Hospital-based Palliative Care Teams Research Articles

Cancer patients have a reduced likelihood of dying in hospital with advance care planning in primary health care and a summarizing palliative plan: a prospective controlled non-randomized intervention trial

Background Advance care planning (ACP) allows patients to define their goals and preferences. Spending more time at home and less time in the hospital, along with avoiding death in the hospital, are often considered desirable outcomes of palliative care (PC). In 2015, 36% of cancer patients died in the hospital and 13% died at home in Norway. Method From 2015 to 2022, this prospective controlled non-randomized intervention trial observed 144 cancer patients with or without an organized ACP conversation in primary health care and a summarizing palliative plan (ClinicalTrials.gov Identifier: NCT02170168, 23 June 2014). The patients were identified through contact with the local cancer outpatient clinic or hospital-based PC team. Results A total of 128 patients died during the observation period. Of these, 67 patients had an organized ACP conversation and summarizing palliative plan (intervention (I) group) and 61 had not (control (C) group). Dying in the hospital was significantly less common for patients in the I group compared to the C group (17.9% vs. 34.4%; X 2 (1, n = 128) = 4.55, p = 0.033). There were no differences between the groups in terms of where they spent their time in the last 90 days of life (home, nursing home, or hospital). Most patients (62%) preferred to die at home. The observed differences between the groups regarding preferred and actual places of death did not reach statistical significance. Conclusion With organized ACP conversations in primary health care and a summarizing palliative plan, cancer patients died less often in the hospital in our observational study. A structured ACP approach integrating palliative care for cancer patients into primary health care can support patients´ preferences at the end of life.

Social work practice in perinatal palliative care: an overview

ABSTRACT Social workers in Perinatal Palliative Care (PPC) play an essential role in caring for birthing people carrying a baby with a life-limiting condition and their families. Perinatal palliative care is consistent with social work values concerning fostering quality of life and promoting social justice and access to care. Social workers play a multidimensional role in providing a holistic approach to caring for the birthing person, baby, and family. Although social workers may be part of an interdisciplinary care team, their role is not defined solely by the goals of the greater team, nor has it been discussed in depth in the perinatal palliative care literature. The purpose of this paper is to describe the knowledge, values, and skills essential to the role of the social worker in a hospital-based perinatal palliative care team. A case study will be used to illustrate the relevant practices, and implications are outlined.

Palliative Care for Newborns in India: Patterns of Care in a Neonatal Palliative Care Program at a Tertiary Government Children's Hospital.

Neonatal palliative care is a specialized area within children's palliative care, which focusses on the needs of infants with life-limiting or life-threatening conditions. Nearly one quarter of global neonatal deaths occur in India, where neonatal palliative care evidence is limited. This study describes the development and implementation of a neonatal palliative care program within a neonatal intensive care unit (NICU) at a government hospital, describing the implementing an 8-month pilot palliative care program for neonates, including the patterns of care, and barriers and enablers of success. The hospital-based palliative care team included trained pediatric palliative care physicians, a nurse, and a counselor. There was a steady increase in monthly referrals. There were 110 referrals in total, including 89 (81%) deaths and 18 (16%) babies were alive at the time of final follow-up, 10 months after the pilot program was completed. The program addressed physical symptoms, including providing morphine, as well as psychosocial and spiritual concerns of families. A model of hospital-based palliative care for neonates can be implemented within NICUs in tertiary government hospitals in India. Neonatal palliative care programs should include partnerships with charitable organizations to support implementation costs and provide palliative care training, mentorship, and capacity-building support.

Cancer patients spend more time at home and more often die at home with advance care planning conversations in primary health care: a retrospective observational cohort study

BackgroundSpending time at home and dying at home is advocated to be a desirable outcome in palliative care (PC). In Norway, home deaths among cancer patients are rare compared to other European countries. Advance care planning (ACP) conversations enable patients to define goals and preferences, reflecting a person’s wishes and current medical condition.MethodThe study included 250 cancer patients in the Romsdal region with or without an ACP conversation in primary health care who died between September 2018 and August 2020. The patients were identified through their contact with the local hospital, cancer outpatient clinic or hospital-based PC team.ResultsDuring the last 90 days of life, patients who had an ACP conversation in primary health care (N=125) were mean 9.8 more days at home, 4.5 less days in nursing home and 5.3 less days in hospital. Having an ACP conversation in primary health care, being male or having a lower age significantly predicted more days at home at the end of life (p< .001). Patients with an ACP conversation in primary health care where significantly more likely to die at home (p< .001) with a four times higher probability (RR=4.5). Contact with the hospital-based PC team was not associated with more days at home or death at home. Patients with contact with the hospital-based PC team were more likely to have an ACP conversation in primary health care.ConclusionPalliative cancer patients with an ACP conversation in primary health care spent more days at home and more frequently died at home. Data suggest it is important that ACP conversations are conducted in primary health care setting.

