Hospital Specialist Palliative Care Research Articles

Patterns of acute hospital and specialist palliative care use among people with non-curative upper gastrointestinal cancer

PurposeUpper gastrointestinal (GI) cancers contribute to 16.7% of UK cancer deaths. These patients make high use of acute hospital services, but detail about palliative care use is lacking. We aimed to determine the patterns of use of acute hospital and hospital specialist palliative care services in patients with advanced non-curative upper GI cancer.MethodsWe conducted a service evaluation of hospital use and palliative care for all patients with non-curative upper GI cancer seen in one large hospital, using routinely collected data (2019–2022). We report and characterise hospital admissions and palliative care within the study time period, using descriptive statistics, and multivariable Poisson regression to estimate the unadjusted and adjusted incidence rate ratio of hospital admissions.ResultsThe total with non-curative upper GI cancer was 960. 86.7% had at least one hospital admission, with 1239 admissions in total. Patients had a higher risk of admission to hospital if: aged ≤ 65 (IRR for 66–75 years 0.71, IRR 76–85 years 0.68; IRR > 85 years 0.53; p < 0.05), or lived in an area of lower socioeconomic status (IMD Deciles 1–5) (IRR 0.90; p < 0.05). Over the 4-year period, the rate of re-admission was higher in patients not referred to palliative care (rate 0.52 readmissions/patient versus rate 1.47 readmissions/patient).ConclusionPeople with advanced non-curative gastrointestinal cancer have frequent hospital admissions, especially if younger or from areas of lower socioeconomic status. There is clear association between specialist palliative care referral and reduced risk of hospitalisation. This evidence supports referral to specialist palliative care.

Quality outcomes for end-of-life care among people with haematological malignancies at a New Zealand cancer centre.

Little is known about the end-of-life (EOL) experience and specialist palliative care use patterns of patients with haematological malignancies (HMs) in New Zealand. This retrospective analysis sought to examine the quality of EOL care received by people with HMs under the care of Auckland District Health Board Cancer Centre's haematology service and compare it to international data where available. One hundred consecutive adult patients with HMs who died on or before 31 December 2019 were identified. We collected information on EOL care quality indicators, including anticancer treatment use and acute healthcare utilisation in the last 30 days of life, place of death and rate and timing of specialist palliative care input. During the final 14 and 30 days of life, 15% and 27% of the patients received anticancer therapy respectively. Within 30 days of death, 22% had multiple hospitalisations and 25% had an intensive care unit admission. Death occurred in an acute setting for 42% of the patients. Prior contact with hospital and/or community (hospice) specialist palliative care service was noted in 80% of the patients, and 67% had a history of hospice enrolment. Among them, 15% and 28% started their enrolment in their last 3 and 7 days of life respectively. The findings highlight the intensity of acute healthcare utilisation at the EOL and high rates of death in the acute setting in this population. The rate of specialist palliative care access was relatively high when compared with international experiences, with relatively fewer late referrals.

Hospital Specialist Palliative Care Team Influence on End-of-Life Care in Coronavirus Disease 2019? A Retrospective Observational Cohort Study.

The coronavirus 19 disease (COVID-19) pandemic has led to a renewed focus on end-of-life care. The majority of COVID-19 deaths occur in hospital, with patients cared for by generalists and hospital specialist palliative care teams (HSPCTs). This project aims at exploring the potential influences of HSPCTs on end-of-life care in COVID-19. A retrospective observational study was carried out by exploring four end-of-life care themes in a Scottish hospital population who died from COVID-19. Comparison was made between cohorts seen by HSPCTs versus generalist clinicians. Analysis of 119 patients across NHS Greater Glasgow and Clyde (NHSGGC) health board demonstrated that COVID-19 patients seen by HSPCTs were more likely to be younger (median 77 vs. 81 years; p = 0.02), have a cancer diagnosis (21.7% vs. 5.4%; p = 0.01), die sooner after admission (median four vs. six days; p < 0.01), and be commenced on a syringe driver (89.1% vs. 42.5%; p < 0.01). Differences detected across four end-of-life care themes comparing HSPCTs with generalist teams were minimal with documentation and prescribing in keeping with available guidance. Consistencies in end-of-life care observed across NHSGGC cohorts draw attention to the potential wider impact of HSPCT roles, including education, guideline development, and mentoring. Understanding such diverse effects is important to support funding and development of HSPCTs. Further research is required to better quantify the impact and heterogenous influences of HSPCTs in general.

