Hospital Palliative Care Team Research Articles

The (un)availability of prognostic information in the last days of life: a prospective observational study

ObjectivesThe aims of this study were (1) to document the clinical condition of patients considered to be in the last 2 weeks of life and (2) to compare patients who...

Naldemedine for opioid-induced constipation in patients receiving palliative care: A real-world registry study (Phase-R OIC Study).

11582 Background: Although naldemedine, a new peripherally-acting mu-opioid receptor antagonist, was approved for the management of opioid-induced constipation (OIC), its safety and effectiveness in real world clinical practice is unknown. Methods: We conducted a real world registry study in 14 hospital palliative care teams and inpatient palliative care units in Japan between April and December 2018. Consecutive cancer patients who received naldemedine for OIC were enrolled in a 7-day observational study. All treatment and assessment procedures were performed according to the accepted clinical practice. The primary outcome of the study was the proportion of patients who experienced spontaneous bowel movement within 24 hours after the initial administration of naldemedine. Adverse events, which indicated a possible or stronger causal relationship with naldemedine treatment, were reported according to the Common Terminology Criteria for Adverse Events (CTCAE) ver 4.0. Results: Overall, 204 patients were enrolled in the study. The mean age of the patients was 63±14 years, and 103 (50.5%) were male. The most common primary cancer site was lung (23.5%), followed by gastrointestinal (13.7%), and urological organs (9.3%). The proportion of patients undergoing active cancer treatment was 59.9%. Oxycodone was the most frequently used regular opioid (n = 115, 56.4%), and the median oral morphine-equivalent daily dose of opioids was 30 mg (interquartile range: 20-60 mg). Magnesium oxide (64.2%) and Senna (17.2%) were used as concomitant laxatives. All patients received 0.2 mg of naldemedine orally once daily. Most patients (90.2%) completed the 7-day observation. In 146 patients, spontaneous bowel movement was observed within 24 hour after the first administration of naldemedine (71.6%, 95% confidence interval 65.4-77.8%). Nearly two-thirds of the patients experienced increased frequency of spontaneous bowel movement in the week after naldemedine administration. The most prevalent adverse events were diarrhea (CTCAE grade 1-2, 35 cases; grade 3, 1 case) and abdominal pain (CTCAE grade 1-2, 10 cases; grade 3, 1 case). No serious adverse events including gastrointestinal perforation were reported. Conclusions: Naldemedine for opioid-induced constipation is safe and effective in the real world oncology and palliative care settings. Clinical trial information: UMIN000031381.

Assistant practitioners in palliative care: doing things differently

The acute hospital palliative care team at London North West University Healthcare NHS Trust provides specialist palliative care advice and supports end-of-life care across the trust. We have experienced a year-on-year increase in demand for our services and have previously managed this by recruiting more clinical nurse specialists. The appointment of two assistant practitioners to support end-of-life care has allowed us to look at a different model of care and new ways of working to meet increasing demands on our service.

Multidisciplinary views towards the clinical pharmacist: a hospital palliative cancer care team perspective in Malta

To explore the views of the multidisciplinary healthcare team towards the role of the clinical pharmacist within the palliative care unit of an oncology hospital in Malta. At present, in Malta, clinical pharmacists are not routinely involved in care provision with palliative cancer care teams and there is a need to consider their role. Three 60 min audio-recorded heterogeneous focus groups were conducted with eligible healthcare providers at Sir Anthony Mamo Oncology Centre in Mater Dei Hospital. The topic guide was based on literature and was assessed for face and content validity by an expert panel. The transcripts were analysed using the framework method whereby emerging categories and themes were devised. A total of four doctors, ten ward nurses, two Hospice community nurses, three nursing aides, one psychologist and six allied healthcare professionals consented to participate. The framework analysis resulted in four main categories namely: (1) pharmacists as the expert reference point; (2) availability of clinical pharmacists in providing clinical services on ward level; (3) attitudes towards potential clinical services provided by clinical pharmacists; and (4) clinical pharmacists as a link with the community on pharmaceutical matters. The general view of healthcare providers on the clinical pharmacist's role in palliative cancer care was largely supportive and positive. This should encourage policy makers to introduce clinical pharmacy services within this setting.

