Differences In Palliative Care Research Articles

A Retrospective Study of Hospice Enrollment in Patients with Diffuse Large B Cell Lymphoma within the Veterans Health Administration

IntroductionDiffuse large B cell lymphoma (DLBCL) is the most common type of non-Hodgkins lymphoma (NHL), constituting 25% of NHL cases. (CA Cancer J Clin PMID: 27618563) Patients with aggressive hematological malignancies (HM) including lymphomas and leukemias have substantial palliative care needs that entail symptoms management and Hospice as an essential component of end of life (EoL) care. Despite significant improvement in treatment options, patients with relapsed refractory (RR) HM have suboptimal EoL care, (Blood PMID: 28774879 and Hematology Am Soc Hematol Educ Program PMID: 33275720) compared to patients with solid malignancies. (J Clin Oncol PMID: 25154824) The purpose of this study was to assess for Hospice enrollment in patients with DLBCL within the Veterans Health Administration (VHA).MethodsTrained abstractors performed a retrospective chart review of 3274 randomly selected patients with an ICD code for lymphoma treated within the VHA between 01/01/2011 and 12/31/2017. During the study period, 1699 veterans were confirmed to have a diagnosis of DLBCL, out of which 830 deceased patients were analyzed for this study. (Figure 1) Rates of palliative care consults, Hospice discussions, and Hospice enrollment were compared by age, race and outcomes of first line treatments using the Chi-Squared test of independence. Overall survival (OS) and time from Hospice to death were compared for the same variables with the Wilcoxon-Mann-Whitney test. A significance level of 0.05 was used for this study and all tests were two-tailed.ResultsThe median age at diagnosis was 70 years. The predominant population was white males. At the time of diagnosis, approximately three fourths had an ECOG performance status of 0 to 2. Over 50% were diagnosed at stage III-IV and had an IPI score of 4 or 5. (Table 1) Within the study, 63%, 60% and 52% of patients were introduced to palliative care, had Hospice discussions, and enrolled in Hospice respectively. The median OS from date of diagnosis to death was 461 days, and the median time from Hospice enrollment to death for those with a known Hospice enrollment date was 12 days. (Table 2) There was no statistically significant difference in palliative care or Hospice usage, median OS or median time in Hospice to death, by age or race. Patients with complete response (CR) to first line treatment had longer median OS in comparison to the four other groups: patients who received no first line treatments, who began a first line treatment which was interrupted by death, who were RR after first line treatment and those with an unknown treatment response. Patients who did not receive any first line treatments, RR patients or those with an unknown treatment response were more likely to have a palliative care consult, discuss Hospice with a provider and enroll in Hospice (p-value <0.005). There were no statistically significant differences in median time within Hospice between the successful treatment group and any of the other four groups.ConclusionIn this retrospective study, more than half of deceased patients with DLBCL within the VHA utilized Hospice services. There was no difference in Hospice use based on age or race, indicating equal access to care. Limitations of this study include a predominant male population and equal health care access that may limit generalizability of our finding to the non-Veterans population. Early recognition of high-risk patients may correlate with earlier enrollment to Hospice and increased lengths of stay in Hospice for patients with aggressive HM. Future educational interventions are needed to improve Hospice utilization for EoL care in patients with HM. [Display omitted] DisclosuresNooruddin: AstraZeneca: Research Funding.

Health care coach support in reducing acute care use in patients with cancer.

