Early Introduction Of Palliative Care Research Articles

Strategies Used by Outpatient Oncology Nurses to Introduce Early Palliative Care: A Qualitative Study.

Although early palliative care is linked to improved health-related quality of life, satisfaction with care, and symptom management, the clinical strategies that nurses use to actively initiate this care are unknown. The aims of this study were to conceptualize the clinical strategies that outpatient oncology nurses use to introduce early palliative care and to determine how these strategies align with the framework of practice. A constructivist-informed grounded theory study was conducted in a tertiary cancer care center in Toronto, Canada. Twenty nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) from multiple outpatient oncology clinics (ie, breast, pancreatic, hematology) completed semistructured interviews. Analysis occurred concurrently with data collection and used constant comparison until theoretical saturation was reached. The overarching core category, pulling it all together , outlines the strategies used by oncology nurses to support timely palliative care referral, drawing on the coordinating, collaborating, relational, and advocacy dimensions of practice. The core category incorporated 3 subcategories: (1) catalyzing and facilitating synergy among disciplines and settings , (2) promoting and considering palliative care within patients' personal narratives , and (3) widening the focus from disease-focused treatment to living well with cancer . Outpatient oncology nurses enact unique clinical strategies, which are aligned with the nursing framework and reflected multiple dimensions of practice, to introduce early palliative care. Our findings have clinical, educational, and policy implications for fostering the conditions in which nurses are supported to maximize their full potential in the introduction of early palliative care.

Intensity at the end of life in pediatric neuro-oncology patients: The case for pediatric palliative care.

10021 Background: Although pediatric cancer is rare, it is the leading cause of death by disease after infancy for children and adolescents in the United States. Children exist in the context of a family; hence, excellent care for a child must also include attention to the needs of the family. Palliative care aims to enhance quality-of-life for these children living with life threatening illnesses and their families. Among pediatric cancers, brain tumors have high disease-related mortality rates; therefore, early introduction of palliative care to these patients is critical. This study aims to evaluate the association of palliative care during the terminal admissions of pediatric neuro-oncology patients and intensity of care provided at the end of life. Methods: Pediatric patients with brain tumors were identified using the Pediatric Health Information System (PHIS). Inclusion criteria were age <18, diagnosis of brain tumor as defined by ICD-10 codes, discharged as deceased, and hospital admission between 1/1/2017 and 12/31/2021. Intensity of care measures included: pediatric intensive care unit (PICU) admission, mechanical ventilation, total parenteral nutrition (TPN), and extracorporeal membrane oxygenation (ECMO). Results: 567 patients met the inclusion criteria. 359/567 (63%) patients had an inpatient palliative care consultation during their terminal hospital stay. Patients receiving a palliative care consultation had a lower percentage of PICU admission (64.9 vs 83.2, p=<0.001), mechanical ventilation use (51.0 vs 76.0, p=<0.001), and TPN use (18.1 vs 25.5, p=0.027). There were no significant differences in length of stay (22.07 vs 22.25 days, p=0.181) and ECMO use (0.28% vs 1.92%, p=0.450). Conclusions: Pediatric patients receiving palliative care consultations during their terminal admission received less intense care while having comparable lengths of stay. Palliative care should be offered to all families, even with aggressive goals, to help incorporate quality of life and comfort in the treatment plan and to ensure bereavement support is available if needed. Similar to data in the adult palliative care literature, this data demonstrates reduced resource utilization among pediatric patients receiving palliative care. Palliative care has been shown to be a supportive service that has the potential to improve the quality of life of patients. The first step toward equitable healthcare is to ensure that all children with a potentially terminal cancer diagnosis have access to full supportive services, including palliative care.

Palliative Care across Settings: Perspectives from Inpatient, Primary Care, and Home Health Care Providers and Staff.