A qualitative study of health care professionals\u2019 views and experiences of paediatric advance care planning

BackgroundGood end-of-life care planning is vital to ensure optimal care is provided for patients and their families. Two key factors are open and honest advance care planning conversations between the patient (where possible), family, and health care professionals, focusing on exploring what their future wishes are; and the development of an advance care plan document. However, in paediatric and neonatal settings, there has been little research to demonstrate how advance care planning conversations take place. This study explored health care professionals’ views and experiences of paediatric advance care planning in hospitals, community settings and hospices.MethodsA qualitative methodology was employed using purposive sampling of health care professionals involved in the end-of-life care for children aged 0–18 years known to the hospital palliative care team, and had died at least three months before, but less than 18 months prior to the study. Ethics committee approval was obtained for the study. Located in the North of England, the study involved three hospitals, a children’s hospice, and community services. Data were collected using semi-structured, digitally recorded, telephone interviews. All interviews were transcribed verbatim and subjected to thematic analysis.ResultsTwenty-one health care professionals participated, including generalist paediatric staff as well as specialist palliative care staff.Two themes were generated from the study: The timing of planning conversations, including waiting for the relationship with the family to form; the introduction of parallel planning; avoiding a crisis situation. Secondly, supporting effective conversations around advance care planning, including where to have the conversation; introducing the conversation; and how to approach the topic encompassing the value of advance care planning and documentation for families.ConclusionThe timing of when to start the advance care planning conversations remains an issue for health care professionals. The value of doing it in stages and considering the environment where the conversations are held was noted. Timely planning was seen as vital to avoid difficult conversations at a crisis point and for co-ordination of care. Good advance care planning is to provide the best person-centred care for the child and experience for the family.

Palliative Care Leadership Centers Are Key To The Diffusion Of Palliative Care Innovation.

Between 2000 and 2015 the proportion of US hospitals with more than fifty beds that had palliative care programs tripled, from 25percent to 75percent. The rapid adoption of this high-value program, which is voluntary and runs counter to the dominant culture in US hospitals, was catalyzed by tens of millions of dollars in philanthropic support for innovation, dissemination, and professionalization in the palliative care field. We describe the dissemination strategies of the Center to Advance Palliative Care in the context of the principles of social entrepreneurship, and we provide an in-depth look at its hallmark training initiative, Palliative Care Leadership Centers. Over 1,240 hospital palliative care teams have trained at the Leadership Centers to date, with 80percent of them instituting palliative care services within two years. We conclude with lessons learned about the role of purposeful technical assistance in promoting the rapid diffusion of high-value health care innovation.

Assessing the Palliative Care Needs of Elderly Patients Seen at The University College Hospital, Ibadan, Nigeria (TH321A)

•Highlight the identified palliative care needs of the elderly.•Explore the current use of the hospital palliative care team in the care of geriatric patient. Nigeria the most populated nation in Africa (over 170 million), growth rate of 2.5% with 5% of the total population aged 60 and above with potential for a rapid growth rate of the older population. The implication is difficulty in meeting the various needs of the elderly with limited healthcare professionals and care homes. 1) To describe characteristics of elderly patients seen in the selected clinics and 2) To assess the needs of the patients as relates physical, spiritual and psychosocial wellbeing. A descriptive cross sectional study was conducted over a 3-month period using an interviewer administered questionnaire after full consent was given by participants. The questionnaire was a combination of the Africa Palliative Care Outcome Scale (APOS), the Edmonton system Assessment Numerical scale and the Hope Spiritual assessment scale. Demographic information and needs in respect to physical, psychosocial and spiritual were obtained. Data was analyzed using IBM SPSS statistics 21. Four- hundred- twenty- four participants completed the questionnaire. Most patients were recruited from the geriatric wards 330(77.8%) with a 2:1 female to male ratio. Most participants fell in the 60 -69 age group. Most common symptom was pain in 240 patients with moderate pain in single or multiple areas. A high percentage, 45.8% were moderately worried about their disease condition and only 66 out of 424 freely discussed this feeling with their family members. Other symptoms observed were nausea, vomiting, anxiety and abdominal discomfort. The study showed the palliative care needs of the elderly and calls for a collaboration between the palliative care team and the physicians in the geriatric unit for better management of the needs of the elderly.

