Non-palliative Care Research Articles

A Scoping Review of the Barriers and Facilitators to Clinician Engagement in Hospital-Based Palliative Care in Australian Hospitals.

Background: Current research has shown that inpatient palliative care (PC) services are under-utilized, poorly integrated, and frequently introduced too late during inpatient hospital stays. The aim of this study was to identify a comprehensive list of multi-disciplinary facilitators and barriers to inpatient PC in Australian hospitals through a scoping literature review. Methods: This review identified articles published since 2000 from 3 electronic databases (CINAHL Plus, MEDLINE and Embase), which included discussion of collaboration among non-palliative care clinicians and palliative care professionals in Australian hospitals. We used an inductive approach to identifying key domains of barriers and facilitators. Results: Thirty-four articles met inclusion criteria following full text review. Barriers and facilitators were categorized in 7 domains: (1) Patient concerns, (2) Family concerns, (3) Clinician knowledge, education, and experience in palliative care, (4) Recognition and acceptance of prognosis when a patient was dying or needing end of life treatment, (5) Reconciliation of individual and professional values around PC, (6) Clinician access to resources for PC in the hospital, and (7) Communication between the PC team and ward clinicians. Each domain included potentially substantial barriers to PC delivery and practice. However, given the small sample sizes and specialized settings of many included studies, it was difficult to draw conclusions on the relative significance of different barriers across hospitals. Conclusion: This review identified a number of barriers and facilitators across studies. Subsequent research needs to more comprehensively compare factors impacting PC use in order to improve implementation of PC across hospital settings.

Comparison of quality-adjusted life years (QALYs) of end-stage patients with gastrointestinal cancers receiving conventional therapies with recipients of supportive-palliative care package.

This study aimed to compare the quality-adjusted life years (QALYs) of patients with gastrointestinal (GI) cancer after receiving palliative and supportive care. Conducted at Firoozgar Hospital in Tehran, Iran, this observational study included 500 end-stage gastrointestinal cancer patients. The study divided these patients into two groups: 250 utilized palliative medicine services, while the remaining 250 did not. The study compared the conditions of patients in both groups. Among those receiving palliative care, only 21% underwent chemotherapy, significantly lower than the 55% in the non-palliative care group (P < 0.001). Hospital mortality rates were considerably reduced in the palliative care group, with 115 patients (46%) compared to 200 patients (80%) in the non-palliative group (P < 0.001). The average hospital stay for patients receiving palliative care was 25.11 ± 5.12 days, significantly shorter than the 96.42 ± 14.15 days in the non-palliative group (P < 0.001). The EuroQol 5-Dimensions 3-Levels (EQ-5D-3L) questionnaire scores showed that patients in the palliative care group experienced significantly better outcomes in pain and mood symptoms, but no significant difference was observed in physical function compared to the non-palliative group. Palliative medicine is recommended for gastrointestinal cancer patients as it can significantly reduce unnecessary hospital referrals and length of hospitalization.

Benefits of specialist palliative care by identifying active ingredients of service composition, structure, and delivery model: A systematic review with meta-analysis and meta-regression.

