to support and foster clinician education and dissemination of PC best practices in oncology.

Purpose To conduct an integrated systematic literature review to explore (1) the presence and impact of stigma surrounding palliative care (PC) in Oncology particularly related to the care of adults with advanced cancer and (2) how Oncology healthcare providers (OHCPs) may contribute and perpetuate PC stigma, a factor associated with the underutilization of PC. Methods A comprehensive search was conducted in four major databases using PRISMA guidelines. Thirty‐two articles met the inclusion criteria focused on the perspectives of PC by OHCPs who treat adults with advanced cancer. Guided by Goffman’s Theory of Stigma, articles were iteratively reviewed and stigma‐related themes were generated. Results Six major themes emerged defining the concept of Oncology PC stigma and were categorized into two groups, which Goffman labels as “stigmatized” and “stigmatizers.” Assumptions, fear, and discomfort are the three common perceptions OHCPs which drive their behaviors as the stigmatizers. Avoidance, undesired differentness, and negative association with the term “palliative care” are the three reoccurring behaviors and perceptions seen in adults with advanced‐stage cancer, who are the stigmatized. A novel conceptual framework is presented with these six major characteristics of Oncology PC stigma with their corresponding outcomes. Conclusion Societal stigma associated with PC in Oncology is pervasive and driven by behaviors and perceptions of not only patients and their families who are reluctant to use PC but OHCPs themselves. Findings underscore the need for interventions that address OHCP’s lack of understanding about how their own perceptions and behaviors may impact patient PC utilization and outcomes.

Amaç: Metropol bir kentte yer alan hastanenin onkoloji kliniğinde çalışmakta olan ve palyatif bakım deneyimi olan hemşirelerin mesleki yaşam deneyimlerinin incelenmesidir. Gereç ve yöntem: Bu araştırma niteliksel bir çalışma deseni olan fenomenolojik bir temele dayanmaktadır. Çalışmanın örneklemini, metropol kentte yer alan bir hastanenin onkoloji kliniğinde ve palyatif bakım ünitesinde çalışan ve palyatif bakım hemşirelik deneyimi olan toplam 7 hemşire oluşturmuştur. Çalışmanın verileri, Mayıs–Haziran 2017 tarihleri arasında toplanmıştır. Bulgular: Katılımcıların tamamı kadınlardan oluşmaktadır. Yaş ortalamaları 32.7 olarak hesaplanmıştır. Katılımcıların %71.5’i evli, %57.4’ü eşi ile birlikte yaşamakta, tamamı lisans mezunudur. Meslekte çalışma yılı ortalamaları 12.8 yıl, palyatif bakım hemşireliği ortalamaları 5.2 yıl aralığındadır. Katılımcıların yaşadıkları meslek deneyimleri incelenmiş, verilerin betimleyici ve yorumlayıcı analizlerinin ardından oluşturulan üç ana tema ve 7 alt tema oluşturulmuştur. Zorluklar temasının; yorgunluk, baş etmede zorlanma / tükenmişlik, iletişim sorunlarından oluşan üç alt teması, kazanımlar temasının; profesyonelleşme/ doyum, hayatı anlamlandırma: yaşam ve ölüm, ekip uyumun yer aldığı üç teması ve başetme yöntemleri temasının; alana özel deneyim/eğitim bir alt teması belirlenmiştir. Sonuç: Çalışmamızda, onkoloji palyatif bakımda çalışan hemşirelerin, meslek deneyimleri sonucunda bir takım zorluklara maruz kaldıkları, buna ek olarak kazanımlarınında olduğu ve bunlarla baş etme becerilerinin yakın ilişkili olduğu saptanmıştır. Bu konuda daha fazla çalışmaya ihtiyaç bulunmaktadır. Anahtar Kelimeler: Palyatif bakım, palyatif bakımda hemşirelik deneyimleri, nitel çalışmalar.

PURPOSEThe burden of cancer disproportionately affects low- and middle-income countries. Low 5-year survival figures for children with cancer in low-income countries are due to late presentation at diagnosis, treatment abandonment, absence of sophisticated multidisciplinary care, and lack of adequate resources. The reasons for late presentation are partly due to limited awareness of cancer symptoms, high treatment costs, and facility-level barriers to timely access to treatment. Given the systemic challenges, the regional need for palliative oncology care for children care is high. Despite the enormity of the need for palliative oncology for children with cancer in Africa, its level of development remains poor. This paper presents the evidence on the status of palliative oncology care for children in sub-Saharan Africa.METHODSThis review provides an overview of the current status of palliative oncology care for children in sub-Saharan Africa, using the WHO building blocks for health systems strengthening as reference points, before proposing a forward-looking prioritized agenda for its development.RESULTSWe noted that survival rates for children with cancer remain much poorer in Africa compared with developed countries and palliative oncology care resources are scant. Our results also show low coverage for palliative oncology care services for children, lack of a critical mass of health workers with the skills to deliver the care, a lack of robust documentation of the burden of cancer, widespread lack of access to essential controlled medicines, limited funding from government and limited coverage for palliative oncology care in most cancer control plans.CONCLUSIONThis review highlights priority areas for action that align to the WHO health system building blocks for strengthening health systems.