1277P The role of palliative care in patients with glioblastoma multiforme: A single centre review

Patients with Glioblastoma Multiforme (GBM) have a prognosis of 16-21 months and high care needs due to progressive neurological deficits, cognitive impairment, and behavioural change. They often do not express the usual symptoms generally associated with advanced incurable cancer. They therefore represent a challenge to the classic palliative care assessment of needs. We aim to review patients with GBM who were referred to a hospital specialist palliative care (HSPC) service in a quaternary centre to inform service development.

Pharmacotherapeutics of aprepitant and pregabalin in neuropathic pain and refractory pruritus in a patient diagnosed with a cutaneous T-cell lymphoma

Background/Aims Palliative care nurse specialists are required to have a high level of knowledge and expertise in the management of complex symptoms. As a result of patient complexity, clinicians are often faced with advising on multiple drug regimes. This often requires clinical nurse specialists to have knowledge of pharmacotherapeutics to ensure safe and rational prescribing. In the form of a case study, the author has critically discussed the use of aprepitant and pregabalin in the management of neuropathic pain and refractory pruritus in a patient diagnosed with a cutaneous T cell lymphoma. These drugs are not routinely prescribed together and therefore the author has explored potential pharmacokinetic interactions. Case presentation The case presented a 49-year-old lady with an advanced metastatic cutaneous T-cell lymphoma with failed remission despite extensive oncological treatment. She was referrd to the to hospital specialist palliative care team for treatment of refractory pruritus and neuropathic pain. Conclusion Aprepitant is considered an effective anti-pruritic agent that is normally well tolerated; however, careful consideration must be taken because of extensive drug interactions. Caution is also required in patients with hepatic impairment. Pregabalin is often used in specialist palliative care for the management of neuropathic pain because of its efficacy and ease of titration. Caution must be taken in prescribing in patients with renal impairment. As pregabalin is not bound to plasma proteins nor metabolised by the liver, the risk of pharmacokinetic interaction with aprepitant is minimal. As both drugs cross the blood brain-barrier, clinicians must monitor for adverse central nervous system activity. This case study highlights the importance of pharmacotherapeutics in ensuring safe and rational prescribing, with the need to continue to integrate this knowledge into future practice as nurse prescribers.

Palliative care virtual ward: early evaluation of a novel model of care to support patients with complex symptom management known to a UK tertiary hospital specialist palliative care team.

Palliative care virtual ward: early evaluation of a novel model of care to support patients with complex symptom management known to a UK tertiary hospital specialist palliative care team.

Evaluating the use of video communication technology in a hospital specialist palliative care team during the COVID-19 pandemic

