Inpatient Palliative Care Team Research Articles

Evaluation of spiritual needs assessments in oncology palliative care: Results of an improvement project.

161 Background: Addressing all facets of serious illness requires attention to patients’ spiritual concerns. At our Cancer Center, we sought to ensure that palliative care (PC) inpatients received evidence-based spiritual care. Methods: Chaplaincy Care, Supportive Care Medicine, and Quality and Safety Departments partnered to improve spiritual care using an iterative Plan-Do-Check-Act Cycle approach. Evidence-based spiritual practices were defined in accordance with the Association of Professional Chaplains and Clinical Practice Guidelines for Quality PC of the National Consensus Project. As a member of the Global Palliative Care Quality Alliance, we also used the web-based Quality Data Collection Tool (QDACT) to guide spiritual assessment. Electronic health record templates were revised to support complete and timely documentation. We monitored performance based on National Quality Forum Measure #1647 for discussion of spiritual/religious concerns. Performance was reviewed monthly by Leadership and with the Chaplaincy Staff. Opportunities to improve performance were discussed and adjustments in practice were made. Results: A total of 1609 oncology patients (average of 89/month) were seen by the inpatient PC team from November 2013–April 2015. With transparent performance reporting and resolution of barriers to spiritual assessment, an increase from 36 to 96% was noted for the percentage of patients with documented spiritual or religious concerns. Spiritual assessment using QDACT indicated that most patients report high spiritual well-being, spiritual peace, and a religious affiliation. Conclusions: As the result of our efforts, the majority of PC oncology patients at our center now have assessment and documentation of spiritual and religious concerns. A team-based approach to quality improvement successfully fostered the integration of spiritual care into oncology palliative care. [Table: see text]

Does Disclosure of Terminal Prognosis Mean Losing Hope? Insights from Exploring Patient Perspectives on Their Experience of Palliative Care Consultations.

A primary barrier to physician disclosure of terminal prognosis is concern that patients will lose hope. Inpatient palliative care (IPC) teams are especially posed to mediate this barrier, but little is known about patient perceptions and experience of IPC. This study aimed to elicit seriously ill patients' perspective and experience of an IPC consultation, and to explore patient attitudes toward information derived from the consultation. An exploratory, qualitative study was conducted at a large nonprofit community hospital in the Los Angeles area. An established IPC team conducted individualized consults with patients and families within 24 hours of referral. Eligible participants were English-speaking adults, aged 18 or over, who had received an IPC consultation within the previous week during their hospitalization. Purposive recruitment of patients was conducted by the IPC social worker. Interviews were conducted at bedside using a semistructured interview protocol employing open-ended questions. Twelve seriously ill patients were interviewed. Four themes were identified from the interview transcripts: (1) holistic care approach, (2) knowledge/information gained, (3) hope and enlightenment, and (4) patient readiness. Results suggest that disclosure of a terminal prognosis does not mean loss of patient hope. Instead, hope was redefined on a goal other than cure. Presenting patients with information and increasing their knowledge about care options and resources may facilitate patients in identifying meaningful goals that are better aligned with their prognosis.

Abstract P5-16-01: End-of-life outcomes and hospice and palliative care utilization in hospitalized patients with metastatic breast cancer

Abstract Background: Hospitalizations in patients with metastatic cancer occur commonly at the end of life but have not been well-described in those with metastatic breast cancer (MBC). The goal of this study was to describe the reasons for admission, end-of-life outcomes, and hospice and palliative care utilization in hospitalized patients with MBC. Methods: We identified all patients with MBC who had their first hospital admission (index admission) at Massachusetts General Hospital since their diagnosis of metastatic disease between 1/1/2009 and 12/31/2010 through a centralized clinical data registry. We collected demographic and clinical information and data on all hospital admissions and utilization of palliative care and hospice services during a three-year follow-up period. Results: We identified 123 patients hospitalized for the first time since their diagnosis of MBC. The median number of hospital admissions during the three-year follow-up period was 2 (range 1 to 17). Uncontrolled symptoms accounted for half (62/123, 50%) of the index admissions [20 (16%) with central nervous system systems, 17 (14%) with respiratory symptoms, 10 (8%) with pain, 9 (7%) with gastrointestinal symptoms, 4 (3%) with failure to thrive, and 2 (2%) with dehydration]. The majority of patients (93/123, 76%) died during the follow-up period. The median time from first hospitalization to death was 6 months (range 0 to 53). Among patients who died, 20/93 (22%) died in the hospital and 49/93 (53%) died within 14 days of hospital discharge. Among the deceased group, the inpatient palliative care team evaluated 53/93 (57%) of patients at least once during an admission, but only 18/93 (19%) patients attended an outpatient palliative care clinic appointment. A minority of patients who died (27/93, 29%) were referred to hospice upon discharge. An additional 34/93 (37%) patients who died were referred to hospice from the outpatient setting. Conclusions: Hospitalized patients with MBC are commonly admitted for uncontrolled symptoms. They have a poor prognosis, and approximately half die within two weeks of a hospital admission. However, only a minority receive outpatient palliative care or are referred to hospice services from the inpatient setting. These findings highlight the need to develop interventions to improve end-of-life care for patients with MBC who are hospitalized. Citation Format: Amanda Parkes, Jennifer A Shin, Helen Knight, Areej El-Jawahri, Lara Traeger, Jennifer S Temel. End-of-life outcomes and hospice and palliative care utilization in hospitalized patients with metastatic breast cancer [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P5-16-01.

