PC-FACS

Abstract

PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6–10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members and members can earn up to 3 CME credits quarterly. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] PC-FACS (Fast Article Critical Summaries for Clinicians in Palliative Care), an electronic publication of the American Academy of Hospice and Palliative Medicine, provides palliative care clinicians with concise summaries of the most important findings from more than 50 medical and scientific journals. Each month, structured summaries and insightful commentaries on 6–10 articles help palliative care clinicians stay on top of the research that is critical to contemporary practice. PC-FACS is free to AAHPM members and members can earn up to 3 CME credits quarterly. Following are excerpts from recent issues, and comments from readers are welcomed at [email protected] Temel JS, Greer JA, Admane S, et al. Longitudinal perceptions of prognosis and goals of therapy in patients with metastatic non-small cell lung cancer: results of a randomized study of early palliative care. J Clin Oncol 2011;29(17):2319–2326. McCloskey RM. A qualitative study on the transfer of residents between a nursing home and an emergency department. J Am Geriatr Soc 2011;59(4):717–724. Doug M, Adi Y, Williams J, et al. Transition to adult services for children and young people with palliative care needs: a systematic review. Arch Dis Child 2011;96(1):78–84. Miner TJ, Cohen J, Charpentier K, et al. The palliative triangle: improved patient selection and outcomes associated with palliative operations. Arch Surg 2011;146(5):517–522. Ledema R, Allen S, Britton K, et al. Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study. BMJ 2011;343:d4423. Mak W. Self-reported goal pursuit and purpose in life among people with dementia. J Gerontol B Psychol Soc Sci 2011;66(2):177–184. Mayer DK, Travers D, Wyss A, Leak A, Waller A. Why do patients with cancer visit emergency departments? Results of a 2008 population study in North Carolina. J Clin Oncol 2011;29(19):2683–2688. Berkowitz RE, Jones RN, Rieder R, et al. Improving disposition outcomes for patients in a geriatric skilled nursing facility. J Am Geriatr Soc 2011;59(6):1130–1136. Catt S, Langridge C, Fallowfield L, Talbot DC, Jenkins V. Reasons given by patients for participating, or not, in Phase 1 cancer trials. Eur J Cancer 2011;47(10):1490–1497. Nursing home (NH) residents are commonly transferred to the emergency department (ED) for acute care. Do these periods of transition put residents at increased risk of receiving suboptimal care? This qualitative study was conducted to examine residents' experience of transfer from NH to ED. Eligible residents of an urban, 198-bed Canadian NH who provided consent were observed during the six-month study period for transfers to a tertiary care facility with 70,000 annual ED registrants. Data were obtained through direct investigator observation of transfers (n=24), interviews with residents (n=5), NH practitioners (n=9), and ED practitioners (n=6), and review of institutional policies and practices. Observed residents (n=61) were all cognitively intact. Most of the interviewed NH and ED practitioners were nurses. NH physicians were available only for a few hours a week and were unavailable by phone for any care issues. Three themes were identified: (a) work of executing transfers, (b) creating and exchanging resident information, and (c) feelings of guilt but not feeling responsible about how resident transfers occurred. NH nurses were responsible for determining resident transfer to the ED, while ED physicians determined transfer to the NH. Practitioners across sites recognized the importance of communicating information across sites, but the time-consuming paperwork completed at the NH was typically disregarded at the ED, and the ED record was rarely sent back to the NH. Paramedics provided only minimal communication between the NH and ED. Practitioners in both the NH and ED reported feeling guilty for the low quality of care but typically pointed to other parties as being responsible for improving residents' transfers. A 2001 Institute of Medicine report indicated that transitions of care require increased care coordination to improve quality of care and reduce errors.1 Almost one in four Medicare beneficiaries “experienced complicated care transitions” after hospital discharge,2 and 19% of patients experienced an adverse event within three weeks of hospital discharge.3 Several projects have started to address this (e.g., the National Transitions of Care Coalition4). The Centers for Medicare and Medicaid Services will soon institute payment incentives encouraging hospitals to reduce unnecessary readmissions, with transfers to and from NHs receiving heightened attention. In