Background: Healthcare professionals’ use of video communication technology has increased during the novel coronavirus disease (COVID-19) pandemic, due to infection control restrictions. Currently there is little published data about the experiences of specialist palliative care teams who are using technology to communicate during the COVID-19 pandemic. The aim of this evaluation was to describe the experience of a UK based hospital specialist palliative care team, who were using video communication technology to support care during the COVID-19 pandemic. Methods: An online survey was distributed to the specialist palliative care team at a University teaching hospital in the North West of the UK. We asked participants to provide their views on the scope of use, barriers and future opportunities to use technology for communication in hospital palliative care. Results: The survey was completed by 14 healthcare professionals. Participants indicated that the most common reasons for using the technology was to receive team updates (n= 14, 100%), participate in multidisciplinary team meetings (n=14, 100%), for education (n=12, 86%) and to facilitate cross-site working (n=9, 64%). We identified barriers to using the technology, which were summarised as: (1) user-based difficulties; (2) inadequate technological infrastructure; (3) data security, privacy and ethical concerns; and (4) concerns regarding staff wellbeing. Participants stated that technology can potentially improve care by improving communication with hospital and community teams and increasing access to education. We have used these findings to develop recommendations to help palliative care teams to implement this technology better in clinical practice. Conclusion: Video communication technology has the potential to improve specialist palliative care delivery; however, it is essential that healthcare organisations address the existing barriers to using this technology, to ensure that these systems work meaningfully to improve palliative care for those who are most vulnerable beyond the COVID-19 pandemic.

Co-construction of the family-focused support conversation: a participatory learning and action research study to implement support for family members whose relatives are being discharged for end-of-life care at home or in a nursing home

BackgroundMany people move in and out of hospital in the last few weeks of life. These care transitions can be distressing for family members because they signify the deterioration and impending death of their ill relative and forthcoming family bereavement. Whilst there is evidence about psychosocial support for family members providing end-of-life care at home, there is limited evidence about how this can be provided in acute hospitals during care transitions. Consequently, family members report a lack of support from hospital-based healthcare professionals.MethodsThe aim of the study was to implement research evidence for family support at the end-of-life in acute hospital care. Informed by Participatory Learning and Action Research and Normalization Process Theory (NPT) we co-designed a context-specific intervention, the Family-Focused Support Conversation, from a detailed review of research evidence. We undertook a pilot implementation in three acute hospital Trusts in England to assess the potential for the intervention to be used in clinical practice. Pilot implementation was undertaken during a three-month period by seven clinical co-researchers - nurses and occupational therapists in hospital specialist palliative care services. Implementation was evaluated through data comprised of reflective records of intervention delivery (n = 22), in-depth records of telephone implementation support meetings between research team members and co-researchers (n = 3), and in-depth evaluation meetings (n = 2). Data were qualitatively analysed using an NPT framework designed for intervention evaluation.ResultsClinical co-researchers readily incorporated the Family-Focused Support Conversation into their everyday work. The intervention changed family support from being solely patient-focused, providing information about patient needs, to family-focused, identifying family concerns about the significance and implications of discharge and facilitating family-focused care. Co-researchers reported an increase in family members’ involvement in discharge decisions and end-of-life care planning.ConclusionThe Family-Focused Support Conversation is a novel, evidenced-based and context specific intervention. Pilot implementation demonstrated the potential for the intervention to be used in acute hospitals to support family members during end-of-life care transitions. This subsequently informed a larger scale implementation study.Trial registrationn/a.

Nurse practitioners' completion of Physician Orders for Scope of Treatment forms in West Virginia: A secondary analysis of 12 months of data from the state registry.

Advanced care planning documents, such as the Physician Orders for Life-Sustaining Treatment (POLST), require authorized medical provider signatures; only recently have nurse practitioners (NPs) been authorized to sign these forms. Recent legislation in West Virginia (WV) granting NPs signatory authority on POLST forms and the creation of a statewide registry provides an opportunity to examine the completion rates. The aim of this study was to investigate how recent legislation allowing NPs signatory authority for POLST forms has affected POLST completion. Data were obtained from the WV statewide registry of POST forms completed by all authorized personnel. Forms submitted by NPs were compared with those completed by physicians on patient demographics, setting, resuscitation status, level of medical intervention, and errors. Variables were cross-tabulated by provider type to determine whether and how NP POST completion differed from that of physicians. Forty-five NPs submitted 430 POST forms to the WV registry, which constituted 14.4% of the POST forms received. Ten NPs in community and hospital specialist palliative care teams submitted more than two thirds of these 430 forms. Nurse practitioner-completed POST forms were more likely to order do not resuscitate and comfort measures than POST forms ordered by physicians (both p < .001) and to be without errors (p < .001). Nurse practitioners practicing in specialist palliative care roles in communities and hospitals have embraced the use of POST and followed through on complete and accurate completion of the forms. With this signatory authority, primary and specialist NPs have the potential to improve end-of-life care.