Early introduction of palliative care can improve patient-centered outcomes for older adults with complex medical conditions. However, identifying the need for and introducing palliative care with patients and caregivers is often difficult. We aim to identify how and why a multi-setting approach to palliative care discussions may improve the identification of palliative care needs and how to facilitate these conversations. Descriptive qualitative study to inform the development and future pilot testing of a model to improve recognition of, and support for, unmet palliative care needs in home health care (HHC). Thematic analysis of semi-structured interviews with providers across inpatient (n = 11), primary care (n = 17), and HHC settings (n = 10). Four key themes emerged: 1) providers across settings can identify palliative care needs using their unique perspectives of the patient's care, 2) identifying palliative care needs is challenging due to infrequent communication and lack of shared information between providers, 3) importance of identifying a clinical lead of patient care who will direct palliative care discussions (primary care provider), and 4) importance of identifying a care coordination lead (HHC) to bridge communication among multi-setting providers. These themes highlight a multi-setting approach that would improve the frequency and quality of palliative care discussions. A lack of structured communication across settings is a major barrier to introducing and providing palliative care. A novel model that improves communication and coordination of palliative care across HHC, inpatient and primary care providers may facilitate identifying and addressing palliative care needs in medically complex older adults.

Identifying the palliative care needs of frail, older, housebound patients in the community: A cross-sectional study.

The early introduction of palliative care can have a positive impact on the quality of life of patients suffering from life-limiting diseases. However, the palliative care needs of older, frail, housebound patients are still mostly unknown, as is the impact of frailty on the importance of these needs. To identify the palliative care needs of frail, older, housebound patients in the community. We conducted a cross-sectional observational study. This study took place in a single primary care center and included patients who were ≥65years old, housebound, followed by the Geriatric Community Unit of the Geneva University Hospitals. Seventy-one patients completed the study. Most patients were female (56.9%), and mean age (SD) was 81.1 (±7.9). The Edmonton Symptom Assessment Scale mean (SD) score was higher in frail patients as opposed to vulnerable patients for tiredness (p=0.016), drowsiness (p=0.0196), loss of appetite (p=0.0124), and impaired feeling of well-being (p=0.0132). There was no difference in spiritual well-being, measured by the spiritual scale subgroup of the Functional Assessment of the Chronic Illness Therapy-Spiritual Well-Being scale (FACIT-sp) between frail and vulnerable participants, although scores in both groups were low. Caregivers were mainly spouses (45%) and daughters (27.5%) with a mean (SD) age of 70.7 (±13.6). The overall carer-burden measured by the Mini-Zarit was low. Older, frail, housebound patients have specific needs that differ from non-frail patients and should guide future palliative care provision. How and when palliative care should be provided to this population remains to be determined.

Barriers to palliative care in hepatocellular carcinoma: A review of the literature.

Hepatocellular carcinoma (HCC) is a deadly and burdensome form of liver cancer with an increasing global prevalence. Its course is unpredictable as it frequently occurs in the context of underlying end-stage liver disease, and the associated symptoms and adverse effects of treatment cause severe suffering for patients. Palliative care (PC) is a medical specialty that addresses the physical, emotional, and spiritual needs of patients and their carers in the context of life-limiting illness. In other cancers, a growing body of evidence has demonstrated that the early introduction of PC at diagnosis improves patient and carer outcomes. Despite this, the integration of palliative care at the diagnosis of HCC remains suboptimal, as patients usually receive PC only at the very terminal phase of their disease, even when diagnosed early. Significant barriers to the uptake of palliative care in the treatment algorithm of hepatocellular carcinoma fall under four main themes: data limitations, disease, clinician, and patient factors. Barriers relating to data limitations mainly encapsulated the risk of bias inherent in published work in the field of PC. Clinician-reported barriers related to negative attitudes towards PC and a lack of time for PC discussions. Barriers related to the disease align with prognostic uncertainty due to the unpredictable course of HCC. Significantly, there exists a paucity of evidence exploring patient-perceived barriers to timely PC implementation in HCC. Given that patients are often the underrepresented stakeholder in the delivery of PC, future research should explore the patient perspective in adequately designed qualitative studies as the first step.

Communication about early palliative care: A qualitative study of oncology providers' perspectives of navigating the artful introduction to the palliative care team.