this article, NH and ED practices mandated the use of ineffective tools and directly inhibited necessary one-to-one communication between practitioners. There was significant misunderstanding of each other's practice setting and a feeling of powerlessness to effect change. Top-to-bottom cultural changes are needed to empower development of effective, site-specific processes and tools that foster efficient, real-time communication to improve care transitions. Transitions of care represent a major, preventable area of health care quality issues and errors; however, both institutional and “at the bedside” changes in practice are necessary to implement needed improvements. Ronald J. Crossno, MD, CMD, FAAFP, FAAHPM, Gentiva Health Service's Hospice Division, Dallas, TX. McCloskey RM. A qualitative study on the transfer of residents between a nursing home and an emergency department. J Am Geriatr Soc 2011;59(4):717–724. 1.Institute of Medicine. Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press, 2001.2.Coleman EA, Min SJ, Chomiak A, Kramer AM. Posthospital care transitions: patterns, complications, and risk identification. Health Serv Res 2004;39(5):1449–1446.3.Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med 2003;138(3):161–167.4.National Transitions of Care Coalition. Available from www.ntocc.org. Accessed August 20, 2011. An increasing number of children diagnosed with life-threatening conditions (LTC) live into adulthood. Are their palliative care needs adequately met during the transition to adult services? This systematic review evaluated the transition from pediatric to adult services for individuals with palliative care needs. A database search of MEDLINE, CINAHL, PsycINFO, the British Education Index, and the International Bibliography of the Social Sciences was conducted. Eligible studies were original articles, reviews, consensus policies, guidelines, or survey recommendations that included patients aged 13–24 years with palliative care conditions who were in the transition process. Empirical study quality was systematically assessed using a validated scoring system (possible score 8–32; higher scores indicating better quality). Ninety-two papers were identified. Thirty-one of 92 studies were empirical (34%) and were of variable quality (mean score 24±3). There were no randomized controlled trials, comparative trials, or economic reviews. Three studies referenced palliative care. Primary study focus was on LTC (n=24), life-limiting conditions (n=20), and severe, progressive neurological conditions (n=2). There were no papers on progressive conditions without curative treatment. Of life-limiting conditions evaluated, cystic fibrosis was the most common and had the most robust evidence for high-quality transition. Information, communication, and planning/coordination were the most common themes described in underlying successful transition. As children with chronic illness reach adulthood, the health care system can either continue to provide care in a pediatric center, transition care to an adult program, seek a blend of pediatric specialist with adult care, or lose the patient who drops out of care (a worst-case scenario). Most transition programs were disease specific (e.g., cystic fibrosis or congenital heart disease). Palliative care providers are well situated to improve transitions because the key components of successful transitions as identified in this review, communication and coordination, are our discipline's strengths. But the other key component, information, has to be delivered to the right place at the right time, and for that reason, transitions of care is a team sport for which palliative care can be a part (but only a part) of a system-wide solution. Although only three articles specifically reference palliative care, group consensus is that transitions from pediatric to adult practices should be individualized and guided by a multidisciplinary team with a dedicated individual to help navigate the transition. Paul E. Tatum, MD, MSPH, CMD, FAAHPM, University of Missouri, Columbia, MO. Doug M, Adi Y, Williams J, et al. Transition to adult services for children and young people with palliative care needs: a systematic review. Arch Dis Child 2011;96(1):78–84. Determining whether palliative surgery is appropriate for patients with advanced cancer is a complicated decision for surgeons, patients, and family caregivers. What are the outcomes of patients managed with the palliative triangle method? Surgical consultations requested for symptom palliation or for improving quality of life in patients with advanced cancer during the five-year study period were prospectively entered into a database. Consultations were screened to identify patients who had been evaluated by the palliative triangle method, which required one or two 60-90 