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative CareNovember 13–15, 2014Orlando, Florida

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

DYING IN HOSPITAL-IS THERE AN UNMET PALLIATIVE CARE NEED FOR PATIENTS WHO DIE WITHIN 48 HOURS OF ADMISSION?

BackgroundThe majority of people in the UK die in hospital and many more die in hospital than are seen by the inpatient specialist palliative care team (SPCT).AimsTo assess the population...

PATIENTS WHO DIE IN HOSPITAL—IS THERE AN UNMET PALLIATIVE CARE NEED?

BackgroundThe majority of people in the UK die in hospital and many more die in hospital than are seen by the inpatient specialist palliative care team (SPCT).AimsTo assess the population...

Racial and Ethnic Variation in Pain Following Inpatient Palliative Care Consultations

Studies have documented high levels of pain in hospitalized individuals at the end of life, with minorities reporting higher levels of pain than whites. In response, inpatient palliative care (IPC) teams have grown rapidly to improve care of seriously ill individuals. Although research indicates that IPC teams effectively reduce and maintain control of pain, racial and ethnic differences in pain following IPC consultation remain unclear. This study investigated racial and ethnic pain differences after an IPC intervention in 385 seriously ill white, black, and Latino individuals aged 65 and older. Using the 11-point Numeric Rating Scale for pain, individuals were asked to rate their pain intensity at four points during hospitalization (before IPC consultation, 2 and 24 hours after the consultation, and at hospital discharge). Results indicate that whites (F1.657, 173.998 = 16.528, P < .001), blacks (F1.800, 95.410 = 7.103, P = .002), and Latinos (F1.388, 73.584 = 10.902, P < .001) all experienced significant reductions in pain after the intervention. Adjusted multivariate models testing between-group racial and ethnic differences revealed that Latinos were 62% more likely than whites to report experiencing pain at hospital discharge (relative risk = 0.38, 95% confidence interval = 0.15-0.97). Regardless of race or ethnicity, IPC effectively reduces and controls pain after consultation. Despite pain decreases, Latinos remain more likely than whites to report pain at follow-up. Further research is needed to determine the mechanisms in operation and to better understand and address the needs of this population.

Unmet Need for Mental Health Care Among Veterans Receiving Palliative Care: Assessment is Not Enough

To determine whether inpatient palliative care teams' assessments of psychological distress affect receipt of in-hospital mental health care (psychotherapy, psychological support, and health and behavior interventions) for seriously ill veterans. Retrospective review of medical records from 287 seriously ill veterans who received inpatient palliative care consults between 2008 and 2010 in the NY/NJ Veterans Healthcare Network. Of the veterans who were cognitively or physically able to answer questions on the Condensed Memorial Symptom Assessment Scale, 44% reported psychological distress. Of those with distress, 38% accessed mental health care. In logistic regression models adjusted for sociodemographic and health characteristics, there was no evidence that psychological distress reported during the palliative care consult was associated with subsequent mental health care receipt from any type of provider. Efforts to increase mental health care to psychologically distressed palliative care patients need to convert assessments into receipt of needed care.