4 Background: Lay health workers (LHWs) who are trained to proactively discuss goals of care and assess patient symptoms have improved value-based cancer care among Veterans and a Medicare Advantage population. Little data exists regarding the effect of integrating LHWs into community oncology care among commercially insured populations. In this study, we implemented an LHW intervention to assist with goals of care and symptom management in collaboration with a private community oncology practice among patients with advanced cancer. This randomized controlled trial evaluates the effect of the intervention on acute care use and secondarily on goals of care documentation and patient satisfaction. Methods: Newly diagnosed patients with advanced stages of solid and hematologic malignancies were randomized from 8/11/2016 through 6/5/2019 into the intervention and control groups. All patients were followed for 12 months or death, whichever was first. Patients reported satisfaction with care using the Consumer Assessment of Healthcare Providers and Systems survey at time of enrollment and 9 months follow-up. We compared risk of death using Cox Models and compared rates of acute care, palliative care and hospice use using generalized models adjusted for length of follow-up. Results: A total of 104 patients were randomized with 52 in the intervention and 52 in the control. In both groups, the mean age was 67 years; 70% were non-Hispanic white, 25% Asian Pacific Islander, 1% Native Hawaiian, 1% American Indian/Alaskan Native, 3% multiple races/ethnicities. There were no differences in cancer diagnoses or stages. There were no differences in rates of survival between the two groups. Intervention patients as compared to the control had lower mean emergency department visits (0.80 +/- 0.17 versus 1.9 +/- 0.46, p = 0.02) and hospitalizations (0.67 +/- 0.19 versus 1.49 +/- 0.37, p = 0.04), greater rates of goals of care documentation (92% versus 33% p = 0.002) and no differences in palliative care (88% versus 77% p = 0.16) or hospice use (27% versus 21% p = 0.45). At 9 months follow-up as compared to baseline, patients in the intervention experienced greater improvements in satisfaction with their care (difference-in-difference: 0.41, 95% CI 0.22-0.60, p &lt; 0.001). Conclusions: An LHW intervention significantly reduced acute care use and improved patient experiences with cancer care as compared to a control group. This intervention may be a solution to improve care delivery and experiences for patients after a diagnosis of cancer in community oncology settings. Clinical trial information: NCT03154190 .

Symptom relief during last week of life in neurological diseases.

ObjectivesThe aim of this study was to investigate symptom prevalence, symptom relief, and palliative care indicators during the last week of life, comparing them for patients with motor neuron disease (MND), central nervous system tumors (CNS tumor), and other neurological diseases (OND).Material & MethodsData were obtained from the Swedish Register for Palliative Care, which documents care during the last week of life. Logistic regression was used to compare patients with MND (n = 419), CNS tumor (n = 799), and OND (n = 1,407) as the cause of death.ResultsThe most prevalent symptoms for all neurological disease groups were pain (52.7% to 72.2%) and rattles (58.1% to 65.6%). Compared to MND and OND, patients with CNS tumors were more likely to have totally relieved pain, shortness of breath, rattles, and anxiety. They were also more likely to have their pain assessed with a validated tool; to receive symptom treatment for anxiety, nausea, rattles, and pain; to have had family members receive end‐of‐life discussions; to have someone present at death; and to have had their family members offered bereavement support. Both patients with CNS tumor and MND were more likely than patients with OND to receive consultation with a pain unit and to have had end‐of‐life discussions.ConclusionsThe study reveals high symptom burden and differences in palliative care between the groups during the last week of life. There is a need for person‐centered care planning based on a palliative approach, focused on improving symptom assessments, relief, and end‐of‐life conversations.

When words make a difference in palliative care.

In the article, the author discusses the importance and effect/s of the words empathy, pity and sympathy in the communication of health professionals (HCP) with patients in palliative care. Other topics include how HCPs develop emotional connection with their patients, such non-verbal empathy like posture mirroring, listening, and silence, as well as how an empathic approach improves a patient's quality of life and dignity in death.

Association of Care at Minority-Serving vs Non–Minority-Serving Hospitals With Use of Palliative Care Among Racial/Ethnic Minorities With Metastatic Cancer in the United States