Palliative Care: A Survey of Program Benchmarking for Productivity and Compensation.

Background: Palliative Care (PC) encompasses an integrated health care philosophy of care for individuals with serious illnesses and their families. Referrals to palliative care often come from other healthcare clinicians who lack the time and skill required to address the needs of the patient and their caregivers. At its heart, palliative care is individualized to the values, beliefs, and goals of the patient. The process of eliciting values, beliefs, and goals takes time and expertise, and correspondingly, palliative care is labor intensive. To date, there has been no concentrated focus on how to accurately capture the productivity or work of palliative care clinicians. As a result, there is not a universally accepted method of measuring the effort which includes impact, activity, composition, and productivity of a palliative care program. Objective: This paper reviews results obtained during a telephone survey of similar hospital-based palliative care programs on how they measure productivity. Currently, based on the survey, there are two focused methods for benchmarking: work relative value units (wRVU) and consult volume. This paper highlights the variability of wRVUs and the challenge of using them to compare different PC programs. Design: The design was an open-ended question telephone survey. Using the characteristics of our hospital program, the team created a composite of descriptions to consider for comparison. Then, various hospital-based palliative care teams were selected based on publicly reported data through Vizient, a national benchmarking organization. Based on a literature review, an open-ended question survey was created. These questions explored program composition, clinician productivity and performance benchmarks. Data was collected manually and stored in a confidential file. Result: Ninety-four programs were queried that met the following composite: (1) participated in Vizient program and (2) self-reported a hospital-based, inpatient palliative program. Forty-one programs responded to the request to participate. Of these, 32 programs consisted of facilities who had hospitalists who provided palliative care, but there was not a dedicated palliative care team. Nine programs had a dedicated palliative care team with clinicians who only practiced palliative medicine. Inquiry to these programs revealed that within these nine programs-two methods of capturing clinician productivity were used-five sites used a wRVU metric and four sites used a consult volume metric. Conclusion: Preliminary findings support the complexity of benchmarking PC programs against peer institutions with a standard productivity model based on the variability in program composition.

Hospital-Based Palliative and End-of-Life Care in the COVID-19 Pandemic: A Scoping Review.

Aim: To identify the nature of the evidence reporting hospital-based palliative and end-of-life care during the COVID-19 pandemic. Background: The COVID-19 pandemic has seen an increase in the numbers of seriously ill people being cared for across all health services worldwide. Due to the rapid progression of severe symptoms, the majority of staff working in hospitals and other healthcare centres were providing end-of-life care. Little is known about the level of hospital-based palliative care service provided during the COVID-19 pandemic, particularly during surges in admission rates with an increased number of deaths accruing. Methods: A scoping review was conducted to search and select potential studies. The scoping review was guided by the framework of Arskey and O’Malley and advanced by the use of the methodology of the Joanna Briggs Institute. Results: Eighteen studies published between March 2020 and July 2021 were identified. Three broad categories included overall management strategy and logistics, symptom prevalence and management of patients with COVID-19 and end-of-life care needs within the current pandemic. Conclusions: This review highlights increased awareness and knowledge of palliative and end-of-life care provided in hospitals. The review also highlights the response of hospital-based palliative care teams to an evolving crisis, within the context of developed health systems under sustained and overwhelming pressure. Implications: Newly established clinical links and referral pathways developed during the initial COVID-19 surge between hospital-based palliative care and other healthcare teams, be continued and further enhanced. Understanding of the role of specialist palliative care providers in supporting palliative and end-of-life care within the hospital setting needs further investigation.