Specialist palliative care (SPC) services address the needs of people with advanced illness. Meta-analyses to date have been challenged by heterogeneity in SPC service models and outcome measures and have failed to produce an overall effect. The best service models are unknown. We aimed to estimate the summary effect of SPC across settings on quality of life and emotional wellbeing and identify the optimum service delivery model. We conducted a systematic review with meta-analysis and meta-regression. Databases (Cochrane, MEDLINE, CINAHL, ICTRP, clinicaltrials.gov) were searched (January 1, 2000; December 28, 2023), supplemented with further hand searches (i.e., conference abstracts). Two researchers independently screened identified studies. We included randomized controlled trials (RCTs) testing SPC intervention versus usual care in adults with life-limiting disease and including patient or proxy reported outcomes as primary or secondary endpoints. The meta-analysis used, to our knowledge, novel methodology to convert outcomes into minimally clinically important difference (MID) units and the number needed to treat (NNT). Bias/quality was assessed via the Cochrane Risk of Bias 2 tool and certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. Random-effects meta-analyses and meta-regressions were used to synthesize endpoints between 2 weeks and 12 months for effect on quality of life and emotional wellbeing expressed and combined in units of MID. From 42,787 records, 39 international RCTs (n = 38 from high- and middle-income countries) were included. For quality of life (33 trials) and emotional wellbeing (22 trials), statistically and clinically significant benefit was seen from 3 months' follow-up for quality of life, standardized mean difference (SMD in MID units) effect size of 0.40 at 13 to 36 weeks, 95% confidence interval (CI) [0.21, 0.59], p < 0.001, I2 = 60%). For quality of life at 13 to 36 weeks, 13% of the SPC intervention group experienced an effect of at least 1 MID unit change (relative risk (RR) = 1.13, 95% CI [1.06, 1.20], p < 0.001, I2 = 0%). For emotional wellbeing, 16% experienced an effect of at least 1 MID unit change at 13 to 36 weeks (95% CI [1.08, 1.24], p < 0.001, I2 = 0%). For quality of life, the NNT improved from 69 to 15; for emotional wellbeing from 46 to 28, from 2 weeks and 3 months, respectively. Higher effect sizes were associated with multidisciplinary and multicomponent interventions, across settings. Sensitivity analyses using robust MID estimates showed substantial (quality of life) and moderate (emotional wellbeing) benefits, and lower number-needed-to-treat, even with shorter follow-up. As the main limitation, MID effect sizes may be biased by relying on derivation in non-palliative care samples. Using, to our knowledge, novel methods to combine different outcomes, we found clear evidence of moderate overall effect size for both quality of life and emotional wellbeing benefits from SPC, regardless of underlying condition, with multidisciplinary, multicomponent, and multi-setting models being most effective. Our data seriously challenge the current practice of referral to SPC close to death. Policy and service commissioning should drive needs-based referral at least 3 to 6 months before death as the optimal standard of care.

Bereaved family members’ perspectives on quality of death in deceased acute cardiovascular disease patients compared with cancer patients – a comparison of the J-HOPE3 study and the quality of palliative care in heart disease (Q-PACH) study

BackgroundOutcome measures during acute cardiovascular disease (CVD) phases, such as quality of death, have not been thoroughly evaluated. This is the first study that compared the family members’ perceptions of quality of death in deceased CVD patients and in deceased cancer patients using a bereaved family survey.MethodsRetrospectively sent questionnaire to consecutive family members of deceased patients with CVD from ten tertiary hospitals from October 2017 to August 2018. We used the short version of the Good Death Inventory (GDI) and assessed overall care satisfaction. Referencing the GDI, the quality of death was compared between CVD patients admitted to a non-palliative care unit (non-PCU) and cancer patients in palliative care units (PCU) and non-PCUs in the Japan Hospice and Palliative Care Evaluation Study (J-HOPE Study). Additionally, in the adjusted analysis, multivariable linear regression was performed for total GDI score adjusted by the patient and participant characteristics to estimate the difference between CVD and other patients.ResultsOf the 243 bereaved family responses in agreement (response rate: 58.7%) for CVD patients, deceased patients comprised 133 (54.7%) men who were 80.2 ± 12.2 years old on admission. The GDI score among CVD patients (75.0 ± 15.7) was lower (worse) than that of cancer patients in the PCUs (80.2 ± 14.3), but higher than in non-PCUs (74.4 ± 15.2). After adjustment, the total GDI score for CVD patients was 7.10 points lower [95% CI: 5.22–8.97] than for cancer patients in PCUs and showed no significant differences compared with those in non-PCUs (estimates, 1.62; 95% CI [-0.46 to 5.22]).ConclusionsThe quality of death perceived by bereaved family members among deceased acute CVD patients did not differ significantly from that of deceased cancer patients in general wards, however, was significantly lower than that of deceased cancer patients admitted in PCUs.

Surgery Prolongs Five-Year Survival for Nonmetastatic Colon Neuroendocrine Tumors