Family members’ perceptions of inpatient palliative care consult services: A qualitative study

Background: Family members are commonly involved in end-of-life decision making and typically involved in inpatient palliative care consultations. Although much research has documented patient outcomes following inpatient palliative care consultation, little is known about family member perceptions of the consultation. Aim: The purpose of this study was to determine how inpatient palliative care consultations impacted family members’ understanding of the patient’s condition, knowledge of available care options, and decision-making ability. Design: An exploratory, qualitative study was conducted employing individual interviews among family members of seriously ill patients, recruited purposively. Interviews were conducted in person, at the hospital, or via telephone, using a semistructured protocol. Setting/participants: Family members of seriously ill patients were recruited from a nonprofit, community hospital. Results: Interviews were conducted among 23 family members. Four themes were identified and included: perceived qualities of the inpatient palliative care consultation, family readiness, impact on decision-making process, and focus on comfort and quality of life. While most comments reflected positive aspects of the inpatient palliative care consult, such as improved pain control and communication, and increased access to medical professionals and time to discuss patient conditions, some themes reflected a lack of adequate preparation for the inpatient palliative care consultation and readiness for discussing prognosis. Conclusion: Family members report discussion with the inpatient palliative care team results in improved communication and knowledge, which contributes to decision-making ability. However, palliative care consultation may be improved by developing stronger protocols for introducing palliative care and by including the attending physician in the process to preclude conflicting, inconsistent information and recommendations.

Evaluating the impact of early versus late inpatient palliative care consultation for cancer patients.

6638 Background: Access to specialist palliative care (hospital-based or hospice) is a recognized measure of quality in cancer care. Most cancer centers do have palliative care consult services, although the availability of a comprehensive program that includes a palliative care unit and outpatient clinic (Hui 2010) is inconsistent. A simultaneous integrated model of palliative care that facilitates earlier access to a specialized palliative care team may improve clinical outcomes. Palliative care programs should measure the access, timing and impact of their clinical service. Methods: Hospital claims data were linked to Social Security Death Index (SSDI) data from the US Department of Commerce. 3,128 adult cancer patients died between January 2009 and July 2011 and had contact with our inpatient palliative care team in their last six months of life. We determined whether IPC earlier than 1 month prior to death had an impact on hospitalizations, in-hospital mortality and referral to hospice. Results: 27.5% of cancer decedents accessed IPC, median of 22 days before death. 13.2% were discharged to hospice, median of 13 days before death. Patients with IPC earlier than 1 month until death were more likely to have hospice and fewer in-hospital deaths but there was no association between early IPC and a 30-day mortality admission. Conclusions: Palliative care services are accessed by a minority of patients and typically in the last 2-3 weeks of life. Although in-hospital deaths were reduced by earlier palliative care consultation, 30 day mortality did not improve. Hospitals may need to implement other strategies including early integration of outpatient palliative care among cancer patients, to achieve an impact on 30-day mortality admissions. [Table: see text]

Inpatient Palliative Care Consultation: Describing Patient Satisfaction

This study identified and measured common patterns of patients' positive care experiences during inpatient palliative consultation, and helped better understand how the journey of discovery experienced by both patients and life-care consult teams can be used to improve the quality of care. We administered questionnaires to a convenience sample of 25 patients who were referred to inpatient palliative care for a goals-of-treatment consult between April 2010 and May 2012. The codified responses to questionnaires revealed the perspectives of our patients rather than predicting outcomes. Respondents identified six areas of satisfaction: treatment with dignity and respect by the hospital health care team; after life-care planning consultation, patients felt they were better informed of their illness and medical context; 95% of all patients who responded felt their overall experience was excellent; all respondents felt the life-care planning consultation helped them form a treatment plan; all patients who responded believed their cultural beliefs and values were respected; and all responding patients noted that the inpatient palliative care team adequately addressed pain and symptom control. We were encouraged by our findings: the feedback from patients and families showed us we were effective, from their perspective, in helping them shape their treatment journey. It also emphasized where we could have been even more effective in improving our communication.

Living With Advanced Illness: Longitudinal Study of Patient, Family, and Caregiver Needs

Inpatient palliative care (IPC) consults are associated with improved quality of care and less intensive utilization. However, little is known about how the needs of patients with advanced illness and the needs of their families and caregivers evolve or how effectively those needs are addressed. The objectives of this study were 1) to summarize findings in the literature about the needs of patients with advanced illness and the needs of their families and caregivers; 2) to identify the primary needs of patients, families, and caregivers across the continuum of care from their vantage point; and 3) to learn how IPC teams affect the care experience. We used a longitudinal, video-ethnographic approach to observe and to interview 12 patients and their families before, during, and after an IPC consult at 3 urban medical centers. Additional interviews took place up to 12 months after discharge. Five patient/family/caregiver needs were important to all family units. IPC teams responded effectively to a variety of needs that were not met in the hospital, but some postdischarge needs, beyond the scope of IPC or health care coverage, were not completely met. Findings built upon the needs identified in the literature. The longitudinal approach highlighted changes in needs of patients, families, and caregivers in response to emerging medical and nonmedical developments, from their perspective. Areas for improvement include clear, integrated communications in the hospital and coordinated, comprehensive postdischarge support for patients not under hospice care and for their caregivers.