A review of specialist palliative care provision and access across London - mapping the capital.

Palliative care provision varies by diagnosis, geography, and setting. The Minimum Data-set provides high-level data on provision, but comprehensive comparative information about specialist palliative care (SPC) provision is lacking. The London Cancer Alliance – now RM Partners’ Accountable Cancer Network - palliative care group (West/South London) and PallE8 (North/East London), with Marie Curie, sought to address this gap. The aim was to provide comparative data on SPC provision across London to support commissioners and providers to assess provision, identify gaps, and reduce inequity. A data-collection template was developed through expert consensus. Demographic, diagnostic, and service data was collected, plus models of care, staffing levels, and use of clinical outcome/experience measures. Results were collated by organisation and CCG. Cleaned data was provided back to each organisation for verification before final analyses.ResultsAll 50 adult SPC providers in London participated, representing hospitals, hospices and community services. •Patients in all 32 CCGs have access to hospice beds, with 322 beds from 15 providers (4 NHS) for a population of 9,323,570 (with 47,583 deaths annually).•SPC in London sees more non-cancer patients than is reported nationally; 79% of hospital advisory, 74% of community, and 88% of hospice in-patient services have higher proportions of non-cancer patients.•Considerable variation in out-of-hours availability of both hospital SPC and community SPC services across London; only 9 of 30 hospital and 17 of 26 community services provide seven-day visiting.•Wide variation in the models of community-based SPC; proportions of community patients attending day services vary from 1 in 4, to 1 in 17, just 13 CCGs have H@H-type provision, with few Rapid Response or Care Coordination services. ConclusionsThis detailed survey demonstrates important gaps in availability and provision of SPC services. Recommendations are made for commissioners and providers to join together to address these. It also gives a comprehensive view of rapidly changing models of community-based care, to inform innovation and service development.

Speak up about your practice

Over the past decade there has been increasing emphasis on patients’ needs and priorities in relation to NHS care. Many government policies have placed patients at the heart of care, and recommended that clinical services are developed to improve their experience. Tremendous progress has been made in oncology in improving patient experience and moving care closer to home. Hospital specialist palliative care services have been extended to cover seven-day working to improve pain and symptom management, and support ward staff in caring for patients with complex needs at the end of life.

Excellence in cost-effective inpatient specialist palliative care in the NHS – a new model

There is little in the literature describing hospital specialist palliative care units (PCUs) within the NHS. This paper describes how specialist PCUs can be set up within and be entirely funded by the NHS, and outlines some of the challenges and successes of the units. Having PCUs within hospitals has offered patients increased choice over their place of care and death; perhaps not surprisingly leading to a reduced death rate in the acute hospital. However, since the opening of the PCUs there has also been an increased home death rate. The PCUs are well received by patients, families and other staff within the hospital. We believe they offer a model for excellence in cost-effective inpatient specialist palliative care within the NHS.

THE USE OF QTC PROLONGING MEDICATIONS & DRUG INTERACTIONS IN PALLIATIVE CARE PATIENTS: AUDIT OF PRESCRIBING IN A TERTIARY CANCER CENTRE

BackgroundUse of medications which prolong the QTc interval in Palliative Care is under scrutiny due to risks of provoking potentially fatal arrhythmias. Risks are increased by drug interactions involving Cytochrome...

A QUALITATIVE STAFF EVALUATION RE-AUDIT OF THE HOSPITAL SPECIALIST PALLIATIVE CARE TEAM AND EVALUATION OF OUR 7 DAY SERVICE

During October 2011 an internal staff questionnaire was designed to gain feedback on the hospital specialist palliative care team from selected nursing groups, junior doctors and consultants. The aim was...