It is not known whether racial/ethnic differences in receipt of palliative care are attributable to different treatment of minorities or lower utilization of palliative care at the relatively small number of hospitals that treat a large portion of minority patients. To assess the association of receipt of palliative care among patients with metastatic cancer with receipt of treatment at minority-serving hospitals (MSHs) vs non-MSHs. This retrospective cohort study used Participant Use Files of the National Cancer Database, a prospectively maintained, hospital-based cancer registry consisting of all patients treated at more than 1500 US hospitals, to collect data from individuals older than 40 years with metastatic prostate, lung, colon, and breast cancer, diagnosed from January 1, 2004, to December 31, 2015. Data were accessed in October 2017, and the analysis was performed in July 2018. Hospitals in the top decile in terms of the proportion of black and Hispanic patients for each cancer type were defined as MSHs. A multilevel logistic regression model that estimated the odds of palliative care was fit, adjusting for year of diagnosis, sex, race/ethnicity, insurance, income, educational level, and cancer type, with an interaction term between cancer type and MSH status and a hospital-level random intercept to account for unmeasured hospital characteristics. A total of 601 680 individuals (mean [SD] age, 67.4 [11.4] years; 95% CI, 67.2-67.6 years; 314 279 [52.2%] male; 475 039 [78.9%] white) were studied. In total, 130 813 patients (21.7%) received palliative care, ranging from 102 019 (25.4%) with lung cancer to 9966 (11.1%) with colon cancer. In total, 16 435 black individuals (20.0%) and 3551 Hispanic individuals (15.9%) received palliative care vs 106 603 non-Hispanic white individuals (22.5%) (P < .001). The MSH patients were less likely than the non-MSH patients to receive palliative care, regardless of race/ethnicity (12 692 [18.0%] vs 118 121 [22.3%]; P = .002). In an adjusted analysis, treatment at an MSH had a statistically significant association with lower odds of receiving palliative care (odds ratio, 0.67; 95% CI, 0.53-0.84). Although the factors associated with minority patients' receipt of palliative care are complex, in this study, treatment at MSHs was associated with significantly lower odds of receiving any palliative care in an adjusted analysis, but black and Hispanic race/ethnicity was not. These findings suggest that the site of care is associated with race/ethnicity-based differences in palliative care.

Diana Children’s Nurses make a difference in palliative care

Specialist children’s nurses in Scotland have helped families to ‘regain a sense of control in desperate circumstances’, a report has found

A comparison of patients with liver cancer receiving palliative care at two Veterans Affairs (VA) Medical Centers.

75 Background: Liver cancer is a leading cause of death. Lack of data exists on palliative care in this group, and care varies by location. We aim to determine if there are differences in palliative care for patients (pts) with liver cancer by VA site. Methods: In an IRB approved protocol, we reviewed medical records of pts at 2 VA medical centers (S1, S2) with liver cancer, who were seen by Palliative Care between 2006 and 2012. Veterans were compared by 1) demographics: Karnofsky performance status &gt; 50 (KPS), marital status, DNR/DNI, 2) palliative intervention: goals of care discussion, referrals to psychology and PT/OT, and 3) outcomes: ED visit within 1 month (mo) of death, ED visit within 6 mo of death, ICU within 30 days of death, and hospice as site of death, time from diagnosis to palliative care, and time from DNR to death. Chi-square, Fisher’s Exact, and T-test were performed with Stata. Results: here were 82 men, 30 from S1 and 52 from S2, median age 61 (35-87) and 63 (54-88) yrs, respectively. Pts were Caucasian 30 (36%), African American 47 (57%), and other 5 (0.1%). Cancer stages were locoregional 15 (50%), metastatic 13 (43%), and unknown 2 (0.1%) at S1 and 28 (54%), 20 (38%), 5 (0.1%) at S2. Differences were seen in KPS &gt; 50: (S1, S2) [10 (33%), 15(29%) p = 0.010], married: (S1, S2) [7 (23%), 24(46%) p = 0.024], DNR/DNI: (S1, S2) [19 (63%), 13(25%), p = 0.001]. Regarding palliative intervention: goals of care discussion (S1, S2) [26 (87%), 44 (85%), p = 0.044], referral to psych (S1, S2) [16 (53%), 42 (81%) p = 0.014], referral to PT/OT (S1, S2) [17 (57%), 15 (29%), p = 0.007]. Finally in regards to outcome: ED visit within 1 mo of death (S1, S2) [7 (23%), 31 (60%), p = 0.001], ED visit within 6 mos of death (S1, S2) [18 (56%), 35 (67%) p = 0.031], ICU within 30 days of death (S1, S2) [0 (0%), 9 (17%) p = 0.019}, and hospice as site of death (S1, S2) [19 (63%), 21 (40%), p &lt; .0001]. Other key differences included median number of days from diagnosis to initial palliative care consult (S1, S2) [97, 39, p = 0.001] and median number of days from DNR to death (S1, S2) [33, 14, p = 0.001]. Conclusions: Results show there are site-specific differences between VA medical centers. These data may be important in the comparison of other centers and provide a baseline for future studies.

