Demand For Palliative Care Services Research Articles

Understanding Family Members in the Palliative Phases of Their Loved Ones: A Qualitative Study.

Because of aging and rising rates of chronic diseases, the demand for palliative care services is increasing worldwide, and patients need family members to care for them throughout the palliative care process. This study aimed to investigate the experiences of the relatives of palliative care patients during hospitalization. This was a qualitative study conducted with 15 family members. A topic guide was used to conduct semistructured face-to-face interviews. Content analysis was used to analyze the textual data. As a result of the analysis, 3 main themes, 6 categories, and 24 subcategories emerged. The main themes were "reactions to the admission," "feeling obligated to care," and "coping processes." The interviews revealed that most participants had misconceptions and a lack of knowledge about palliative care. Almost all of the family members expressed that they experienced various emotions during this process and had trouble coping. The significant finding of our study is that culture and religious beliefs have a considerable influence on caregiving. A limited number of studies in the literature provide detailed insight into the state of patient relatives. Therefore, this study is critical in guiding palliative care professionals in understanding the requirements of this vulnerable group.

Development of a palliative paramedicine framework to standardise best practice: A Delphi study.

Growing global demand for palliative care services has prompted generalist clinicians to provide adjunct support to specialist teams. Paramedics are uniquely placed to respond to these patients in the community. However, embedding palliative care principles into their core business will require multifactorial interventions at structural, healthcare service and individual clinician and consumer levels. To develop a palliative paramedicine framework suitable for national implementation, to standardise best practice in Australia. Delphi study utilising questionnaire completion; each round informed the need for, and content of, the next round. Free text comments were also sought in Round 1. Two rounds of Delphi were undertaken. Sixty-eight participants took part in Round 1, representing six countries, and 66 in Round 2. Participants included paramedics, palliative care doctors and nurses, general practitioners, researchers and carers with lived experience and expertise in palliative paramedicine. Seventeen of the original 24 components gained consensus; 6 components were modified; and 9 new components arose from Round 1. All modified and new components gained consensus in Round 2. Only one original component did not gain consensus across both rounds and was excluded from the final 32-component framework. This study has developed a comprehensive national framework addressing the macro-, meso- and micro-level interventions required to standardise palliative paramedicine across Australia. Future research ought to engage a multidisciplinary team to create an implementation strategy, addressing any perceived barriers, facilitators and challenges for applying the framework into policy and practice.

Promoting Specialty Diversity in Hospice and Palliative Medicine: A Call to Action

The Covid-19 pandemic amplified not only the well-established gap between the supply of the palliative care workforce and the demand for palliative care services across a wide range of specialties, but also the importance of diversity in rising to the challenges of our time. 1 Kamal AH Bull JH Swetz KM Wolf SP Shanafelt TD Myers ER. Future of the palliative care workforce: preview to an Impending Crisis. Am J Med. 2017; 130: 113-114 Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar , 2 Kamal AH Wolf SP Troy J et al. Policy changes key to promoting sustainability and growth of the specialty palliative care workforce. Health Aff (Millwood). 2019; 38: 910-918 Crossref PubMed Scopus (71) Google Scholar , 3 Cooper Z Bernacki RE. To face coronavirus disease 2019, surgeons must embrace palliative care. JAMA Surg. 2020; 155: 681-682 Crossref PubMed Scopus (9) Google Scholar , 4 Shalev D Nakagawa S Stroeh OM et al. The creation of a psychiatry-palliative care liaison team: using psychiatrists to extend palliative care delivery and access during the COVID-19 crisis. J Pain Symptom Manage. 2020; 60: e12-e16 Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar , 5 Dundin A Siegert C Miller D et al. A pivot to palliative: an interdisciplinary program development in preparation for a coronavirus patient surge in the Emergency Department. J Emerg Nurs. 2020; (S0099-1767(20)30286-5) Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar , 6 DiversityEquity & Inclusion Strategic Plan. American Academy of Hospice and Palliative Medicine, 2022http://aahpm.org/uploads/Final_Revised_D__I_Strategic_Plan_Approved_3_13_19.pdf Google Scholar The pool of physicians represented under the 10-member multispecialty board recognizing Hospice and Palliative Medicine (HPM) is critical for filling this workforce gap and for bridging specialty palliative care and the parent specialties. Surgeons, anesthesiologists, psychiatrists, emergency medicine physicians, and others outside the field of internal medicine (IM) are critical emissaries both to and for palliative care. These clinicians, educators, and researchers promote primary palliative care education in their parent specialties, foster acceptance and receptivity to palliative care interventions among their primary specialty colleagues, and build the programs and evidence base that ensure patient access to palliative care across the full spectrum of serious illness. They also bring diverse knowledge, skills, perspectives, and experiences to HPM, informing and shaping the field and augmenting its capacity to serve the needs of a broad range of patients and families. 7 Bassette E Salyer C McCammon S Veazey Brooks J Spoozak L Value of hospice and palliative medicine fellowship after surgical training: bridging the gap for improved patient care. Am J Hosp Palliat Care. 2022; (Epub ahead of print)10499091221128966https://doi.org/10.1177/10499091221128966 Crossref PubMed Scopus (0) Google Scholar