Expanding palliative care's reach in the community via the elder service agency network.

Over the past two decades, palliative care has established itself as a promising approach to address the complex needs of individuals with advanced illness. Palliative care is well-established in US hospitals and has recently begun to expand outside of the hospital setting to meet the needs of non-hospitalized individuals. Experts have called for the development of innovative community-based models that facilitate delivery of palliative care to this target population. Elder service agencies are important partners that researchers should collaborate with to develop new and promising models. Millions of older adults receive aging network services in the U.S., highlighting the potential reach of these models. Recent health care reform efforts provide support for community-based initiatives, where coordination of care and services, delivered via health and social service agencies, is highly prioritized. This article describes the rationale for developing such approaches, including efforts to educate elder service agency clients about palliative care; training agency staff in palliative care principles; building capacity for elder services providers to screen individuals for palliative care needs; embedding palliative care "champions" in agencies to educate staff and clients and coordinate access to services among those with palliative care needs; and leveraging telehealth resources to conduct comprehensive assessments by hospital palliative care teams for elder service clients who have palliative care needs. We maintain that leveraging the resources of elder service agencies could measurably expand the reach of palliative care in the community.

Care of cancer patients at the end of life in a German university hospital: A retrospective observational study from 2014.

BackgroundCancer care including aggressive treatment procedures during the last phase of life in patients with incurable cancer has increasingly come under scrutiny, while integrating specialist palliative care at an early stage is regarded as indication for high quality end-of-life patient care.AimTo describe the demographic and clinical characteristics and the medical care provided at the end of life of cancer patients who died in a German university hospital.MethodsRetrospective cross-sectional study on the basis of anonymized hospital data for cancer patients who died in the Munich University Hospital in 2014. Descriptive analysis and multivariate logistic regression analyses for factors influencing the administration of aggressive treatment procedures at the end of life.ResultsOverall, 532 cancer patients died. Mean age was 66.8 years, 58.5% were men. 110/532 (20.7%) decedents had hematologic malignancies and 422/532 (79.3%) a solid tumor. Patients underwent the following medical interventions in the last 7/30 days: chemotherapy (7.7%/38.3%), radiotherapy (2.6%/6.4%), resuscitation (8.5%/10.5%), surgery (15.2%/31.0%), renal replacement therapy (12.0%/16.9%), blood transfusions (21.2%/39.5%), CT scan (33.8%/60.9%). In comparison to patients with solid tumors, patients with hematologic malignancies were more likely to die in intensive care (25.4% vs. 49.1%; p = 0.001), and were also more likely to receive blood transfusions (OR 2.21; 95% CI, 1.36 to 3.58; p = 0.001) and renal replacement therapy (OR 2.65; 95% CI, 1.49 to 4.70; p = 0.001) in the last 7 days of life. Contact with the hospital palliative care team had been initiated in 161/532 patients (30.3%). In 87/161 cases (54.0%), the contact was initiated within the last week of the patient’s life.ConclusionsOverambitious treatments are still reality at the end of life in cancer patients in hospital but patients with solid tumors and hematologic malignancies have to be differentiated. More efforts are necessary for the timely inclusion of specialist palliative care.