minute meetings between the patient, family, and surgeon prior to making a decision regarding surgery. Participants (n=227) were mean age 67 years (±1.2 years); 44% were male. Median overall survival for all patients was 212 days. One hundred six patients (48%) underwent palliative surgery. Patients selected for surgery had a better performance status than those who did not undergo surgery (P=0.001) and a higher median overall survival (528 days vs. 129 days; P < 0.001). Surgical indications included gastrointestinal (GI) obstruction (36%), local control of tumor-related symptoms (26%), and jaundice (10%); explicit documentation of patient-reported symptom improvement or resolution was noted in 91%, all within 30 days. Postoperative complications occurred in 20% of patients. Of the 121 patients (53%) not undergoing surgery, reasons included low symptom burden (24%), personal preference (20%), decision for nonoperative intervention (19%), and potential complications (16%). This study is a valuable contribution to existing literature regarding palliative surgical options. Data remain scarce with respect to the role of surgery in palliative patients. It remains well accepted that palliative surgical interventions are highly effective, especially when dealing with GI obstruction. In spite of this, practitioners in many centers are hesitant to incorporate palliative surgical options because of high peri-operative mortality as well as medicolegal concerns. However, the survivability data presented in this article support an active role by our surgical colleagues. This prospective trial supports a more involved role for our surgical colleagues to work with patients who demonstrate symptoms anatomically amenable to procedural palliation. Although not explicitly evaluated, the authors propose that good communication among patients, families, and physicians – a fundamental component of the “palliative triangle” – results in selection of patients likely to achieve symptom relief and improved quality of life, with fewer postoperative complications than previously reported with palliative surgeries. Surgical options should be actively considered in select circumstances for symptom palliation, especially symptoms related to GI obstruction. Harold Goforth, MD, Duke University and Durham VA Medical Centers, Durham, NC. Miner TJ, Cohen J, Charpentier K, et al. The palliative triangle: improved patient selection and outcomes associated with palliative operations. Arch Surg 2011;146(5):517–522. Current health care incident disclosure methods do not meet patient and family member expectations. How do patients and family members perceive the health care incident disclosure process and how can disclosure be improved? This qualitative study was conducted to understand patients' and relatives' perceptions of their health care incident disclosure experiences and their perceptions of effective incident disclosure. In this two-phase Australian study, individuals who had experienced a severe to very severe health care incident leading to death, permanent disability, or long-term harm and their relatives were recruited from participating health services (phase 1) and through the national print media and Internet research companies (phase 2). One hundred semistructured interviews were conducted face to face (audio and video recorded) or over the telephone (audiotaped). Participants (n =119) were patients (n=39) and family members (n=80). Patients were average age 57 years (range 4 days-94 years). The majority of incidents occurred in medical (28%) and surgical (24%) inpatient settings. Overarching themes included inadequate family preparation for disclosure, inappropriate disclosure, lack of subsequent support, lack of closure, and inadequate improvement of safety through the disclosure process. From these and related ancillary concerns, the authors generated multiple recommendations for improving the process of incident disclosure, including adequate preparation of all involved, investigation of the incident and agreed-upon cause, presence of a patient support person during the process, two-way dialogue that included perceptions of affected individual and mutually agreed upon strategy to prevent recurrence, patient input into timing for closure, and provision of follow-up information on the improvement process. The Institute of Medicine1 has recommended systems for disclosing medical errors to patients and families, and most U.S. and Canadian physicians agree with this policy.2 The authors of this study provide an important insight to the effectiveness of Australia's open disclosure policy by seeking direct feedback from the key stakeholders – patients and families. There may be a sample bias, which they acknowledge, from the recruitment method of solicitation through national print and Internet