Current public perception of, and barriers to, palliative care in China: a mixed-methods study

Cancer is a major cause of death in China, accounting for 2·56 million deaths in the country in 2018 alone. Yet, on that year, only 28 600 patients (1·1%) at the end of life received palliative care. Existing studies in palliative care have mainly been done in medical environments. The aim of this study was to focus instead on the general public and to identify the public's perceptions of, and demand for, various palliative care services, as well as barriers to palliative care in China. A convergent mixed-methods design was used to facilitate an understanding of the Chinese public's knowledge of palliative care services and the demand for palliative care. An interdisciplinary team of scholars and practitioners worked collaboratively to develop a contextually and culturally relevant questionnaire for the public in China (named KNPCP-1) to explore these issues. Quantitative and qualitative evaluation phases in the development of KNPCP-1 ensured its high validity. We did cross-over comparison analyses of the findings from the quantitative survey (conducted using KNPCP-1). Stata version 17.2 and NVivo version 12.6.1 were used for data analysis. 6120 people completed the qualitative surveys, and 19 survey respondents and 20 medical staff were also interviewed. No significant difference in knowledge of palliative care and general need for various palliative care services was found between men and women. A greater demand for palliative care services was found among rural respondents than among their urban counterparts. Convergent analysis indicates that factors or mechanisms associated with the low availability of palliative care services include scarce knowledge about palliative care, a cultural taboo around death, factors related to patient-clinician conflict, and the pressure on adult children to fulfil their filial duty of care for elderly parents. Several factors contribute to the low availability of palliative care services in China despite recent governmental awareness campaigns. Innovative and culturally sensitive approaches are needed to promote palliative care services in relation to the factors synthesised from the analysis. Ministry of Education of China, Youth Project of Humanities and Social Sciences (project number 20XJC840001); China Postdoctoral Science Foundation (project number 2021M691521); and 2020 Young Teacher Development Project of the Chinese Universities Scientific Fund (project number 230600001002020030).

A Retrospective Study Analyzing a Palliative Care-Hospital Medicine Collaboration to Improve Quality of Care of Patients With Advanced Illness.