Differences in palliative care needs among cancer survivors in an inner city academic facility versus a suburban community facility.

61 Background: To determine differences in palliative care (PC) needs in newly diagnosed cancer patients from an inner-city academic facility compared to a suburban, community facility. Also, to identify ways to improve PC for cancer patients in these locations. Methods: 270 subjects with cancer were prospectively identified, 85 from an inner city academic facility (Site A), and 185 from a suburban community facility in the same metropolitan area. (Site B) All patients received treatment from board-certified oncologists. Master’s level Social Workers asked all subjects to complete a standardized, validated questionnaire to determine their palliative care needs prior to treatment. Completed questionnaires were collected and data was depersonalized and analyzed by the authors. Statistical differences were assessed using standard methods. Results: Site A patients were younger (56.3 vs 61.5years) less likely to be caucasian (35/85, 41.2% vs 114/185, 61.6%) and less likely to have private insurance (28/85, 32.9% vs 187/185, 47%). Site B patients were more likely to express a fear of pain, (112/185, 60.5% vs 28/85,32.9%) dying, (112/185, 60.5% vs 18/85, 21.2%) being alone, (112/185(60.5% vs 15/85, 17.7%) or nausea (117/185, 63.2% vs 10/85, 11.8%). Site A patients were more likely to express fear of not having transportation, (35/85, 41.2% vs 42/185, 22.1%) inability to pay for prescriptions, (28/85, 32.9% vs 40/185, 21.6%) or child care (13/85, 15.3% vs 9/185, 4.9%). All differences were significant at a p &lt; 0.05. Conclusions: There are major differences in the PC needs of patients presenting to an inner-city academic vs suburban community facility. To be most effective, PC programs must be tailored to the community. Interventions proposed for the suburban community facility include early access to: 1) grief counseling, 2) support groups, 3) Nurse-Navigators. Interventions proposed for the inner city academic facility include early access to: 1) Medication cost assistance programs (local philanthropies, facility-based pharmacy discounts) 2) travel services (cab vouchers, coordination with public transportation schedules) 3) on-site child care facilities.

Assessment of health-related quality of life in end-stage chronic obstructive pulmonary disease and non-small-cell lung cancer patients in Serbia.

Under conditions in which palliative care has not yet become part of clinical practice, the differences in palliative care needs between patients with cancer and other life-limiting diseases can yield knowledge that will be very valuable for future planning. The aim of our investigation was to compare health-related quality of life (HRQoL) for patients with end-stage chronic obstructive pulmonary disease (COPD) and those with non-small-cell lung cancer (NSCLC) in Belgrade, Serbia. We also evaluated the influence of demographic, socioeconomic, and clinical factors on HRQoL for both patient groups. This cross-sectional study included 100 NSCLC patients (stages IIIb and IV) and 100 patients with stage IV COPD. Measures included the SF-36 questionnaire, the EORTC QLQ-C30, the St. George's Respiratory Questionnaire, and the Beck Depression Inventory (BDI). Associations of demographic, socioeconomic, and clinical factors with QoL were examined using linear regression analyses. The COPD group scored significantly lower compared to NSCLC patients in all SF-36 domains except for bodily pain. Additionally, a significantly higher level of depressive symptoms was observed in COPD patients. A worse physical QoL for COPD patients was independently associated with a longer duration of unemployment, a lack of wage earning, lower Karnofsky Performance Status (KPS) scores, and higher levels of depression. A worse mental QoL for COPD patients was related to a longer duration of disease, poorer KPS scores, and higher BDI scores. The independent variables significantly associated with worse physical and mental QoL of NSCLC patients were lower KPS and higher BDI scores. A worse QoL, a significantly higher level of depressive symptoms, and adverse socioeconomic status in the COPD group imposes the need for development of more intensive psychosocial and community support for COPD patients during implementation of palliative care.