Exploring the Use of Psilocybin Therapy for Existential Distress: A Qualitative Study of Palliative Care Provider Perceptions

ABSTRACT There is a growing body of research suggesting that palliative care patients coping with existential distress may benefit from psilocybin. However, there is a large gap regarding the perceptions of palliative care providers who may provide education, counseling services, recommendations, and/or prescriptions for psilocybin if it is decriminalized, commercialized, and/or federally rescheduled and legalized. The aim of this study was to explore the experiences and perceptions of interdisciplinary palliative care providers regarding existential distress and the use of psilocybin therapy. Five (n = 5) health care providers from a hospital-based palliative care team completed a semi-structured interview related to their experiences supporting patients with existential distress and their beliefs and attitudes related to psilocybin as a possible treatment modality. A qualitative descriptive approach was used to identify key themes which included: 1) multiple barriers to addressing existential distress at the cultural, institutional/organizational, relational, and individual levels, 2) the duality and power of presence, 3) suffering as an intrinsically subjective phenomenon, and 4) uncertainty about the risks and benefits of psilocybin. To inform an inclusive, safe, and holistic approach, more research is needed regarding the possible integration of psilocybin therapy within palliative care for the treatment of existential distress.

Palliative Care in the Republic of Kazakhstan: Current Situation and Legal Regulation

It is known that diseases do not choose either the geography, age, or gender of the patient. And when the patient faces with terrible incurable or progressive diseases, the task arises not only to stop pain, but also to provide maximum supportive psychological assistance to both the patient and his/her relatives. Issues related to the provision of palliative care are relevant for many countries: this is a problem of not one single country or even a group of countries.&#x0D; Talking about palliative care, we mean comprehensive care for a patient diagnosed with an incurable disease, including: assessment and control of chronic pain; evaluation and control of other severe symptoms of developing disease and side effects of drugs; nursing and family training in nursing skills; psychological support for the patient and his/her family members; social and legal assistance.

Palliative Care Specialist Access is Associated With Rankings of Hospital Quality

ContextIncreasing evidence has shown that access to specialty palliative care, particularly outpatient palliative care clinics, can yield improved health outcomes and be a marker of hospital quality. ObjectiveTo determine whether an association exists between access to specialty palliative care programs and hospital rankings found in the 2020-2021 U.S. News & World Report Best Hospitals. MethodsThis study used publicly available data from the Center to Advance Palliative Care (CAPC) Provider Directory to determine access to in-patient and out-patient palliative care in the 2020-2021 U.S. News & World Report Best Hospitals Rankings. Descriptive statistics and chi-squares were performed. Data were also analyzed across the four U.S. Census Bureau regions (Northeast, South, Midwest, West). ResultsAround 100% of the Top 20 hospitals include hospital-based palliative care consultation teams, and 95% offered outpatient palliative care. Of the second cohort of 83 hospitals, 99% offered inpatient palliative care, and 65% offered outpatient palliative care. Of the third cohort of 75 hospitals ranked, 96% had inpatient palliative care services, while only 41.3% offered outpatient palliative care. This represents a significant association between rank position and access to outpatient palliative care (P < 0.01). Ranked hospitals also have significantly higher access to hospital-based palliative care teams compared to the national prevalence rate (P < 0.01). ConclusionThese findings reflect the association of access to specialty palliative care with USNWR rankings for hospital quality. Further study is necessary to determine the specific influence of access to palliative care and USNWR rank position.

Anxiety, depression and psychosocial needs are the most frequent concerns reported by patients: preliminary results of a comparative explorative analysis of two hospital-based palliative care teams in Germany and Japan

In the partnership between the medical departments of Würzburg University, Germany, and Nagasaki University, Japan, palliative care is a relevant topic. The aim of the study was to perform a comparative analysis of the hospital-based palliative care teams in Würzburg (PCT-W) and Nagasaki (PCT-N). Survey of staff composition and retrospective analysis of PCT patient charts in both PCTs were conducted. Patients self-assessed their symptoms in PCT-W and in Radiation Oncology Würzburg (RO-W). The (negative) quality indicator ‘percentage of deceased hospitalised patients with PCT contact for less than 3 days before death’ (Earle in Int J Qual Health Care 17(6):505–509, 2005) was analysed. Both PCTs follow a multidisciplinary team approach. PCT-N saw 410 cancer patients versus 853 patients for PCT-W (22.8% non-cancer patients). The Eastern Cooperative Oncology Group Performance Status at first contact with PCT-N was 3 or 4 in 39.3% of patients versus 79.0% for PCT-W. PCT-N was engaged in co-management longer than PCT-W (mean 20.7 days, range 1–102 versus mean 4.9 days, range 1–48). The most frequent patient-reported psychological symptom was anxiety (family anxiety: 98.3% PCT-W and 88.7% RO-W, anxiety 97.9% PCT-W and 85.9% RO-W), followed by depression (98.2% PCT-W and 80.3% RO-W). In 14 of the 148 deceased patients, PCT-N contact was initiated less than 3 days before death (9.4%) versus 121 of the 729 deceased PCT-W patients (16.6%). Psychological needs are highly relevant in both Germany and Japan, with more than 85% anxiety and depression in patients in the Japanese IPOS validation study (Sakurai in Jpn J Clin Oncol 49(3):257–262, 2019). This should be taken into account when implementing PCTs.