Despite robust evidence for the integration of early palliative care for patients with advanced cancer, many patients still access this approach to care late. Communication about the introduction of Early Palliative Care is an important skill of healthcare providers working in this setting. In the context of limited community understanding about palliative care, patients and their families may express fear or negative reactions to its early introduction. Health professionals may lack the confidence or skill to describe the role and benefits of early palliative care. This study sought to explore clinicians' perspectives on communication about referral to early palliative care, specifically identifying facilitators in undertaking this communication task. An exploratory qualitative study set within a tertiary oncology service in Victoria, Australia. Semi-structured interviews were conducted with purposively sampled oncology clinicians exploring their perspectives on communication about referral to early palliative care. A reflexive thematic analysis was undertaken by two researchers, including both latent and semantic coding relevant to the research question. Reporting of the research was guided by the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist. Twelve oncology clinicians (58% female, with 67% > 15 years clinical experience) from medical oncology, surgical oncology, and haematology participated. The artful navigation of communication about early palliative care was characterised by the need for a 'spiel' involving the adoption of a series of strategies or 'tactics' when introducing this service. These themes included: 1) Using carefully selected and rehearsed language; 2) Framing in terms of symptom control; 3) Framing as additive to patient care; 4) Selling the service benefits of early palliative care; 5) Framing acceptance of referral as an altruistic act; and 6) Adopting a phased approach to delivering information about palliative care. This study highlights the wide ranging and innovative communication strategies and skills required by health professionals to facilitate referral to early palliative care for cancer patients and their families. Future focus on upskilling clinicians around communication of this topic will be important to ensure successful implementation of models of early palliative care in routine cancer care.

Referral of patients with cancer to palliative care: Attitudes, practices and work-related experiences among Swedish physicians.

This study aimed to explore the attitudes, practices and work-related experiences among Swedish physicians regarding the referral process, integration and transition between oncology care and palliative care (PC). A cross-sectional online survey was performed with a study-specific questionnaire in 2016-2017 in south-eastern Sweden. Physicians working with cancer patients within surgical specialties, medical specialties and paediatric oncology participated. The vast majority of the 130 participating physicians (99.2%) stated that PC was beneficial for the patient and were positive about early integration of PC (65.5%). Still, only 27.6% of the participants introduced PC at an early stage of non-curable disease. However, paediatric oncologists had a very early introduction of PC in comparison with medical specialties (p = 0.004). Almost 90% of the study population said they wanted to know that the patient had been taken care of by another care facility. Despite the physicians' positive attitude towards early integration and referral to PC, they often acted late in the disease trajectory. This late approach can reduce the patient's opportunity of improving quality of life during severe circumstances. There is a need for in-depth knowledge of the physicians' challenges in order to bridge the gap between intentions and actions.

Coping with deterioration over months – Glioma

Considering the short life expectancy of malignant glioma patients and their care needs throughout the disease trajectory, coping strategies should be considered a key component in the management of Brain Tumor patients. Patients' coping styles have an important influence in critical aspects of care such as communication of diagnosis and prognosis, discussion with patients and their caregivers about goal of treatments, early introduction of palliative care and advanced planning of patients' preferences concerning end of life treatment and issues. Understanding the coping style along the disease trajectory may help clinicians to personalize communication strategies, to promote adherence to treatment, to assess the time of transition to terminal care and to prepare in advance a shared end of life decision making process. Available data show that, despite the aggressiveness of the disease and the poor prognosis, at diagnosis and during the first line treatment, most of BT patients are able to display functional coping strategies such as combative spirit which favors active participation and adherence to treatment; also, cognitive avoidance coping style preserves the individual from excessive exposure to distress. According to recent studies in advanced cancer, coping style adopted may strongly influence patients' prognostic awareness and patients' availability to participate to prognosis discussions. This data are in line with previous literature on other cancer patients, demonstrating that coping style is not a persistent dimension of personality, but can change depending on the situation.

Coping with deterioration over years - multiple sclerosis

Multiple sclerosis presents with a wide range of physical, mental and psychiatric symptoms. It is also a major cause of disability globally. Studies have demonstrated that patients living with MS often experience physical, mental, social, and spiritual suffering which significantly impacts their health and quality of life. Palliative care can help provide patients with relief from suffering by reducing pain and discomfort, providing emotional support, improving functional ability and quality of life, as well as addressing end-of-life and legacy issues. It is often unclear to physicians, and patients what elements of palliative care should be provided and when. One reason for this is the uncertainty that surrounds the progression of the disease, the wide range of symptoms, and the prognosis of the patient. As a result, patients are often poorly prepared to cope with the impact of new symptoms, disabilities, or loss of function. While little can be done about the uncertainty of MS, the adoption of a care model where palliative care is introduced early and provided alongside neurological care can help patients cope with the suffering experienced with MS. Specific triggers to intensify palliative care can be arranged while EDSS milestones can be used to revise the palliative care plan. Early introduction of palliative care can also allow physicians to gain a better sense of the patient's priorities and care preferences, which is important for the development of a care plan that allows them to achieve their goals, reduce suffering, and improve quality of life over the years.