Satisfying needs and expectations of terminal cancer patients: Organizational challenges to social workers

Despite medical and scientific advances, numerous clinical essays, and research to fight cancer, endless concerns associated with this pathology continue to persist in the twenty-first century, with a strong impact on individuals’ lives particularly at the economic, social, emotional, relational, behavioural, and spiritual levels. However, metamorphosing this into reality still seems to be a distant event because this pathology is still considered one of the leading causes of death in different countries worldwide, and Portugal is no exception. This study aims to study the motivations expressed by terminally ill cancer patients and their caregivers, whose main diferences are characterized. The results show that the clinical, social, spiritual, economic, and emotional issues associated with the end -of- life context are numerous, therefore patients and their caregivers may have a number of circumstances to face. The presentation of the patients' and their caregivers’ needs, expression of motivations, requests for social work, and emotions experienced at the end of life are some of the core features of the study. We show disparities between patients and their caregivers, including different motivations, needs, requests, and different manifestations related to the place of death that constitute a major challenge for social work in the context of palliative care and care at the end of life. The paper identifies a number of organizational issues relevant to healthcare management contexts. Such issues recognize the importance of integrating innovative social work procedures and protocols into internal medicine departments, planning hospital discharges, making psychosocial and complicated grief risk screening at patients' admission, promoting social work palliative care education and training for hospital social workers, and the creation and development of more hospital palliative care teams in acute care hospitals. Also the relation between cost and quality of healthcare seems to place social workers in a very relevant healthcare management position.

Hospital Palliative Care Teams and Post-Acute Care in Nursing Facilities: An Integrative Review.

Although palliative care consultation teams are common in U.S. hospitals, follow up and outcomes of consultations for frail older adults discharged to nursing facilities are unclear. To summarize and critique research on the care of patients discharged to nursing facilities following a hospital-based palliative care consult, a systematic search of PubMed, CINAHL, Ageline, and PsycINFO was conducted in February 2016. Data from the articles (N = 12) were abstracted and analyzed. The results of 12 articles reflecting research conducted in five countries are presented in narrative form. Two studies focused on nurse perceptions only, three described patient/family/caregiver experiences and needs, and seven described patient-focused outcomes. Collectively, these articles demonstrate that disruption in palliative care service on hospital discharge and nursing facility admission may result in high symptom burden, poor communication, and inadequate coordination of care. High mortality was also noted. [Res Gerontol Nurs. 2017; 10(1):25-34.].

Poverty Reduction in India through Palliative Care: A Pilot Project.

Poverty Reduction in India through Palliative Care: A Pilot Project.

How Do Hospital Palliative Care Teams Use the WHO Guidelines to Manage Unrelieved Cancer Pain? A 1-Year, Multicenter Audit in Japan.

It has been reported that pain relief for patients with cancer is suboptimal in Japan. This has been mainly attributed to inadequate dissemination of the World Health Organization (WHO) guidelines for cancer pain management. To better understand this problem, we reviewed how 6 hospital palliative care teams (HPCTs) used the WHO guidelines for unrelieved pain in a 1-year audit that included 534 patients. The HPCT interventions were classified according to the contents of the WHO guidelines. In our study, HPCT interventions involved opioid prescriptions in >80% of referred patients, and "For the Individual" and "Attention to Detail" were the 2 most important principles. Our study indicates which parts of the WHO guidelines should be most heavily emphasized, when disseminating them in Japan.

Effectiveness of Hospital Palliative Care Teams for Cancer Inpatients: A Systematic Review.

Although the benefits of palliative care in the outpatient setting are well established, there has been little to support the employing of hospital palliative care services for inpatients with cancer. We conducted a systematic literature review to evaluate the effectiveness of palliative care for cancer patients in the acute inpatient hospital setting. Two electronic databases-PubMed and CINAHL Plus-were searched for articles published between 1 January 2005 and 28 May 2015. The search was augmented by hand-searches of specific journals and by examining the reference lists of short-listed articles. Studies were included if they evaluated a hospital palliative care service for cancer patients. Data extracted included study design, patient population, study setting, composition of the team, nature of the intervention, outcomes measured, and main findings. No randomized controlled trials were found. There were 14 pre-post studies that evaluated patient outcomes, of which only 2 had a control group. We also reviewed a further seven studies that evaluated other aspects of the palliative care intervention. The studies were not robust enough to confirm the efficacy of hospital palliative care services for cancer patient outcomes. Nonetheless, published studies provide a glimpse into the wider benefits of palliative care interventions. Data to support the benefit of palliative care interventions in the inpatient acute hospital setting are still lacking. Future studies should employ innovative strategies to further this field of research.