282 Background: Palliative care in oncology encompasses a wide array of care, and optimal performance metrics remain uncertain. To address this issue we held a regional meeting that included patient advocates, clinicians, private and public payers and researchers to identify quality indicators for palliative care, discuss palliative care (PC) quality measurement in the region, review preliminary results and metrics for PC, and identify opportunities to improve care. Methods: Regional experts facilitated discussions. Data was presented from a regional insurance claims-cancer registry linked database. Participants were asked to: discuss and prioritize interventions to improve palliative care in oncology and create metric dashboards for healthcare providers. Results: Oncology-specific recommendations for interventions: early and continuous palliative care discussions from diagnosis through EOL; training existing care team on palliative care conversations, through standard certification programs; pair patients with an experienced patient/patient advocate; educate caregivers, patients and providers respectively on how to communicate about PC and care choices; and patient navigation to manage symptoms of advanced cancer. Feedback on prioritization of palliative care/EOL metrics: see Table. Conclusions: A multi-stakeholder approach can be effective for developing metrics and interventions to improve palliative care by providing an understanding of the information needs of the community. [Table: see text]

Although much evidence has accumulated demonstrating its benefit, relatively little is known about outpatient palliative care in patients with cancer. This paper reviews the literature and perspectives from content experts to describe the current state of outpatient palliative care in the oncology setting and current areas of innovation and promise in the field. Evidence, including from controlled trials, documents the benefits of outpatient palliative care in the oncology setting. As a result, professional medical organizations have guidelines and recommendations based on the key role of palliative care in oncology. Six elements of the practice sit at the frontier of outpatient oncology palliative care, including the setting and timing of palliative care integration into outpatient oncology, the relationships between primary and specialty palliative care, quality and measurement, research, electronic and technical innovations, and finances. Evidence of clinical and health care system benefits supports the recommendations of professional organizations to integrate palliative care into the routine treatment of patients with advanced cancer.

Palliative care complements anti-cancer treatment, and may actually improve the therapeutic effect by optimising performance status, functioning, symptom management and quality of life, thus improving compliance to treatment. A series of randomised controlled trials investigating early integration of palliative care and oncology document clear benefits in patient-centred outcomes. Still, palliative care is often introduced late in the disease trajectory, if at all. One reason may be that that palliative care is perceived as end-of-life care only, a too common perception among healthcare providers, patients and the public alike. Another, and maybe the most important, reason is the cultural differences between the two disciplines, oncology and palliative care. While the predominant focus in oncology is treatment and cure of the disease, i.e., a tumour-centred focus, the focus in palliative care is the patient with the disease, i.e., the patient-centred approach. Integration of oncology and palliative care implies that these two cultures approach each other, collaborate and recognise that this is not an either or, but time to collaborate with the best interest of the patients. To accomplish this, an organisational model to provide optimal patient-centred palliative care is necessary at all levels. Such a model must structure the collaborations between different professions, across different levels and the patient flow between the silos in healthcare, and should describe the content of care. Using models like this is not common, and requires changes in systems and cultures on organisational, administrative, educational and individual levels. To successfully achieve profound changes is challenging. For example, it may be hampered by professional autonomy in the different disciplines and hinder collaboration and the achievement of a shared mental model. The use of standardised care pathways may be one way to integrate the tumour-centred and patient-centred approaches, reduce cultural barriers and improve patient care.