WHAT FACTORS INFLUENCE THE TERMINALLY ILL PATIENT REFERRED TO THE HOSPITAL SPECIALIST PALLIATIVE CARE TEAM IN A NHS HOSPITAL, NOT ACHIEVING THEIR PREFERRED PLACE OF DEATH? A CRITICAL EVALUATION

BackgroundThe purpose of "The End of Life Care Strategy" document (2008), was to introduce a strategy to promote high quality end of life care (EOLC) for patients approaching the end...

ESTIMATING GLOMERULAR FILTRATION RATE IN PALLIATIVE CARE PATIENTS: COMPARISON OF THE COCKROFT- GAULT AND ABBREVIATED MODIFICATION OF DIET IN RENAL DISEASE FORMULAS-IS IT RELEVANT TO CLINICAL PRACTICE?

BackgroundThe National Kidney Foundation, Kidney Disease Outcomes Quality Initiative recommends the Cockcroft Gault (CG) or abbreviated modified diet in renal disease (aMDRD) formulas for estimating Glomerular Filtration Rate (GFR). Clinical...

Does the ‘Liverpool Care Pathway’ facilitate an improvement in quality of care for dying cancer patients?

Background:The Liverpool Care Pathway for the Dying Patient (LCP) aims to transfer hospice principles of care for dying patients to other health-care sectors. This post-bereavement survey explored the LCP's effectiveness in improving quality of care for cancer patients.Methods:Postal self-completion questionnaires were sent to 778 next-of-kin to consecutive deceased patients who had died an ‘expected' cancer death in a hospice and acute tertiary hospital.Results:Following exclusions (n=53), 255 of the 725 next-of-kin agreed to participate (35.2% response rate). Overall hospice participants reported the best quality of care, and hospital participants, for whom care was not supported by the LCP, reported the worst quality of care. Multivariate analysis showed the hospice was an independent predictor for patients being treated with dignity (OR 8.46) and receiving adequate family support (OR 7.18) (P<0.0001). Care supported by the LCP and the hospital specialist palliative care team were both associated with good family support, but neither was an independent predictor.Conclusions:From the bereaved relatives' perspective, within the hospital, the LCP is effective in improving specific aspects of care, such as symptom control for dying patients. Further improvement is required, however, to attain the hospice standard of care.

Hospital specialist palliative care units – an innovative model delivering cost-effective choice?

BackgroundThe End of Life Strategy makes clear the importance of patient choice. The subsequent drive towards community end of life care masks the reality that even in the best performing...

‘Many hands make light work’ or ‘too many cooks spoil the broth’? Achieving the tricky balance of appropriate involvement in palliative care for cancer

BackgroundAddressing the care needs of people with advanced cancer is often complex, requiring communication between different professional and lay care providers, across different geographical and professional boundaries. Achieving the right...

Development and implementation of the Rapid Discharge Pathway Version 12 to enable imminently dying patients to die in the place of their choice

This study reports on the further development and implementation of a Rapid Discharge Home to Die Care Pathway (RDP Version 12). A rapid discharge pathway (RDP) was originally developed by members of the Hospital Specialist Palliative Care Team at the Royal Liverpool and Broadgreen University Hospitals NHS Trust in response to an identified clinical need to enable imminently dying patients to die in their place of choice when a clinical situation has changed rapidly and there has been an urgent request for a patient to die at home. The initial development and early evaluation, along with an example of the pathway itself, was published in 2004. The current study reports specifically on the subsequent development of the pathway that occurred alongside that of the generic Version 12 of the Liverpool Care Pathway for the Dying Patient published in December 2009. The study outlines the process of development and implementation of the RDP Version 12; patient scenario and a completed example are included to further illustrate the circumstances in which it can be used and the resultant process.