media. However, the themes presented and the suggested practice improvements are pertinent and practical. Timely and transparent disclosure by the correct person (the nurse or physician directly involved with the incident) with adequate support and follow-up is most important to patients and families. As patient advocates, we can encourage the hospitals and hospices we work with to adopt such policies. Medical errors and incidents should be reported to patients and families quickly, with input from the patient and family on how to address the issues adequately. Tommie W. Farrell, MD, Texas Tech University Health Science Center, Lubbock, TX. Ledema R, Allen S, Britton K, et al. Patients' and family members' views on how clinicians enact and how they should enact incident disclosure: the “100 patient stories” qualitative study. BMJ 2011;343:d4423. 1.Institute of Medicine. To err is human: Building a safer health system. Washington, DC: National Academies Press, 2000.2.Gallagher TH, Waterman AD, Garbutt JM, et al. US and Canadian physicians' attitudes and experiences regarding disclosing errors to patients. Arch Intern Med 2006;166(15):1605–1611. Patients admitted to skilled nursing facilities (SNFs) are at high risk for early unplanned rehospitalization. Can interventions in an SNF impact discharge dispositions? This observational study took place in a single 50-bed SNF that contained a long-term care hospital on campus. Discharge outcomes were compared in the one-year period before and after implementation of the intervention. The three-component intervention consisted of a standardized physician admission template, automatic palliative care consultation for patients with three or more hospitalizations in the past six months, and twice monthly multidisciplinary conferences to conduct root-cause analyses for rehospitalized patients. All 1,725 admissions to the SNF during the study period were evaluated (862 control, 863 intervention). During the study period, 79% of patients had one admission, 16% had two, and 5% had three or more. Fifty-five palliative care consultations occurred during the control period versus 116 during the intervention. Overall discharge dispositions were significantly different between nonintervention and intervention years (P=0.03). The rate of rehospitalization declined from 17% to 13%, discharges to home increased from 69% to 73%, SNF deaths increased from 1% to 2%, and discharges to long-term care facilities (LTCFs) decreased from 14% to 12%. Multivariable logistic regression analysis controlled for age, sex, case-mix index, and repeated admissions of individual patients demonstrated that patients were more likely to die in the SNF than to be transferred to the hospital during the intervention compared with the control period (odds ratio 2.45; 95% confidence interval 1.1–5.5). The primary objective of this intervention study using historical controls was to reduce hospital readmissions for nursing home residents. Nursing home providers were aware of this objective and were engaged as stakeholders in the intervention. One component of the intervention was a routine trigger for palliative care consultation; other components enhanced attention to broader aspects of geriatric care quality. The study site is a unique LTCF with a strong research presence and onsite physician staff; it is uncertain whether all components of the intervention could be exported to other nursing homes given current practice standards. Patient and family perspective on quality of care was not measured. Expert palliative and geriatric care can reduce hospital admissions for residents of nursing homes; this intriguing single-site intervention merits further study with attention to its effect on patient and family outcomes. Laura C. Hanson, MD, MPH, FAAHPM, University of North Carolina-Chapel Hill, Chapel Hill, NC. Berkowitz RE, Jones RN, Rieder R, et al. Improving disposition outcomes for patients in a geriatric skilled nursing facility. J Am Geriatr Soc 2011;59(6):1130–1136. During the recruitment process, concerns about communication and legitimate consenting may surface when the motives of potential patients are not aligned with the nature of phase 1 (P1) cancer trials. What factors influence a patient's decision to participate in P1 trials? This descriptive study was part of a larger one that aimed to improve communication between health care professionals and prospective P1 subjects. To avoid selection bias, patients were recruited consecutively as they came to any of the five participating U.K. cancer centers for P1 trial discussion. After going through the audio recorded consultation, consenting patients underwent an interview that probed their perspectives on what had just been discussed. They were then sent home and asked to answer three questionnaires after