Palliative care seeks to improve outcomes for patients with advanced illness (AI). Advocacy exists for making it part of mainstream care for hospitalized patients with AI. To determine if a partnership between hospital-medicine and specialized palliative care would increase identification of AI patients with palliative care needs requiring palliative consultation. Secondary outcomes: Decreasing 30-day readmission, length of stay (LOS) and pain scores, increasing documentation reflecting goals and advanced care planning. Retrospective chart review of patients with AI admitted to a hospitalist-resident run unit divided into Care Models, "A" and "B," and analyzed over two ten-month periods, "1" and "2." Triggers for palliative needs were provided for "A." During biweekly rounding, needs were assessed and generalist vs. specialist level palliative care concepts were used for consultation. Quaternary-level teaching center in the New York Metropolitan area. 3,395 AI patients were analyzed, 1,707 from "1," and 1,688 from "2." Comparing care models and time frames, palliative care consultation increased in "A" (P-value = .0013, P-value = .0005). When investigating "A" in "1" to "2," CMI was higher. Comparing "B" between "1" and "2," found older age and lower LACE. When adjusting for confounders (LACE and CMI), our models did not show a difference. Data on discharge disposition was significant for subacute rehab but not for mortality. There were no differences between care models and time-periods for secondary outcomes. Our study demonstrated the demand for palliative care services integrated into hospital medicine and highlighted areas of focus for future studies.

Exploring the Changes in Code Status During the COVID-19 Pandemic and the Implications for Future Pandemic Care.

Objective: We aim to explore patterns of inpatient code status during the COVID-19 pandemic compared with a similar timeframe the previous year, as well as utilization of palliative care services.Methods: This is a retrospective cohort study using data from the Montefiore Health system of all inpatient admissions between March 15-May 31, 2019 and March 15-May 31, 2020. Univariate logistic regression was performed with full code status as the outcome. All statistically significant variables were included in the multivariable logistic regression.Results: The total number of admissions declined during the pandemic (16844 vs 11637). A lower proportion of patients had full code status during the pandemic (85.1% vs 94%, P < .001) at the time of discharge/death. There was a 20% relative increase in the number of palliative care consultations during the pandemic (12.2% vs 10.5%, P < .001). Intubated patients were less often full code (66.5% vs 82.2%, P < .001) during the pandemic. Although a lower portion of COVID-19 positive patients had a full code status compared with non-COVID patients (77.6% vs 92.4%, P<.001), there was no statistically significant difference in code status at death (38.3% vs 38.3%, P = .96).Conclusions: The proportion of full code patients was significantly lower during the pandemic. Age and COVID status were the key determinants of code status during the pandemic. There was a higher demand for palliative care services during the pandemic.

Grey systems in the management of demand for palliative care services in Poland

BackgroundThe concept of care for people in a critical or even terminal health condition, who are in the last stage of their life, has become the mission of palliative care facilities. Therefore, the life of a sick patient poses a number of challenges for health care services to make sure that medical services are tailored to the trajectory of the disease, as well as the various needs, preferences and resources of patients and their families.MethodsHealth systems financed from public funds need to adopt new methods of management to meet the high and arising demand for a long-term care. There are several ways of assessing the demand for long-term care services. The method recommended by the author and presented in more detail in this paper is the one relying on grey systems, which enables the estimation of forecasting models and, finally, actual forecasts of the number of potential future patients.ResultsGST can be used to make predictions about the future behaviour of the system, which is why this article aims to present the possibility of using the first-order grey model GM (1,1) in predicting the number of patients of palliative care facilities in Poland. The analysis covers the data from 2014 to 2019, whereas the prediction of the number of patients has been additionally formulated for 2020.ConclusionsHealth systems, particularly publicly funded ones, are characterised by a certain kind of incompleteness and uncertainty of data on the structure and behaviour of its individual components (e.g. potential patients or payers). The present study aims to prove how simple and effective grey systems models are in the decision-making process.

Nurses Barriers to Evidence-Based Practice in Palliative Care: A Systematic Review.

Research shows low evidence-based practice (EBP) uptake among palliative care nurses, a global concern because the demand for palliative care services is rising, raising the urgent need to improve healthcare quality. Promoting EBP uptake in palliative care can improve healthcare quality. This systematic review investigated nurses' barriers to EBP implementation in palliative care. PubMed, MEDLINE, CINHAL, and Google Scholar were used to identify seven articles. Articles were included for review if they were published within the past 10 years (English only) and investigated barriers to EBP implementation in palliative care. Four barriers were identified: (a) time and resource constraints, (b) lack of readiness for organizational change, (c) negative attitudes toward palliative care, and (d) process-specific difficulties. This systematic review's findings can inform policy changes to improve the uptake of EBP in palliative care.