Palliative care is increasing, but curative care is growing even faster in the last months of life.

The introduction of early palliative care might be hoped to moderate the medicalisation of dying and the increasingly frequent medical and surgical treatment that patients generally receive in the last months of life. Indeed the old concept of an abrupt change from curative to palliative care when a person is terminally ill and imminently dying is giving way gradually to the better concept of a phased introduction of palliative care from diagnosis of a life-threatening illness, as advocated in Figure 1.1 Figure 1. Contrasting the old concept of curative care being suddenly replaced by palliative care to a gradual introduction of palliative care from diagnosis of any life-threatening illness. By 2018, GPs in Scotland recognised 69% of their patients for a palliative care approach by the time …

Como incluir os cuidados paliativos na formação de médicos nefrologistas: Revisão da literatura

Objetivo: O artigo tem como objetivo apresentar as vantagens dos cuidados paliativos (CP) para pacientes com doença renal crônica (DRC) e evidenciar os conhecimentos necessários aos nefrologistas para oferecer um tratamento holístico e adequado a esses pacientes. Metodologia: Essa revisão foi produzida usando a Pubmed (Biblioteca Nacional Americana de Medicina), a Biblioteca Virtual em Saúde (BVS) e a Scientific Eletronic Library Online (SciELO). A busca avançada teve como descritores: cuidados paliativos, doença renal crônica e planejamento antecipado de cuidados. Posteriormente, filtrou-se os artigos em inglês e português com publicações entre 2015 e 2020, sendo selecionados os mais pertinentes. Resultados: A análise das referências elucidou o CP e o seu papel na DRC, as competências inerentes aos nefrologistas e os principais sintomas dos pacientes com DRC. Conclusão: A instituição do CP, precocemente, é necessária para melhorar a qualidade de vida dos pacientes com DRC, sem restringir às medidas de fim de vida e sem excluir procedimentos intervencionistas. Assim, é indispensável investir na capacitação dos nefrologistas para que atendam às demandas da assistência paliativa em DRC.

Nurse-Led Palliative Care Clinical Trial Improves Knowledge and Preparedness in Caregivers of Patients with Idiopathic Pulmonary Fibrosis.

Rationale: Patients with idiopathic pulmonary fibrosis (IPF) and their caregivers experience stress, symptom burden, poor quality of life, and inadequate preparedness for end-of-life (EOL) care planning as the disease progresses. The hypothesis for this study was that the early introduction of palliative care in the course of IPF would improve knowledge and preparation for EOL, patient-reported outcomes, and advance care planning in patients with IPF and their caregivers. Objectives: We sought to determine the feasibility, acceptability, and efficacy of a nurse-led early palliative care intervention entitled "A Program of SUPPORT" (Symptom management, Understanding the disease, Pulmonary rehabilitation, Palliative care, Oxygen therapy, Research participation, and Transplantation) in patients with IPF and their caregivers. Methods: Patients with IPF (diagnosed in the year previous to their initial center visit) from the University of Pittsburgh Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease at University of Pittsburgh Medical Center-together with their caregivers-were randomized to receive the intervention "A Program of SUPPORT" or usual care. This included a total of three research visits aligned with their clinic visit over a period of 6 to 8 months. We measured feasibility, acceptability, and efficacy of this intervention. Results: A total of 136 patient/caregiver dyads were eligible, and a total of 76 dyads were enrolled and participated. Participants were predominately White males >65 years old. Thirteen percent did not have an identified caregiver. Feasibility was limited; 56% of eligible dyads were enrolled. Eligible dyads (24%) were interested in participating but too fatigued to stay after their clinic visit. There was high attrition (20% of participants died before the study was completed). "A Program of SUPPORT" was acceptable to participants. Efficacy demonstrated a significant improvement in caregiver's knowledge, disease preparedness, and confidence in caring for the patient as well as an improvement in knowledge and advance care planning completion in patient participants. Conclusions: Patients with IPF and their caregivers have unmet needs regarding knowledge of their disease, self-management strategies, and preparedness for EOL planning. This nurse-led intervention demonstrated acceptability and efficacy in knowledge and advance care planning completion in patients and in knowledge, disease preparedness, and confidence in caregivers. Future research should identify additional strategies, including telemedicine resources to reach additional patients and their caregivers earlier in their disease course. Clinical trial registered with clinicaltrials.gov (NCT02929017).