Palliative care experiences of adult cancer patients from ethnocultural groups: a qualitative systematic review protocol.

Review question/objective The objective of this review is to synthesize the best available evidence on palliative care experiences of adult cancer patients from ethnocultural groups. More specifically, this systematic review seeks to answer the following questions: 1. What are the palliative care experiences of adult cancer patients from diverse ethnocultural groups? 2. What meanings do adult patients with cancer from diverse ethnocultural groups assign to their experiences with palliative care? Inclusion criteria Types of participants This qualitative systematic review will consider studies that include adult cancer patients from ethnocultural groups whose ethnicity differs from that of the main population in the country of care, with inclusion of studies that compare experiences of under-represented groups with main groups in the country of care. Types of phenomena of interest The phenomenon of interest is the experience of palliative health care. Context The context for this review will be adult patients with a diagnosis of cancer who are receiving palliative care and are from different ethnocultural groups.

The role of tumor associated macrophages in ovarian cancer

Objectives: The aim of this study was to determine differences in palliative care needs inwomenwith gynecologic cancers from anurban, inner city, academic facility compared to a suburban, community facility and also, to identify interventions that could improve palliative care for gynecologic cancer patients in varying locations. Methods: 71 women with gynecologic cancer were prospectively identified, 54 from an urban, inner city academic cancer center, and 17 from a suburban community cancer center in the same metropolitan area. All subjects were asked to complete a standardized, validated questionnaire intended to determine their palliative care needs after diagnosis but prior to treatment. Palliative care trained, Master's level social workers introduced themselves and the questionnaire to patients, and offered to help with additional needs. Completed questionnaires were collected and appropriate data was extracted. The data was depersonalized and analyzed by the authors. Statistical differences were assessed with SigmaStat V.2.0. Results: All patients were treated by board-certified gyn oncologists. The types of cancers seen and treatments offered (all of which met NCCN guidelines) were similar. Inner city academic patients were less likely to complete the questionnaire than the suburban community patients (64% vs 100% of those offered, p b 0.001). Patients from the inner city academic group were younger (54 years old vs 61 years old, p b 0.05) and more likely to be African–American (77% vs 29%, p b 0.05) than those from the suburban community group. The ratio of Medicaid to private/Medicare insurance coverage was higher in inner city academic patients than suburban community patients (58% vs 22%, p b 0.05). The most common palliative care concerns identified by suburban community patientswere: 1) pain, 2) anxiety, 3) depression, 4) nausea/vomiting. In comparison, the most common concerns identified by inner city academic patients were: 1) paying for medications, 2) travel to the treatment facility, 3) pain, and 4) child care. Conclusion: There are major differences in the palliative care needs of patients from an inner city academic facility compared to a suburban community facility. Interventions proposed for the suburban community facility were early access to: 1) grief counseling, 2) patient support groups, and 3) Nurse–Navigator services. Interventions proposed for the inner city academic facility include early access to: 1) programs for assistance with medication costs (local philanthropies, facility-based pharmacy discounts), 2) travel services (cab vouchers, coordination of treatments with public transportation schedules), and 3) on-site child care facilities. Further, inner city academic patients should be encouraged to voice their palliative care concerns. More specific determinations of patient concerns are needed to help structure palliative care services in different types of facilities.