deciding on trial entry: (a) Accept/ Decline Questionnaire, which documented motivations for trial involvement; (b) Life Orientation Test-Revised (LOT-R), which measured tendency to be optimistic; and (c) General Health Questionnaire-12-item version (GHQ12), which detected the presence of probable psychological morbidity. Participants (n=40) were 55% male, with a mean age of 59 years (standard deviation 11). Thirty-six of 40 patients (90%) agreed to P1 participation. Reasons for declining included quality-of-life considerations, other treatment options, and time constraints. Most of the patients indicated they received ample oral (97%) and written (97%) trial information, trusted their treating physician (97%), wanted to help with research (97%), and felt they had nothing to lose (90%). A few were concerned about being a “guinea pig” (33%) and the inability to refuse (16%). Top reasons for granting consent were thoughts of gaining either medical benefit (21%) or hope (15%), the thought that the trial was the best option available (21%), and the desire to help with research (13%). Only one patient (2%) agreed to enlist so that others may benefit from trial results. Among cancer patients, optimism may be imaged as grains of sand in an hourglass that become depleted over time. Unless hope is redefined from a noun to a verb, it is often the impetus behind patients' keen interest in various types of treatments, including P1 trials. Patients who equate treatment with hope maintain an unrealistic hope for cure or life prolongation. This trial shows a stark disconnect between patients' expectations of benefit and study objectives of defining drug safety, tolerability, and pharmacologic profiles. Suggestions to reconcile these divergent goals include improving physician-patient communication and patient understanding of P1 trial outcomes as well as timely and compassionate conveyance of prognosis. The simultaneous provision of palliative care as part of P1 trial design should be considered in light of existing symptom burden and potential study drug side effects.1,2 Advanced cancer patients who enroll in P1 clinical trials are largely engaged by prospects of personal benefit. Renato V. Samala, MD, and Mellar P. Davis, MD, FCCP, FAAHPM, The Cleveland Clinic Foundation, Cleveland, OH. Catt S, Langridge C, Fallowfield L, Talbot DC, Jenkins V. Reasons given by patients for participating, or not, in Phase 1 cancer trials. Eur J Cancer 2011;47(10):1490–1497. 1.Hui D, Parsons H, Nguyen L, et al. Timing of palliative care referral and symptom burden in phase cancer patients: a retrospective cohort study. Cancer 2010;116(18):4402–4409.2.Meyers FJ, Linder J, Beckett L, et al. Simultaneous care: a model approach to the perceived conflict between investigational therapy and palliative care. J Pain Symptom Manage 2004;28(6):548–556. Amy P. Abernethy, MD, FAAHPM, of Duke University Medical Center, is the Editor-in-Chief of PC-FACs. Donna S. Zhukovsky, MD, FACP, FAAHPM, of UT M.D. Anderson Cancer Center, is Associate Editor-in-Chief. The editors thank Jane Wheeler, MSPH, and Robin Fowler, MDiv, for their assistance in compiling this feature. The AAHPM thanks the following for their reviews of the critical summaries and preparation of the commentaries: Robert M. Arnold, MD Stephen Bekanich, MD Janet Bull, MD, FAAHPM Ira Robert Byock, MD Ronald J. Crossno, MD, CMD, FAAFP, FAAHPM Mellar P. Davis, MD, FCCP Mary Ersek, PhD, RN, FAAN, FPCN Tommie W. Farrell, MD Betty Ferrell, PhD, MA, FAAN, FPCN, CHPN Perry G. Fine, MD Daniel Fischberg, MD, PhD Anthony Nicholas Galanos, MA, MD Gail Gazelle, MD, FACP, FAAHPM Harold W. Goforth, MD Laura Hanson, MD, MPH, FAAHPM Peter Mahler, MD, PhD John F. Manfredonia, DO Gregory J. Miller, MD J. Cameron Muir, MD Alan Nixon, MB BCh, BAO, FAAHPM David Nowels, DM Aaron Olden, MD, MS John Peppin, DO, FACP Francine Rainone, DO, PhD, MS, FAAHPM Brad Stuart, MD Paul E. Tatum III, MD, MSPH, CMD, FAAHPM James A. Tulsky, MD Joanne Wolfe, MD The views expressed herein are those of the individual authors and are not necessarily those of the Academy. Information included herein is not medical advice and is not intended to replace the judgment of a practitioner with respect to particular patients, procedures or practices. To the extent permissible under applicable laws, the Academy disclaims responsibility for any injury and / or damage to persons or property as a result of any actual or alleged libelous statements, infringement of intellectual property or other proprietary or privacy rights, or from use or operation of any ideas, instructions, procedures, products or methods contained in this publication. American Academy of Hospice and Palliative Medicine 4700 West Lake Avenue Glenview, IL 60025-1485, USA Phone: 847-375-4712 Fax: 877-734-8671 E-mail: Website: www.aahpm.org