Emotional and cognitive barriers of bereavement care among clinical staff in hospice palliative care.

Bereavement care is one of the major components of hospice palliative care. Previous studies revealed the barriers to the success of the system, including lack of time or support from mental health professionals. Few studies have explored the intrapersonal barriers to bereavement care by clinical staff. The aims of the study were to explore (1) the emotional and cognitive barriers of bereavement care by hospice palliative care staff and (2) the demographic and work characteristics related to these emotional and cognitive barriers. The participants were clinical staff (n = 301) who were working in hospice palliative care units, including hospice wards, home care, and hospital-based palliative care teams. Their professional backgrounds included physicians (n = 12), nurses (n = 172), social workers (n = 59), psychologists (n = 34), spiritual care specialists (n = 15), and others (n = 9). A cross-sectional design was used and a standardized questionnaire including emotional and cognitive barriers was developed. Information on demographic and work characteristics was also collected. Content validity index, an exploratory factor analysis, and multiple regression analysis were conducted. One emotional barrier, "negative emotional reactions" (13 items, Cronbach's α = 0.92), and three cognitive barriers, "lack of ability" (7 items, Cronbach's α = 0.85), "belief in avoidance" (5 items, Cronbach's α = 0.86), and "outcome expectancy" (4 items, Cronbach's α = 0.85) were identified. Clinical staff who had higher working stress, lower self-rated ability for bereavement care, and higher negative impact from major life loss tended to have higher emotional and cognitive barriers. Clinical staff should be aware of intrapersonal barriers to bereavement care. Educational programs should be developed to improve the ability to engage in bereavement care.

End-of-Life Nursing and Education Consortium Communication Curriculum for Interdisciplinary Palliative Care Teams.

Background: Expert communication skills are essential for the delivery of effective palliative care across the domains of care. However, few health care providers receive formal communication training. To promote communication education for interdisciplinary palliative care teams, a train-the-trainer course for interdisciplinary hospital-based palliative care teams was developed to prepare them to teach other health care professionals communication skills. Course Design: The curriculum was organized by the eight domains of the National Consensus Project Guidelines for Quality Palliative Care and provided communication skills training for California-based teams. The two-day train-the-trainer course included skill-building exercises and interactive discussions to assist participants in integrating communication skills building into their clinical settings. Using a goal-directed method of teaching, faculty assisted teams in developing three institutional goals for providing palliative care communication training to other health care professionals. Evaluation of the course included immediate postcourse evaluation and follow-up evaluation at six and nine months. Results: The first statewide interdisciplinary communication training took place in January 2018 with 26 palliative care teams consisting of primarily nurses, followed by social workers, chaplains, and physicians. The 46 course participants' postcourse evaluations demonstrated high satisfaction with the course. On a scale of 1 to 5 (1 = lowest), the course met participants' expectations and objectives (4.8). The teams' precourse goals focused on (1) staff education, training, and mentorship, and (2) institution-wide system changes. Conclusion: Palliative care interdisciplinary teams can incorporate communication skills into their practice and provide communication skills training to their institutions.

Interdisciplinary palliative care communication for quality palliative care: Outcomes of a statewide train-the-trainer course.