Improving access to timely pain management in an underserved oncology clinic: A palliative care-oncology partnership.

e18672 Background: In the 4 years since inception, the palliative care (PC) clinic at Olive-View UCLA Medical Center (OVMC) cared for less than 6% of pain-positive cancer patients based on guidelines put forth by ASCO. As with other under-resourced safety-net settings, the demand for PC services at OVMC far exceeds the manpower available for optimal pain management in oncology patients. This year long project aims to improve pain management in a busy oncology clinic via enhanced identification and prompt treatment of cancer pain by Oncologists. Methods: At the project start, Oncologists were surveyed to identify key elements to be incorporated into formal didactics on pain management principles, case-based discussions and real-time mentoring. At the weekly oncology clinic, patients were screened for pain using the multi-modal PEG scale: Average Pain intensity (P), interference with Enjoyment of life (E), and interference with General activity (G) over the preceding week. The Oncologist was notified of the PEG score if a patient had an average score ≥4 (0-10 scale) for review and intervention. Patients were screened using the same method at subsequent visits. EHR of patients with PEG scores ≥4 were reviewed to determine whether therapeutic interventions were made by the Oncologist. A comparison of PEG scores to the standard nursing intake pain scores was also conducted. Results: Over a 4-month period, 513 PEG forms were administered, 37% of which resulted in a pain score ≥4. Of the 172 patients who screened positive, 54 patients were screened at follow up visit(s). Comparing the pain-positive cohort, we observed an average decrease in pain by 25.5% (7.1 to 5.3) in patients who received intervention as opposed to 7.4% (5.0 to 4.7) in patients who did not receive intervention by their Oncologist. Further, there was a remarkable divergence between the average PEG score (6.7) and nurse intake pain score (1.4) in this patient cohort. Conclusions: Our findings suggest that improved Oncologist real-time pain assessment and intervention incorporating a validated pain screening tool leads to timely pain management in cancer patients. Implementation of a Palliative Care-Oncology partnership promotes provider awareness and confidence in treating patients with complex pain. A functional pain assessment, using PEG, can more accurately reflect pain compared to the current standard nursing intake process. Particularly in resource challenged settings where access to PC is limited, facilitating timely pain management through training and mentoring of oncologists or other primary providers can be a sustainable model to improve patient access to primary palliative care. Given the early indicators of success we hope to expand this workflow in training other healthcare providers within our County safety net system. Research Sponsor: California Health Care Foundation.

Population-based palliative care planning in Ireland: how many people will live and die with serious illness to 2046?

Background: All countries face growing demand for palliative care services. Projections of need are essential to plan care in an era of demographic change. We aim to estimate palliative care needs in the Republic of Ireland from 2016 to 2046. Methods: Static modelling of secondary data. First, we estimate the numbers of people who will die from a disease associated with palliative care need. We combine government statistics on cause of death (2007-2015) and projected mortality (2016-2046). Second, we combine these statistics with survey data to estimate numbers of people aged 50+ living and dying with diseases associated with palliative care need. Third, we use these projections and survey data to estimate disability burden, pain prevalence and health care utilisation among people aged 50+ living and dying with serious medical illness. Results: In 2016, the number of people dying annually from a disease indicating palliative care need was estimated as 22,806, and the number of people not in the last year of life aged 50+ with a relevant diagnosis was estimated as 290,185. Equivalent estimates for 2046 are up to 40,355 and 548,105, increases of 84% and 89% respectively. These groups account disproportionately for disability burden, pain prevalence and health care use among older people, meaning that population health burdens and health care use will increase significantly in the next three decades. Conclusion: The global population is ageing, although significant differences in intensity of ageing can be seen between countries. Prevalence of palliative care need will nearly double over 30 years, reflecting Ireland’s relatively young population. Older people living with a serious disease outnumber those in the last year of life by approximately 12:1, necessitating implementation of integrated palliative care across the disease trajectory. Urgent steps on funding, workforce development and service provision are required to address these challenges.