Building capacity for palliative care delivery in primary care settings: Mixed-methods evaluation of the INTEGRATE Project.

To evaluate an intervention aimed at building capacity to deliver palliative care in primary care settings. The INTEGRATE Project was a 3-year pilot project involving interprofessional palliative care education and an integrated care model to promote early identification and support of patients with palliative care needs. A concurrent mixed-methods evaluation was conducted using descriptive data, provider surveys before and after implementation, and interviews with providers and managers. Four primary care practices in Ontario. All providers in each practice were invited to participate. Providers used the "surprise question" as a prompt to determine patient eligibility for inclusion. Provider attitudes toward and confidence in providing palliative care, use of palliative care tools, delivery of palliative care, and perceived barriers to delivering palliative care. A total of 294 patients were identified for early initiation of palliative care, most of whom had multiple comorbid conditions. Results demonstrated improvement in provider confidence to deliver palliative care (30% mean increase, P < .05) and self-reported use of palliative care tools and services (25% mean increase, P < .05). There was substantial variation across practices regarding the percentage of patients identified using the surprise question (0.2% to 1.5%), the number of advance care planning conversations initiated (50% to 90%), and mean time to conversation (13 to 76 days). This variation is attributable, in part, to contextual differences across practices. A standardized model for the early introduction of palliative care to patients can be integrated into the routine practice of primary care practitioners with appropriate training and support. Additional research is needed to understand the practice factors that contribute to the success of palliative care interventions in primary care and to examine patient outcomes.

Customised pediatric palliative care: Integrating oncological and palliative care priorities.

To describe the experience involving the early introduction of palliative care (PC) in oncological patients treated within the paediatric oncology unit of the Istituto Nazionale Tumori of Milan and compare this cohort with a cohort of patients resident in the same area treated before the introduction of early palliative care. A virtual team was assembled in 2015. The PC providers operate outside the hospital. Conference calls were scheduled to discuss patients' problems. This sample was compared with the clinical records of patients residing in the same area who died between 2009 and 2014. Between January 2015 and April 2019, 41 patients residing in the Milan area mainly with CNS tumours or sarcomas were referred to the team. Comparing the results with the previous cohort, there was a rise in the number of patients dying at home or in a hospice and the duration of PC increased over time. From 2015, none of the patients died in an intensive care unit. Patients managed by the virtual team were able to continue their cancer treatments, take part in Phase I trials and receive PC. All patients with a poor prognosis should have PC at an early stage.

Integration of Neuro-Oncology and Pediatric Palliative Care at Diagnosis in the Outpatient Setting. (FR436)