83 Background: Expert communication skills are essential for the delivery of effective palliative care across the domains of care. However, few healthcare providers receive formal communication training. The purpose of this presentation is to describe a train-the-trainer course for interprofessional hospital-based palliative care teams to prepare them to teach other healthcare professionals palliative care communication skills. Methods: This project was organized by the eight domains of the National Consensus Project (NCP) guidelines for quality palliative care and provided communication skills training for California-based teams. Funded by the Archstone Foundation, this 2-day train-the-trainer course included skill-building exercises and interactive discussions to assist participants in integrating communication skills-building into their clinical settings. Using a goal-directed method of teaching, the faculty assisted teams in developing three institutional goals for providing palliative care communication training to other healthcare professionals. Evaluation of the course included immediate post-course evaluation and follow-up evaluation at 6 and 9 months. Results: The first statewide interprofessional communication training took place in January 2018 with 26 palliative care teams consisting of primarily nurses, followed by social workers, chaplains and physicians. The 46 course participants’ post-course evaluations demonstrated high satisfaction with the course. On a scale of 1 to 5 (1 = lowest), the course met participants’ expectations and objectives (4.8). The teams’ pre-course goals focused on: 1) staff education, training and mentorship, and 2) institution-wide system changes involving communication with palliative care. Conclusions: A 6 and 9 month follow-up will evaluate team progress on institutional goals (e.g. status and implementation) and provide an update on the additional healthcare professionals trained by course participants and changes implemented within their health system.

Specialist Palliative Care Service for Children With Life-Threatening Conditions: A Nationwide Survey of Availability and Utilization

ContextAccording to the International Observatory on End of Life Care, the level of pediatric palliative care in Japan is Level 2 (capacity building) and the current status of palliative care for children in Japan has not been clarified. ObjectivesThe objective of the study was to clarify the availability and utilization of specialist palliative care services among children with life-threatening conditions in Japan. MethodsA questionnaire was administered to assess the availability of specialist palliative care services among children with life-threatening conditions. All 427 certified regional cancer centers having hospital-based adult palliative care teams, 15 certified children's cancer centers having pediatric palliative care teams, and 368 medical institutions having a certified palliative care unit were surveyed. ResultsFifteen to twenty-one percent of adult palliative care teams and more than 90% of pediatric palliative care teams had experience providing palliative care to children with cancer. By contrast, only 2%–3% of adult palliative care teams and 15% of pediatric palliative care teams had experience providing care for the noncancer population. An estimated 12% of children with cancer in Japan used hospital-based palliative care teams in 2015. Eight children used a palliative care unit in 2015, and of those, seven (88%) had a solid tumor. An estimated 1.3% of children with cancer who died in Japan used a palliative care unit. ConclusionAn estimated 12% of children with cancer in Japan used hospital-based palliative care teams and an estimated 1.3% of children with cancer who died in Japan used a palliative care unit in 2015.

Child’s Play: The Role of Play in Mitigating the Fear of Death Among Pediatric Palliative Care Team Patients, Families, and Caregivers

ABSTRACTTerror Management Theory (TMT), derived from Ernest Becker’s The Denial of Death (1974), maintains that humans are motivated by the desire to overcome our fear of death by constructing meaning and significance in our lives in various ways, including making light of our mortality. In this paper, we examine the role of play as seriously ill children involved with a hospital-based palliative care team live out what may be the remainder of their lives. We question the function that play has, if any, in mitigating the fear of death among dying children and their caregivers. We explore formal and informal manners of therapeutic play among children and adults occurring in moments of terrible stress, pain, and the looming threat of death. We draw on playful representations of death from popular culture and from extended field research conducted with a pediatric palliative care team in a large regional children’s hospital caring for seriously ill children and their families, as patients, families, and caretakers struggle to make sense of their suffering, fear and loss.

The development of hospital-based palliative care services in public hospitals in the Western Cape, South Africa.

With the recent approval of a South African (SA) National Policy Framework and Strategy for Palliative Care by the National Health Council, it is pertinent to reflect on initiatives to develop palliative care services in public hospitals. This article reviews the development of hospital-based palliative care services in the Western Cape, SA. Palliative care services in SA started in the non-governmental sector in the 1980s. The first SA hospital-based palliative care team was established in Charlotte Maxeke Johannesburg Academic Hospital in 2001. The awareness of the benefit of palliative care in the hospital setting led to the development of isolated pockets of excellence providing palliative care in the public health sector in SA. This article describes models for palliative care at tertiary, provincial and district hospital level, which could inform development of hospital-based palliative care as the national policy for palliative care is implemented in SA.