Population-based palliative care planning in Ireland: how many people will live and die with serious illness to 2046?

Background: All countries face growing demand for palliative care services. Projections of need are essential to plan care in an era of demographic change. We aim to estimate palliative care needs in Ireland from 2016 to 2046. Methods: Static modelling of secondary data. First, we estimate the numbers of people in Ireland who will die from a disease associated with palliative care need. We combine government statistics on cause of death (2007-2015) and projected mortality (2016-2046). Second, we combine these statistics with survey data to estimate numbers of people aged 50+ living and dying with diseases associated with palliative care need. Third, we use these projections and survey data to estimate disability burden, pain prevalence and health care utilisation among people aged 50+ living and dying with serious medical illness. Results: In 2016, the number of people dying annually from a disease indicating palliative care need was estimated as 22,806, and the number of people not in the last year of life aged 50+ with a relevant diagnosis was estimated as 290,185. Equivalent estimates for 2046 are 40,355 and 548,105, increases of 84% and 89% respectively. These groups account disproportionately for disability burden, pain prevalence and health care use among older people, meaning that population health burdens and health care use will increase significantly in the next three decades. Conclusion: The global population is ageing, although significant differences in intensity of ageing can be seen between countries. Prevalence of palliative care need in Ireland will nearly double over 30 years, reflecting Ireland’s relatively young population. People living with a serious disease outnumber those in the last year of life by approximately 12:1, necessitating implementation of integrated palliative care across the disease trajectory. Urgent steps on funding, workforce development and service provision are required to address these challenges.

Population-based palliative care planning in Ireland: how many people will live and die with serious illness to 2046?

Background: All countries face growing demand for palliative care services. Projections of need are essential to plan care in an era of demographic change. We aim to estimate palliative care needs in Ireland from 2016 to 2046. Methods: Static modelling of secondary data. First, we estimate the numbers of people in Ireland who will die from a disease associated with palliative care need. We combine government statistics on cause of death (2007-2015) and projected mortality (2016-2046). Second, we combine these statistics with survey data to estimate numbers of people aged 50+ living and dying with diseases associated with palliative care need. Third, we use these projections and survey data to estimate disability burden, pain prevalence and health care utilisation among people aged 50+ living and dying with serious medical illness. Results: In 2016, the number of people dying annually from a disease indicating palliative care need was estimated as 22,806, and the number of people not in the last year of life aged 50+ with a relevant diagnosis was estimated as 290,185. Equivalent estimates for 2046 are 40,355 and 548,105, increases of 84% and 89% respectively. These groups account disproportionately for disability burden, pain prevalence and health care use among older people, meaning that population health burdens and health care use will increase significantly in the next three decades. Conclusion: The global population is ageing, although significant differences in intensity of ageing can be seen between countries. Prevalence of palliative care need in Ireland will nearly double over 30 years, reflecting Ireland's relatively young population. People living with a serious disease outnumber those in the last year of life by approximately 12:1, necessitating implementation of integrated palliative care across the disease trajectory. Urgent steps on funding, workforce development and service provision are required to address these challenges.

Palliative care as an emerging role for respiratory health professionals: Findings from a cross-sectional, exploratory Canadian survey