•Gain knowledge about the common types of life-threatening brain tumors seen in children, cutting edge treatments for these tumors, and why an understanding of neuro-oncology is critical to pediatric palliative care providers.•Describe the barriers to introducing palliative care at the time of diagnosis of a high grade pediatric brain tumor and how the pediatric neuro-oncology and palliative care teams negotiated a patient/family-focused approach that overcame the barriers.•Weigh the advantages and disadvantages of several different models for overcoming the logistical challenges of integrating palliative care into a pediatric neuro-oncology clinic.•Be able to quote data that supports the benefits of early introduction of palliative care in the management of pediatric neuro-oncology patients diagnosed with life-threatening tumors. Brain tumors are the second most common tumor in children accounting for about 1 in 4 tumors. They are also the leading cause of cancer-related death in children. The tumors and their treatments are associated with significant physical symptoms, psychological strain, learning difficulties, and mortality. For these reasons, it is imperative that children with brain tumors have access to palliative care starting at the time of diagnosis. Unfortunately, access to palliative care for these children is not universal and when available is often indroduced late in the couse of disease. The prognosis and treatment of the most common life-threatening brain tumors will be reviewed by a neuro-oncology team. The neuro-oncology team will also share five years of experience embedding palliative care into the pediatric oncology clinic at a large tertiary care hospital. In this setting, it has been shown that families are very open to and appreciative of early palliative care when it is framed by the oncology team as an essential part of the care of children with brain tumors. The neuro-oncology team and the palliative care team will dialogue about the sources of resistance to early introduction of palliative care and how this resistance can be overcome. The practical considerations involved in the implementation of clinic-based palliative care will also be discussed. This will include staffing and the advantages of different clinic models including 1) embedded clinics, 2) floating clinics, and 3) free standing clinics. Finally, a retrospective review of 5 years of clinical data collected on over 60 pediatric neuro-oncology patients concurrently followed in palliative care clinic will be presented. The data will include type of brain tumor, time from diagnosis to palliative consult, symptom frequency, time from POLST completion to death, time from hospice referal to death, and location of end of life care.

“I’m going to push this door open. You can close it”: A qualitative study of the brokering work of oncology clinic nurses in introducing early palliative care

Background: Early palliative care improves quality of life during life-prolonging treatment for patients with cancer, but the role of nurses in facilitating the early involvement of palliative care is unclear. Aim: To conceptualize the psychosocial processes involved in the introduction and provision of palliative care by oncology nurses. Design: A constructivist qualitative grounded theory study was conducted. Setting/participants: A total of 20 nurses (6 staff nurses, 10 nurse practitioners, and 4 advanced practice nurses) completed semi-structured interviews. Participants were from multiple ambulatory care oncology clinics (i.e. breast, pancreatic, hematology) in a comprehensive cancer center. Results: The core category, brokering palliative care, represented the overarching concept of the study that linked other subcategories. The other subcategories were as follows: opening the door—creating the possibility of discussing early palliative care at a time when patients show signs of being receptive to this discussion; building trust—establishing relationships with patients as a starting point for open discussions about palliative care; tackling misconceptions—addressing patients’ assumptions about palliative care as signifying death; and advocating with oncologists—seeding the process of referral by bringing patients’ concerns forward. Conclusion: Oncology nurses play a central role in “brokering” the introduction of early palliative care; this process is supported by their relational proximity to patients and their location “in between” the patient and the oncologist. Training all nurses in palliative care and empowering them to have proactive discussions in a collaborative practice context would allow greater access to early palliative care.

Impact of early palliative care on survival in advanced-stage cancer patients: An institution-based retrospective cross-sectional study

Background: While treating patients with the advanced disease it becomes very challenging for the clinicians to decide as to when the active treatment is justified and when should palliative care be introduced in patient's treatment. American Society of Clinical Oncology (ASCO) suggested that patients with advanced cancer, regardless of patient or outpatient, should receive dedicated palliative care services, early in the disease course, simultaneous with active treatment. Similar recommendations have been proposed by the European Society of Medical Oncology (ESMO). Keeping in view this background, we aimed to do this study. Aim: To study the impact of the introduction of early palliative care into routine oncological management on patient's survival.Methods: This retrospective cross-sectional study is based on hospital data for patients who died in the hospice between the year 2017 and 2018. The complete information including age, gender, date of death, diagnosis, procedures, and medical interventions, as well as the date of documentation, was obtained of each patient.Results: A total of 27 patients were enrolled in this study. The mean age at presentation was 50.3 years. 11 (40.7%) patients received oncological treatment integrated with palliative care in the last month of life. The median duration of survival from diagnosis till death was 7 months in the patients who received only palliative care and 10 months in patients who received integrated onco-palliative care in the last month of life (P=0.452). 14 (51.8%) patients received early palliative care. The median survival of the patients who received early palliative care and of those who were offered palliative care towards the end of life was 8.5 months and 7 months respectively (P=0.040).Conclusion: Based on our results, we strongly believe that early palliative care when integrated into standard oncological treatment in advance stage cancer patients can prolong patient's survival.