Abstract Background: While treatment guidelines for colon neuroendocrine tumors recommend surgical intervention when feasible, evidence in the literature is limited for patients with nonmetastatic tumors. Objectives: This study assessed the efficacy of surgery in terms of five year survival for patients with nonmetastatic colon neuroendocrine tumors. Design: This was a retrospective cohort study. Patient and Methods: This study used the National Cancer Database (NCDB) which compiles data from 1500 + facilities accredited to the Commission on Cancer. Data from patients with histologically confirmed colon neuroendocrine tumors from 2007 to 2018 were collected. Other inclusion criteria were age more than 18 years, nonmetastatic, nonpalliative care, known surgery status/type, and chemotherapy status. The five year survival rates were assessed using Kaplan–Meier curves and multivariate adjusted Cox proportional hazards regression to analyze the efficacy of surgery for these tumors. In addition, sensitivity analyses were performed to determine the associations in patients with well differentiated and early stage (stage 1) tumors. Main Outcome Measure: The main outcome was five year overall survival. Sample Size: A total of 3,340 patients met the inclusion criteria from the NCDB. Results: The majority of patients received some form of surgery (95.8%), while fewer patients (4.3%) received nonsurgical treatment. Overall, patients were on average 61.5 ± 13.3 years old, female (54.3%), and majority white (77.7%). Five year survival rates were 65.5% for the no surgery group and 79.5% for the surgery group [Kaplan–Meier log rank, P &lt; .0001]. Moreover, multivariate proportional hazards regression showed prolonged five year survival after surgery [adjusted hazards ratio (aHR) (95% confidence interval): 0.39 (0.28–0.54)]. In addition, all sensitivity analyses revealed prolonged survival of patients who underwent surgery. Conclusion: To our knowledge, this is the first study to assess survival for nonmetastatic colon neuroendocrine tumors using a national database. Limitations: This study was limited by retrospective review, potential selection bias from a registry, and missing data. Conflicts of Interest: None.

Provision of palliative care for people with chronic obstructive pulmonary disease: a narrative review.

Chronic obstructive pulmonary disease (COPD) is characterized by persistent and progressive airflow restriction and is the third leading cause of death and disability, globally. People with severe COPD generally experience long-term functional decline punctuated by periods of acute exacerbation. Symptom burden can be severe and debilitating, and typically includes breathlessness, cough, fatigue, pain, anxiety, depression, and overall reduced quality of life. Understanding current palliative care needs and provisions in this group is an essential step to expanding access in future. A narrative review of specialist and generalist (primary) palliative care provisions for people with COPD, with an emphasis on breathlessness symptom management. This paper aims to examine the current landscape of palliative care provision and highlight barriers and facilitators to palliative care access for people with severe COPD. People living with severe COPD, as well as the people who care for them, are routinely under-serviced in best-practice end-of-life care, despite having symptom burden that is comparable to that of people with advanced cancer. Barriers to palliative care in this group include lack of specialist palliative care resources, uncertainty surrounding prognostication, and poor recognition of need from both patients and clinicians. Routine early palliative care involvement, including integration of specialist palliative care into respiratory services and upskilling of other healthcare providers to adopt palliative care principals within usual care (primary palliative care), have been shown to improve outcomes indicative of high-quality end-of-life care in this group, including symptom control, place of death, and legal preparations. Ongoing integration of specialist palliative care and professional education for generalist and non-palliative care specialist healthcare providers in the recognition and management of unmet palliative care needs is required to increase capacity beyond traditional specialist palliative care models. Despite high level of symptom burden, many people with COPD miss out on palliative care. Expanding capacity of traditional specialist palliative care by upskilling generalist healthcare providers and integrating specialist palliative care into existing respiratory services is necessary to improve access for people with COPD.

Opioid initiation timing and palliative care referrals in advanced cancer: retrospective study

ObjectivesEarly opioid initiation is recommended for advanced cancer pain, however the timing of opioid commencement in relation to diagnosis has not been described, and the role of palliative care prescribers...

Core competencies in palliative care among oncology nurses: An observational study

BACKGROUND: Palliative care requires a collaborative approach from a multidisciplinary team, incorporating nurses with ethical, clinical, communicative-relational, psychosocial, and teamwork skills. However, many professionals feel unprepared to face end-of-life challenges, highlighting a lack of skills, especially regarding psychosocial and spiritual aspects. AIM: The purpose of this study is to explore nurses' self-perception of competencies in palliative care. METHODS: A single-center descriptive observational study was conducted among palliative and non-palliative care nurses at the Fondazione IRCCS Istituto Nazionale dei Tumori in Milan (INT), using the short Italian version of the Professional Competence Scale (PCSQ). The Kruskal-Wallis test was used along with multivariate ANOVA for statistical analysis. RESULTS: 122 nurses participated (response rate: 52%), predominantly women (78%), aged 25-34 (50%), with a degree (46%) and over 10 years of experience (41%). The majority had no experience (71%) in palliative care, while 16% were currently working in this field. Statistical analysis revealed no significant correlations between educational level and responses. The Kruskal-Wallis test showed that experience in palliative care significantly influenced self-assessment scores, such as in activating non-pharmacological management strategies (p=0.004). CONCLUSIONS: Nurses perceive high competence in ethical and clinical decision-making in palliative care, influenced more by experience than by training. Addressing patients' subjective needs and using non-pharmacological interventions remain a challenge for nurses not working in palliative care settings.