IntroductionRespiratory Health Professionals (RHPs) with specialty training in the management of asthma and COPD, often care for patients with advanced respiratory disease, who have less access to palliative care than patients with similar disease burden. The aims of this study were to: (i) explore the current and desired roles of RHPs in terms of palliative care and (ii) examine barriers to discussions with patients about palliative care.MethodsAn online survey addressing the aims of this study was developed and pilot tested. The survey was distributed nationally using the database of the Lung Association’s RESPTREC respiratory educator training program. Descriptive statistics were performed.ResultsA total of 123 completed surveys were returned, with respiratory therapists comprising the largest group of respondents. The majority indicated that end-of-life care was less than optimal for patients with advanced respiratory illnesses and agreed that palliative care should be a role of RHPs. Patient- and family-related barriers to having end-of-life discussions included: difficulty accepting prognosis, limitations and complications, and lack of capacity. For providers, the most important barriers were: lack of training, uncertainty about prognosis, and lack of time. The health care system barriers of concern were increasing demand for palliative care services and limited accessibility of palliative care for those with advanced respiratory diseases and difficulties in accurate prognostication for these conditions.DiscussionIncorporating a more defined role in palliative care was generally seen as a desirable evolution of the RHP role. A number of strategies to mitigate identified barriers to discussions with the patient are described. Better alignment of the services required with the needs of patients with advanced respiratory disease can be addressed in a number of ways.ConclusionsAs RHP roles continue to evolve, consideration should be given to the ways in which RHPs can contribute to improving the quality of care for patients with advanced respiratory disease. Building collaborations with RHPs, palliative care, and other existing health programs can ensure high quality of care. Creating and taking advantage of learning opportunities to build skills and comfort in using a palliative approach will benefit respiratory patients.

Short-Stay Palliative Pain Management for Southwestern VA: Process Improvement Plan.

The increased demand for palliative care services has led to concerns surrounding workforce knowledge and resiliency, specifically with regard to palliative pain management for patients with life-limiting illnesses. Educational preparedness of nurses along with best processes and practices is necessary to promote optimal care for patients requiring palliative pain management. Through analyzing Veterans Administration Strategic Analytics for Improvement and Learning data, a deficiency in short-stay self-reported palliative patient pain management at the Southwestern Veterans Administration Medical Center, a level 1B, tertiary care referral center was defined. Best practices in the palliative care industry were then identified, and a quality improvement plan in the form of a nurse-driven palliative care pain education hands-on simulation was generated to promote excellence in care. Quality improvement for short-stay palliative pain management at the Southwestern Veterans Administration Medical Center was the end goal.

The Advanced Practice Registered Nurses Palliative Care Externship: A Model for Primary Palliative Care Education.

Nationally, the contribution of palliative care to high-quality health care continues to be recognized resulting in demand for palliative care services. This has resulted in an expected shortage of clinicians with palliative care knowledge and experience. The education and scope of practice of advanced practice registered nurses (APRNs) provides an ideal foundation for further palliative care education and training to fill this gap. The authors sought a method to provide midcareer APRNs with education and training in primary palliative care. The program took place at a well-established palliative care program at an academic medical center. This article describes an Institutional Review Board-approved week-long intensive APRN externship designed to provide education and training in primary palliative care for APRNs across disease populations. To best educate these APRNs, who did not have formal palliative care in their graduate education, the externship includes didactic, experiential, and clinical components to meet the needs of APRNs with minimal palliative care education and/or experiences. Precourse and postcourse data collection was performed. Results demonstrated increased knowledge, skills, and confidence in palliative care. This is a sustainable model for primary palliative care and midcareer APRNs who wish to enter palliative care. It is replicable for other disciplines as well.

Update in Mechanical Ventilation, Sedation, and Outcomes 2014.

Novel approaches to the management of acute respiratory distress syndrome include strategies to enhance alveolar liquid clearance, promote epithelial cell growth and recovery after acute lung injury, and individualize ventilator care on the basis of physiological responses. The use of extracorporeal membrane oxygenation (ECMO) is growing rapidly, and centers providing ECMO must strive to meet stringent quality standards such as those set out by the ECMONet working group. Prognostic tools such as the RESP score can assist clinicians in predicting outcomes for patients with severe acute respiratory failure but do not predict whether ECMO will enhance survival. Evidence continues to grow that novel modes of mechanical ventilation such as neurally adjusted ventilatory assist are feasible and improve patient physiology and patient-ventilator interaction; data on clinical outcomes are limited but supportive. Critical illness causes long-term psychological and function sequelae: the risk of a new psychiatric diagnosis and severe physical impairment is significantly increased in the months after discharge from the intensive care unit. These long-term effects might be amenable to changes in sedation practice and increased early mobilization. Daily sedation discontinuation enhances the validity of routine delirium assessment. Many critically ill patients merit assessment by palliative care clinicians; the demand for palliative care services among critically ill patients is expected to grow. Future trials to test therapies for critical illness must ensure that study designs are adequately powered to detect benefit using realistic event rates. Integrating "big data" approaches into treatment decisions and trial designs offers a potential means of individualizing care to enhance outcomes for critically ill patients.