Experience of providing palliative care in critical care settings

BackgroundChanging demographics and medical advances have led to an increased demand for beds in critical care units. Patients in critical care are at risk of physical and psychosocial suffering. The...

Breathlessness and opioid therapy: A retrospective chart analysis in 2,958 patients.

192 Background: Breathlessness is a common and distressing symptom, which increases in many diseases as they progress and is difficult to manage. It is widely accepted that opioids are safe and effective for treating dyspnea, although no single opioid has an authorization for the treatment of breathlessness. The aims of the study were to assess prevalence rates of breathlessness as well as the treatment approaches especially with respect to opioid therapy in all patients cared by a hospital palliative care team in a university hospital over a period of five years. Methods: A systematic review of all electronically available records of patients under palliative care service from April 2010 – April 2015 was performed. Results: Breathlessness was the third most common symptom in our patient group behind fatigue and pain. Furthermore it was classified as the utmost distressing symptom of all. Many patients suffering from breathlessness were opioid-naive before contact with our palliative care team. Many of these patients were put on prolonged-release opioids together with short-acting opioids (mucosal fentanyl) as rescue medication for breathlessness. Opioid therapy was judged to be very effective by the majority of patients suffering from breathlessness however caused (cancer-related or due to a benign disease e.g. chronic obstructive pulmonary disease). Conclusions: In a large cohort of patients breathlessness is a major topic and is clearly positively influenceable by opioids. In our opinion it is longtime overdue to strive for an authorization for opioids against breathlessness.

Survival prediction for advanced cancer patients in the real world: A comparison of the Palliative Prognostic Score, Delirium-Palliative Prognostic Score, Palliative Prognostic Index and modified Prognosis in Palliative Care Study predictor model

PurposeThe aim of this study was to investigate the feasibility and accuracy of the Palliative Prognostic Score (PaP score), Delirium-Palliative Prognostic Score (D-PaP score), Palliative Prognostic Index (PPI) and modified Prognosis in Palliative Care Study predictor model (PiPS model). Patients and methodsThis multicentre prospective cohort study involved 58 palliative care services, including 19 hospital palliative care teams, 16 palliative care units and 23 home palliative care services, in Japan from September 2012 to April 2014. Analyses were performed involving four patient groups: those treated by palliative care teams, those in palliative care units, those at home and those receiving chemotherapy. ResultsWe recruited 2426 participants, and 2361 patients were finally analysed. Risk groups based on these instruments successfully identified patients with different survival profiles in all groups. The feasibility of PPI and modified PiPS-A was more than 90% in all groups, followed by PaP and D-PaP scores; modified PiPS-B had the lowest feasibility. The accuracy of prognostic scores was ⩾69% in all groups and the difference was within 13%, while c-statistics were significantly lower with the PPI than PaP and D-PaP scores. ConclusionThe PaP score, D-PaP score, PPI and modified PiPS model provided distinct survival groups for patients in the three palliative care settings and those receiving chemotherapy. The PPI seems to be suitable for routine clinical use for situations where rough estimates of prognosis are sufficient and/or patients do not want invasive procedure. If clinicians can address more items, the modified PiPS-A would be a non-invasive alternative. In cases where blood samples are available or those requiring more accurate prediction, the PaP and D-PaP scores and modified PiPS-B would be more appropriate.

Prospective Cohort Study of Hospital Palliative Care Teams for Inpatients With Advanced Cancer: Earlier Consultation Is Associated With Larger Cost-Saving Effect.