Maintaining family life balance while facing a child's imminent death-A mixed methods study.

To understand parents' experiences and needs during a child's end-of-life care at home and to identify systemic factors that influence its provision. A child's end-of-life phase is an extremely difficult time for the whole family. Parents have specific needs, especially when they care for a dying child at home. Concurrent embedded mixed methods design. This sub-study of the nationwide survey, 'Paediatric End-of-Life Care Needs in Switzerland' (2012-2015) included 47 children who received EOL care at home from 2011-2012. We extracted quantitative data from patients' medical charts and obtained information via parental questionnaire and then compared parents whose child died at home or in hospital by computing generalized estimation equations. We thematically analysed interviews with parents who provided EOL care at home. Parents created an intimate lifeworld and a sense of normality for the child at home. They constantly balanced the family's lifeworld with the requirements and challenges posed by the outside world. This work exhausted parents. Parental 'readiness' and social support drove EOL care for children at home. Parents needed practical help with housekeeping and had negative experiences when dealing with insurance. In only 34.8% of cases was a child's EOL home care supported by paediatric palliative care team. Paediatric end-of-life care at home is only feasible if parents make extraordinary efforts. If family-centred end-of-life home care is provided by a hospital-based paediatric palliative home care team, which includes paid housekeeping help and psychological support, parents' needs could be better met.

Hospital-Based Palliative Care with Medicare Claims: Evidence From Colorado.

The prevalence of hospital-based palliative care has been largely anecdotal as an increasing service being provided and there is a need to understand what trends can be analyzed with Medicare data. To compare 2 methods of identifying hospital-based palliative care in the Medicare population in Colorado. Through Medicare claims data and phone surveys, we ascertained the presence of hospital-based palliative care services, number of patients receiving palliative care, and number of care visits provided during the previous year. Data were collected from every Medicare-certified hospital in Colorado during 2008 and 2013. We measured the presence of hospital-based palliative care teams and their average number of consultations through a phone survey and cross-referenced using a v-code modifier of Medicare claims indicating a palliative care consult visit. The number of hospital-based palliative care consultations increased five-fold from 2008-2013, and Medicare claims under-counted the number of these consultations compared to phone surveys. The systematic measurement of palliative care nationally is a key priority. More evidence is needed from other states to better understand the usefulness of Medicare claims in this effort.

Excess Consult Volume for Hospital-Based Palliative Care Teams in the U.S. (S774)

•Review current estimates of palliative care consult volume across the U.S.•Determine predictors of self-reported excess palliative care consult volume.•Describe strategies to manage excess consult volume implemented by palliative care programs. The surge in demand for palliative care consultation over the past decade has quickly outstripped the supply of available palliative care specialists. We sought to understand how this imbalance impacts hospital-based palliative care teams and their perceptions of consult volume. We invited American Academy of Hospice and Palliative Medicine members and affiliates to complete a confidential, web-based survey querying demographic factors, job responsibilities, and information about inpatient palliative care consults. We used a generalized linear model with logit link function and robust standard errors to identify predictors of self-reported excess volume, defined as the proportion of time teams are inadequately staffed to see new consults. We received 884 responses (response rate 11.4%). Majorities of respondents were physicians (86.9%), female (60.8%), had <10 years’ experience post-training (73.3%), and spent ≥6 months per year on an inpatient consult team (62.9%). Palliative care teams see a mean of 16.2 (standard deviation 13.1) total consults per day, including 5.4 new consults. Respondents reported inadequate staffing to see new consults in a timely fashion a mean of 35.8% (95% confidence interval 33.6%-38.1%) of the time. In the multivariable model, women and respondents with ≥10 years of experience reported having inadequate staffing more commonly (both p=0.04). For example, clinicians with ≥10 years of experience reported inadequate staffing 39.4% of the time, while those with <10 years reported it 33.9% of the time. Most (84.9%) of palliative care teams have implemented at least one strategy to manage excess workload, including triaging consults (62.6%), dividing them among team members (59.7%), signing off earlier (45.3%), and setting a formal consult cap (9.9%). Most hospital-based palliative care teams have already implemented strategies to address the problem of excess consult volume.

What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city

ObjectiveFor patients with advanced cancer, several randomised controlled trials have shown that access to palliative care at least 6 months before death can improve symptoms, reduce unplanned hospital admissions, minimise...