Prospective Tracking of Pediatric Urology Consults: Knowing is Half the Battle

The planned clinical activity of pediatric urologists has been well described. However, little is known about nonscheduled work (eg consultation requests). We describe the unplanned clinical activity of pediatric urologists at a high volume academic medical center. Demographic data regarding inpatient, operating room and emergency department pediatric urology consults were prospectively entered into an internal database. Consults from July 2008 through June 2010 underwent retrospective chart abstraction to identify reasons for consultation. Bivariate and multivariate statistics were used to evaluate 1) temporal trends in unplanned clinical activity, and 2) patient and service specific factors associated with whether a consult was billable (ie seen by attending physician within 24 hours). During the study period 665 pediatric consults were obtained. Mean ± SD patient age was 8.4 ± 7.7 years. Nearly all consults were seen at the emergency department (51%) or the inpatient wards (47%). The most common primary diagnoses were infection, obstruction/hydronephrosis and neurogenic bladder. The number of consults per month decreased during the course of the academic year (r(2) = 0.1422). Nearly three fourths of consults were eligible for billing. The factors associated with consult eligibility for billing included specific attending physician (p = 0.03), location (p <0.0001) and house officer experience (p = 0.007). At our academic pediatric hospital we averaged nearly 1 unplanned pediatric urology consult per day. Several service specific factors (unrelated to patient diagnosis or acuity) were associated with whether the consult had the potential to generate revenue. Unplanned clinical activity is an important factor to consider when planning departmental funding, staffing and training.

Pediatric Nurses' Individual and Group Assessments of Palliative, End-of-Life, and Bereavement Care

Although pediatric nurses working in children's hospitals often provide care to dying children, little is known about their palliative care beliefs and experiences as individuals or members of groups within the hospital. To describe pediatric nurses' ratings of palliative care goals and problems, as individuals and members of clusters of nurses with similar views, and nurses' degree of collaboration with an inpatient palliative care team across hospital units. A cross-sectional survey of nurses at a freestanding children's hospital in 2005. Nurses rated the most important goals as managing pain, maintaining the child's quality of life, and improving communication. Commonly cited problems were lack of opportunity to debrief after a patient's death, uncertainty about the goals of care, and the health care team's reluctance to discuss hospice with family. Based on individual views about goals and problems, nurses clustered into 5 groups that differed in terms of the adamancy of their views and the scope of the goals and problems they considered important or significant. The hospital unit was the most important factor in predicting nurses' degree of collaboration with the palliative care team even after accounting for individual characteristics. Pediatric nurses broadly endorse both the importance of palliative care goals and the presence of problems yet perceive the importance of these goals and problems differently. Further, they vary in their level of collaborative practice with a palliative care team in ways that should be accounted for when planning and implementing palliative care programs.

Transitions in End-of-Life Care: The Oregon Trail

Hospitals can create an environment that supports patients, families, and healthcare professionals so that they are better able to recognize the best way to care for each patient during times of transition. This article highlights some of the supports intentionally put into place to assist patients, family, and staff through difficult transitions at Oregon Health & Science University. These supports include an expert inpatient and outpatient palliative care team to coach patients, families, and staff at the bedside; statewide efforts to raise the skill level of all healthcare professionals through education; and the Physician Orders for Life-Sustaining Treatment (POLST) program, which helps ensure that care decisions made in one setting are respected as the patient moves to another care setting.