Introduction: Palliative care aims to improve quality of life for people living with a life-limiting illness. There are approximately 2.5 million people with cancer in the UK, and this may reach 4 million by the year 2030. An integrated approach to palliative care and cancer care is recommended to achieve continuity of care and address unmet needs. However, this is not yet common practice - symptom burden, futile treatment, and fragmented care continue to be significant issues that impede quality of life for patients and their families. Existing evidence demonstrates the benefits of integrated palliative care in oncology, for symptom burden, quality of life, and health service resource use. However, we do not know which interventions produce the best outcomes for patients and families, when best to initiate palliative care (for whom, or at what stage in the disease trajectory), or the optimal delivery method in terms of healthcare settings, the necessary infrastructure, and required staff competencies. Aims: We aim to explain how integrated palliative care in oncology works, for whom, and in what contexts; and to use this understanding to develop guidance to optimise integration. Methods: Realist synthesis is a theory-driven approach to a literature review, designed to understand complex interventions or phenomena by illuminating the interactions between context and mechanisms in leading to outcomes. The realist synthesis involves five iterative stages: 1) locating existing theories; 2) searching for evidence; 3) article selection; 4) extracting and organising data; 5) synthesising evidence and drawing conclusions. This synthesis is supported by an international stakeholder group, comprising healthcare professionals, NHS management, community groups, and public contributors. Close collaboration with this group ensures our findings are communicated in ways that meet the needs of key audiences, and that implications are relevant to current practice. Results: Emerging findings indicate that the integration of palliative care is more likely when: -Professionals across multiple disciplines work together effectively, -There is continuity of care across different care settings, -There are positive perceptions of palliative care, -There is education for healthcare professionals and for patients and caregivers. Conclusion: Through the synthesis of a range of evidence, this project contributes a detailed understanding of how integrated palliative care and cancer care can be achieved. Ongoing refinement of findings with our stakeholder group allows for implications to be co-produced, and facilitates our dissemination strategies. Therefore, the project helps to realise the benefits of integrated care for adults with cancer, i.e., improved symptom management, quality of life, and appropriate use of health service resources.

Describe the actions implemented for pain management in palliative care oncology and analyze the contribution of Hospital do Câncer IV, as a reference unit at the National Cancer Institute. Study of the history of the present time, whose sources were written documents and interviews with five participants. The collection took place from February to June 2018. The analysis of the written sources took place through internal and external criticism of the documents, considering their chronology and theme. Professionals contributed with actions for pain management in palliative oncology care: in discussions and final drafting of ordinances, as rapporteurs at national and international events, in the elaboration of humanization conducts and systematization of assistance in addressing pain. These actions favored assistance in palliative oncology care at various levels of health care for patients and families, with greater technical and scientific recognition for all.

To evaluate the sensitivity and specificity of the Distress Thermometer (DT) as a screening tool for emotional distress in oncological palliative care patients and to compare the DT with the Edmonton Symptom Assessment System-revised (ESAS-r) and the gold standard to determine the most appropriate assessment method in palliative psychological care. Data were collected from psychological screening tests (ESAS-r and DT), and clinical interviews (gold standard) were conducted by a clinical psychologist specialist in palliative oncology from January 2021 to January 2022 in an oncology palliative care service. The sample consisted of 356 first-time patients with a diagnosis of advanced cancer in palliative care. The most frequently reported oncological diagnoses were gastrointestinal tract (49.3%) and breast (18.3%). Most patients were female (n=206; 57.9%), 60.4% were married/with a partner, 55.4% had between 6 and 9years of schooling, and a median age of 57 (range, 46-65) years. The cutoff of the DT was 5, with a sensitivity of 75.88% and specificity of 54.3%. Emotional problems (sadness and nervousness) had a greater area under the curve (AUC) when measured using the DT than the ESAS-r; however, only in the case of the comparative sadness and discouragement was the difference between the AUC marginally significant. The use of the DT as a screening tool in oncological palliative care is more effective in the evaluation of psychological needs than the ESAS-r. The DT, in addition to evaluation by an expert psychologist, allows for a more comprehensive identification of signs and symptoms to yield an accurate mental health diagnosis based on the International Classification of Diseases-11th Revision and/or Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition.

Palliative care has emerged as an essential component of comprehensive oncology care, addressing the physical, psychological, and emotional needs of patients across the cancer continuum. Early integration of palliative care alongside disease-directed therapies improves symptom control, enhances quality of life, reduces healthcare costs, and supports patient-centred decision-making. This chapter examines the role of palliative care in oncology, with a focus on evidence-based symptom management strategies, including pain control, management of non-pain symptoms, and psychosocial support. Various models of integration—such as concurrent care, specialist palliative care clinics, and dual training programs—are discussed to highlight collaborative approaches that optimize outcomes. Emerging evidence demonstrates that integrated palliative and oncology care improves quality of life, symptom burden, and, in some populations, clinical outcomes across adult and paediatric oncology settings. As oncology continues to evolve, expanding access to palliative care services, fostering interdisciplinary collaboration, and promoting early referral remain critical. Integrating palliative care as a core element of cancer treatment is vital for delivering compassionate, holistic, and patient-centred care.

Burden on family caregivers of the elderly in oncologic palliative care