Oncology Case Report - When Is the Appropriate Time to Integrate Palliative Care?

Many patients with advanced, non-curable cancer experience disease progression to a stage requiring symptomatic care alone. The integration of palliative care into oncology practice is therefore important, with many studies showing the benefits of early introduction of palliative care. In addition to symptom relief, palliative care can include psychological, social, and spiritual support. Although all oncologists provide basic palliative care, recent data indicate that the parallel involvement of a specialist palliative team that addresses the psychological, social, and spiritual needs of patients may be advantageous for both patients and their families. This mode of early integration of palliative care has been found to enhance patient quality of life and to provide more effective use of costly treatments. In Czech hospitals, however, this mode is rarely employed. Palliative care is usually perceived as an end-stage approach, which is initiated only when all other anticancer treatment modalities have been exhausted. This case describes the challenges and missed opportunities when palliative care was initiated late during the dying phase of a young female patient with metastatic colorectal cancer, and it discusses the potential benefits of early integration of palliative care. Supported by Ministry of Health of the Czech Republic, grant No. 15-33590A. All rights reserved. The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study. The Editorial Board declares that the manuscript met the ICMJE recommendation for biomedical papers. Submitted: 27. 11. 2018 Accepted: 7. 6. 2019.

"Why Would I Choose Death?": A Qualitative Study of Patient Understanding of the Role and Limitations of Cardiac Devices.

Although cardiology organizations recommend early introduction of palliative care for patients with heart failure (HF), integration has remained challenging, particularly in patients with cardiac devices such as cardiac implantable electronic devices and left ventricular assist devices. Study authors suggest that patients often have limited and erroneous understanding of these devices and their implications for future care. The aim of this study was to assess perceptions of cardiac devices in patients with HF and how these perceptions impacted advance care planning and future expectations. This study used qualitative semistructured interviews with 18 community-dwelling patients with New York Heart Association stage II to IV HF. We interviewed 18 patients (mean ejection fraction, 38%; mean age, 64 years; 33% female; 83% white; 39% New York Heart Association class II, 39% class III, and 22% class IV). All had a cardiac implantable electronic device (6% permanent pacemaker, 56% implantable cardioverter-defibrillator, 28% biventricular implantable cardioverter-defibrillator); 11% had left ventricular assist devices. Patients with devices frequently misunderstood the impact of their device on cardiac function. A majority expressed the belief that the device would forestall further deterioration, regardless of whether this was the case. This anticipation of stability was often accompanied by the expectation that emerging technologies would continue to preempt decline. Citing this faith in technology, these patients frequently saw limited value in advance care planning. In our sample, patients with cardiac devices overestimated the impact of their devices on preventing disease progression and death and deprioritized advance care planning as a result.

Integrating early palliative care into routine practice for patients with cancer: A mixed methods evaluation of the INTEGRATE Project.

With increasing evidence from controlled trials on benefits of early palliative care, there is a need for studies examining implementation in real-world settings. The INTEGRATE Project was a 3-year real-world project that promoted early identification and support of patients with cancer who may benefit from palliative care. This study assesses feasibility, stakeholder experiences, and early impact of the INTEGRATE Project METHODS: The INTEGRATE Project was implemented in four cancer centers in Ontario, Canada, and consisted of interdisciplinary provider education and an integrated care model. Providers used the Surprise Question to identify patients for inclusion. A mixed methods evaluation of INTEGRATE was conducted using descriptive data, interviews with providers and managers, and provider surveys. A total of 760 patients with cancer (lung, glioblastoma, head and neck, gastrointestinal) were included. Results suggest improvement in provider confidence to deliver palliative care and to initiate the Advanced Care Planning (ACP) conversation. The majority of patients (85%) had an ACP or goals of care (GOC) conversation initiated within a mean time to conversation of 5-46days (SD 20-93) across centers. A primary care report was transmitted to family doctors 48-100% of the time within a mean time to transmission of 7-54days (SD 9-27) across centers. Enablers and barriers influencing success of the model were also identified. A standardized model for the early introduction of palliative care for patients with cancer can be integrated into the routine practice of oncology providers, with appropriate education, integration into existing clinical workflows, and administrative support.