The Effects of an Inpatient Palliative Care Team on Discharge Disposition

Inpatient palliative care teams' (PCT) contribution to improved quality of life and patient satisfaction as well as decreased utilization and costs has been well established. Yet few studies have examined the specific effect of an inpatient PCT on discharge disposition, despite evidence of an association between hospice enrollment, decreased rehospitalization, and improved resource utilization. Patients admitted to a large nonprofit multisite hospital between June 2004 and December 2007 and seen by the PCT were matched to usual care (UC) patients on age, mortality risk, prior year hospitalized days, and disease severity. Discharge disposition and demographic factors were abstracted from hospital administrative claims; mortality data was collected from the social security death index. Analyses were performed using Wilcoxon's test, chi(2) analysis, and multinomial logit regression. Three hundred sixty-one matched pairs were available for analysis. Compared to UC, patients who received a PCT consultation were 3.24 times more likely to be discharged to hospice (p < 0.0001), 1.52 times more likely to be discharged to a nursing facility, and 1.59 times more likely to be discharged home with services (p < 0.001), controlling for patient demographics and disease severity. PCT patients were also referred to hospice earlier in their disease trajectory, rather than in the last few weeks of life. Patients receiving an inpatient PCT consultation are more likely to receive follow-up services upon discharge from the hospital. These services likely contribute to better quality of care and financial benefits, and warrants further study, especially considering the current focus on health care efficiency and quality.

Physician and Nurse Perceptions of a New Inpatient Palliative Care Consultation Project: Implications for Education and Training

Few studies have examined ease of integrating palliative care programs into hospital culture. The purpose of this article is to report findings from focus groups conducted among physicians and nurses to elicit their perceptions of an inpatient palliative care team consultation service after 1 year of operation. The study consisted of four homogeneous focus groups drawn from a purposive sample of physicians (2 groups; total n = 16) and nurses (2 groups; n = 17) at a large urban managed care center. Structured interview protocols were used to elicit participant perceptions regarding the impact of implementation. Focus groups were audiotaped and transcribed verbatim. We analyzed the data using grounded theory techniques to elicit themes and subthemes. Five major themes emerged regarding the positive and/or transformational impact of the program on patient/family services, medical staff, the hospital, quality of care, and time. Physician and staff observations regarding perceived barriers to integration included subthemes pertaining to the sharing of information, patient/family resistance and cultural differences, and the need for increased services. The vast majority of comments expressed were related to positive aspects of the program. However, barriers exist that prevent some terminally ill patients from receiving these services. Findings from this study have implications for the need for education and training among providers on palliative and hospice services and, in particular, on the benefits of an inpatient palliative care team for patients, regardless of their attitudes toward end-of-life care programs.

9 Palliative Care Patients’ Electronic Medical Records in the Community Pharmacy: Current Benefits and Future Directions

Kamsons, a busy community pharmacy, provides a comprehensive supply and clinical pharmacy service to St Catherine’s Hospice located 3 miles away. Various elements of the pharmacy service are provided both to the hospice inpatient and community-based specialist palliative care teams. In 2006, prompted by a desire to improve clinical reporting and auditability and promote flexible and integrated care …

Impact of an Inpatient Palliative Care Team: A Randomized Controlled Trial

Palliative care improves care and reduces costs for hospitalized patients with life-limiting illnesses. There have been no multicenter randomized trials examining impact on patient satisfaction, clinical outcomes, and subsequent health care costs. Measure the impact of an interdisciplinary palliative care service (IPCS) on patient satisfaction, clinical outcomes, and cost of care for 6 months posthospital discharge. Multicenter, randomized, controlled trial. IPCS provided consultative, interdisciplinary, palliative care to intervention patients. Controls received usual hospital care (UC). Five hundred seventeen patients with life-limiting illnesses from a hospital in Denver, Portland, and San Francisco enrolled June 2002 to December 2003. Modified City of Hope Patient Questionnaire, total health care costs, hospice utilization, and survival. IPCS reported higher scores for the Care Experience scale (IPCS: 6.9 versus UC: 6.6, p = 0.04) and for the Doctors, Nurses/Other Care Providers Communication scale (IPCS: 8.3 versus UC: 7.5, p = 0.0004). IPCS patients had fewer intensive care admissions (ICU) on hospital readmission (12 versus 21, p = 0.04), and lower 6-month net cost savings of $4,855 per patient (p = 0.001). IPCS had longer median hospice stays (24 days versus 12 days, p = 0.04). There were no differences in survival or symptom control. IPCS patients reported greater satisfaction with their care experience and providers' communication, had fewer ICU admissions on readmission, and lower total health care costs following hospital discharge.

Transitions of Care: Optimal Communication Between Hospital and Hospice

In this article, the key elements of a successful transition of terminally ill patients from the inpatient hospital to home hospice care setting are described. This article describes the role and responsibilities inpatient palliative care teams and receiving hospice agencies have for communicating with patients and families and preparing them for hospice care. This article explains one approach to educating the varied members of the health care team and describes how to collaborate on care plans to facilitate an effective and satisfying transfer of care.