Previous studies report that early palliative care is associated with clinical benefits, but there is limited evidence on economic impact. This article addresses the research question: Does timing of palliative care have an impact on its effect on cost? Using a prospective, observational design, clinical and cost data were collected for adult patients with an advanced cancer diagnosis admitted to five US hospitals from 2007 to 2011. The sample for economic evaluation was 969 patients; 256 were seen by a palliative care consultation team, and 713 received usual care only. Subsamples were created according to time to consult after admission. Propensity score weights were calculated, matching the treatment and comparison arms specific to each subsample on observed confounders. Generalized linear models with a γ distribution and a log link were applied to estimate the mean treatment effect on cost within subsamples. Earlier consultation is associated with a larger effect on total direct cost. Intervention within 6 days is estimated to reduce costs by -$1,312 (95% CI, -$2,568 to -$56; P = .04) compared with no intervention and intervention within 2 days by -$2,280 (95% CI, -$3,438 to -$1,122; P < .001); these reductions are equivalent to a 14% and a 24% reduction, respectively, in cost of hospital stay. Earlier palliative care consultation during hospital admission is associated with lower cost of hospital stay for patients admitted with an advanced cancer diagnosis. These findings are consistent with a growing body of research on quality and survival suggesting that early palliative care should be more widely implemented.

Improving quality of care for serious illness: findings and recommendations of the Institute of Medicine report on dying in America.

Background In 1997, in response to growing public awareness and a landmark study,1 the IOM issueda report entitledApproachingDeath: Improving Care at the End of Life.2 This document, aswell as a subsequent report dedicated to children,3 focused attention on the excessive andunnecessarysufferingexperiencedbydyingpatientsandhelped tocatalyzeamovement for change.4 Impressively,manyof thegoals articulated in that report have been achieved, including the creationofpalliativemedicine specialty status, increasedaccess toopioids for patients with pain, and the widespread adoption of hospital palliative care teams. And yet, both research and the everyday experienceofpatients, familymembers, andclinicians suggest that huge gaps remain in the quality of care for themost vulnerable patients. This poor care continues against a backdrop of rising health care costs and a sense that the patients who account for the greatestpercentageof thisexpendituredonotbenefit from,andmayeven be harmed by, its excess. Furthermore, policy reform efforts have beenstymiedbyaccusationsof “deathpanels”andhijackedbyatoxic health care political debate. In response, the IOM decided to assemble a diverse expert panel, review the progress since the prior report, and restartmomentumtoward improving care.OnSeptember 17, 2014, this IOM committee issued Dying in America: ImprovingQualityandHonoring IndividualPreferencesNear theEndofLife.5

The Accuracy of Physicians' Clinical Predictions of Survival in Patients With Advanced Cancer

ContextAccurate prognoses are needed for patients with advanced cancer. ObjectivesTo evaluate the accuracy of physicians' clinical predictions of survival (CPS) and assess the relationship between CPS and actual survival (AS) in patients with advanced cancer in palliative care units, hospital palliative care teams, and home palliative care services, as well as those receiving chemotherapy. MethodsThis was a multicenter prospective cohort study conducted in 58 palliative care service centers in Japan. The palliative care physicians evaluated patients on the first day of admission and followed up all patients to their death or six months after enrollment. We evaluated the accuracy of CPS and assessed the relationship between CPS and AS in the four groups. ResultsWe obtained a total of 2036 patients: 470, 764, 404, and 398 in hospital palliative care teams, palliative care units, home palliative care services, and chemotherapy, respectively. The proportion of accurate CPS (0.67–1.33 times AS) was 35% (95% CI 33–37%) in the total sample and ranged from 32% to 39% in each setting. While the proportion of patients living longer than CPS (pessimistic CPS) was 20% (95% CI 18–22%) in the total sample, ranging from 15% to 23% in each setting, the proportion of patients living shorter than CPS (optimistic CPS) was 45% (95% CI 43–47%) in the total sample, ranging from 43% to 49% in each setting. ConclusionPhysicians tend to overestimate when predicting survival in all palliative care patients, including those receiving chemotherapy.