Differences in palliative care needs among women with gynecologic cancers in an inner city, academic facility versus a suburban, community facility

Objectives: The aim of this study was to determine differences in palliative care needs inwomenwith gynecologic cancers from anurban, inner city, academic facility compared to a suburban, community facility and also, to identify interventions that could improve palliative care for gynecologic cancer patients in varying locations. Methods: 71 women with gynecologic cancer were prospectively identified, 54 from an urban, inner city academic cancer center, and 17 from a suburban community cancer center in the same metropolitan area. All subjects were asked to complete a standardized, validated questionnaire intended to determine their palliative care needs after diagnosis but prior to treatment. Palliative care trained, Master's level social workers introduced themselves and the questionnaire to patients, and offered to help with additional needs. Completed questionnaires were collected and appropriate data was extracted. The data was depersonalized and analyzed by the authors. Statistical differences were assessed with SigmaStat V.2.0. Results: All patients were treated by board-certified gyn oncologists. The types of cancers seen and treatments offered (all of which met NCCN guidelines) were similar. Inner city academic patients were less likely to complete the questionnaire than the suburban community patients (64% vs 100% of those offered, p b 0.001). Patients from the inner city academic group were younger (54 years old vs 61 years old, p b 0.05) and more likely to be African–American (77% vs 29%, p b 0.05) than those from the suburban community group. The ratio of Medicaid to private/Medicare insurance coverage was higher in inner city academic patients than suburban community patients (58% vs 22%, p b 0.05). The most common palliative care concerns identified by suburban community patientswere: 1) pain, 2) anxiety, 3) depression, 4) nausea/vomiting. In comparison, the most common concerns identified by inner city academic patients were: 1) paying for medications, 2) travel to the treatment facility, 3) pain, and 4) child care. Conclusion: There are major differences in the palliative care needs of patients from an inner city academic facility compared to a suburban community facility. Interventions proposed for the suburban community facility were early access to: 1) grief counseling, 2) patient support groups, and 3) Nurse–Navigator services. Interventions proposed for the inner city academic facility include early access to: 1) programs for assistance with medication costs (local philanthropies, facility-based pharmacy discounts), 2) travel services (cab vouchers, coordination of treatments with public transportation schedules), and 3) on-site child care facilities. Further, inner city academic patients should be encouraged to voice their palliative care concerns. More specific determinations of patient concerns are needed to help structure palliative care services in different types of facilities.

Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage. A national study using spatial analysis

BackgroundA range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services.MethodsAll inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation – Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person’s home postcode, and stratified by socio-economic disadvantage.ResultsThis study covered July – December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a person’s home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage.ConclusionThese data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.

What is the meaning of palliative care in the Asia‐Pacific region?

This paper describes the preliminary work required to understand cultural differences in palliative care in the United Kingdom and three countries in the Asia-Pacific region, in preparation for a cross-country study. The study is intended to address cultural understandings of palliative care, the role of the family in end of life care, what constitutes good care and the ethical issues in each country. Suggestions are then made to shape the scope of the study and to be considered as outcomes to improve care of the dying in these countries. It is anticipated that the method used to achieve consensus on cross-country palliative care issues will be both qualitative and quantitative. Identifying key priorities in the delivery and quality measures of palliative care will involve participants in focus groups, a Delphi survey and in the development of clinical indicators towards creating standards of palliative care common to the Asian Pacific region.

Making a difference in palliative care nursing

One of the benefits of an international journal such as the International Journal of Palliative Nursing is that it showcases the diverse nature of palliative nursing. The published articles reflect a variety of work settings, roles, cultures and populations, as well as our commonalities, one of which I believe is our commitment to palliative nursing. We are constantly striving to make a difference in the lives of those we care for.

Making a difference in palliative care

Making a difference in palliative care

Complementary therapies: making a difference in palliative care.

Palliative care is concerned with people who have a life-threatening illness and has been at the forefront of incorporating complementary therapies into orthodox care. The reasons why such people are likely to seek out complementary therapies and recent research that links the two movements are discussed. The main focus is on the innovative programme of complementary therapies offered to both patients and carers by North Devon Hospice. Thirty-eight patients and carers discussed the provision of complementary therapies in focus groups. The therapies were seen as being an integral part of the Hospice's provision and valuable as a means of introducing people to other services offered by the Hospice. Both potential benefits and possible problems are also discussed. Suggestions are made for expanding the provision of the therapies and to improve access to them.