Knowledge of Palliative Care: An Indian's Perspective

Background: Globally, the demand for palliative care services is markedly increased for the past decade due to emerging chronic diseases and ageing population. As a result, the health system needs to recognise and meet the needs of the people with life limiting illness. Palliative care is a specialised discipline of health care with the aim of providing care for the patient with terminal illness. Furthermore, there is evidence that minority ethnic groups have lack of knowledge on palliative care services in Australia. Purpose: To explore the issues in accessing palliative care services in Australia and provide recommendations to improve access. Methods & design: The research design chosen was constructivist grounded theory approach. Ethics approval was obtained from the study setting and from the university. Data collection was carried out in two phases. Semi-structured interview guide was used to collect the data. An in-depth interview was conducted and each interview lasts for 45 min to one and half hours. Snow ball sampling technique was done to recruit the participants. The inclusion criteria were: first generation Indian migrants; who understands, read and write English; Indian people receiving or already received palliative care services. Data was analysed by using grounded theory analytic technique. Findings: After analysing the data, two major themes were identified: knowledge about health care services, and knowledge on palliative care services. Conclusion: Although palliative care services are delivered effectively across Australia, still there are issues in accessing palliative care services among minority ethnic groups. Therefore, identifying these gaps and fulfilling these needs are the major focus in the Australia health care system.

HOW CAN WE DELIVER GOOD PALLIATIVE CARE EFFICIENTLY?

The changing patterns of disease and growth in demand for palliative care services will necessitate new approaches to service provision at end of life. As demand and expectations for good...

Exploring the leadership role of the clinical nurse specialist on an inpatient palliative care consulting team.

Demand for palliative care services in Canada will increase owing to an aging population and the evolving role of palliative care in non-malignant illness. Increasing healthcare demands continue to shape the clinical nurse specialist (CNS) role, especially in the area of palliative care. Clinical nurse specialists bring specialized knowledge, skills and leadership to the clinical setting to enhance patient and family care. This paper highlights the clinical leadership role of the CNS as triage leader for a hospital-based palliative care consulting team. Changes to the team's referral and triage processes are emphasized as key improvements to team efficiency and timely access to care for patients and families.

Effectively Training the Hospice and Palliative Medicine Physician Workforce for Improved End-of-Life Health Care in the United States

The widening gap between the demand for palliative care services and the supply of trained palliative care professionals has resulted in considerable end-of-life distress for patients. Without formal training in palliative medicine and end-of-life symptom management, physicians in the United States are less equipped to competently address seriously ill and dying patients' medical, emotional, and spiritual needs. Recent attempts within graduate medical education training deliberately seek to prepare a critical mass of physicians as the new hospice and palliative medicine workforce in the United States. In addition, healthcare reform proposals may re-define the National Health Service Corps (NHSC) post-graduate training over the next five years and the Hospice Medicare Benefit altogether. Healthcare policy options include steady changes at multiple levels of medical training -namely, medical school curriculum mandates, requiring all graduate physician residency training to foster patient-centered communication skills and discussions about advanced directives, and instituting palliative medicine proficiency Continuing Medical Education (CME) requirements for all states' medical licensing boards. Attracting qualified physicians to serve patients at the end of life, innovative medical school loan repayment programs and scholarships will also foster excellence in the field of hospice and palliative medicine. Correcting our current paucity of formal training in palliative medicine better utilizes hospice and restores patients' dignity at the end of life.