Abstract PO3-10-04: Palliative Care, Healthcare Utilization, and Disparities in Deceased Breast Cancer Patients in U.S. Hospitals: Analysis of National Inpatient Sample

Abstract Objective: This study aims to explore the characteristics of receiving palliative care and the patterns of utilization among breast cancer patients using a large-scale representative population-based sample. Methods: A retrospective analysis was performed on hospitalization data obtained from the National Inpatient Sample (NIS) covering the period from January 2016 to December 2019. The objective of the study was to investigate the characteristics and disparities associated with the provision of palliative care to breast cancer patients who had passed away, and to evaluate its impact on healthcare utilization as indicated by discounted hospital charges and length of stay (LOS). To achieve this, multivariate linear and logistic regression analyses were conducted, with the data stratified according to age, race, Charlson comorbidity index, insurance status, patient's zip code, and hospital characteristics. The classification and identification of the study population were performed using ICD-10 codes. Results: In the study, a total of 6,325 deceased breast cancer patients were identified from hospitalization records. Among them, 59.16% (n=3,742) received palliative care during their hospital stay. Multivariate linear regression analysis revealed that patients who received palliative care experienced a significant reduction in LOS by an average of 0.67 days (-1.246 to -0.898, p = 0.02) compared to those who did not receive palliative care. Furthermore, the palliative care group exhibited lower total charges, with a mean decrease of $21,392 (-28205 to -14578, p=0.00) compared to the non-palliative care group. Multivariate logistic regression analysis indicated that patients with black race had lower odds of receiving palliative care, while those with higher household income and patients admitted to larger hospitals had higher odds of receiving palliative care. Additionally, patients with private insurance had a higher probability of receiving palliative care compared to other insurance groups. Conclusion: Palliative care has demonstrated its benefits in reducing healthcare utilization costs and length of stay for breast cancer patients. However, disparities exist in access to palliative care, particularly among Black patients and those with lower household income. Larger hospitals and patients with private insurance show higher rates of palliative care utilization. Addressing these disparities is crucial to ensure equitable access, optimize patient outcomes, and improve resource allocation. Integrating palliative care into breast cancer hospitalizations requires targeted interventions. Further research and implementation efforts are needed to enhance the availability and delivery of palliative care services for all patients, regardless of their demographics or socioeconomic backgrounds. Health policymakers should consider these findings in their resource allocation decisions as palliative care plays an increasingly important role in cancer treatment. Odds of Receiving Palliative care among deceased breast cancer patients XX XX Length Of Stay and Total Charges XX XX Citation Format: Rushin Patel, Zalak Patel, Mrunal Patel, Darshil Patel, Afoma Onyechi, Akshit Chitkara, Femina Patel. Palliative Care, Healthcare Utilization, and Disparities in Deceased Breast Cancer Patients in U.S. Hospitals: Analysis of National Inpatient Sample [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO3-10-04.

From their Perspective: Primary Palliative Care Educational Needs for Non-Palliative Care Trainees

From their Perspective: Primary Palliative Care Educational Needs for Non-Palliative Care Trainees

Long-Term Impact of the End-of-Life Care Nursing Education Consortium on Knowledge, Attitudes, and Practice (KAP) of Indian Nurses Working in Non-Palliative Care Settings: A KAP-GAP Analysis.

Background: The End-of-life Care Nursing Education Consortium (ELNEC) program aims to equip nurses with knowledge and skills in palliative and end-of-life care. While this program improves knowledge and attitudes of Indian nurses regarding palliative care and end-of-life care, its long-term impact on their knowledge, attitude, and clinical practice remains unknown. This study aims to assess ELNEC's long-term impact on knowledge, attitude, and practice of Indian nurses. Methods: A 18-month follow-up survey of practicing nurses at a tertiary care institute who completed ELNEC in September 2021. Data was collected between April-June 2023 via a questionnaire covering demographics, Palliative Care Quiz for Nurses (PCQN), Frommelt Attitude Toward Care of the Dying Scale Form B (FATCOD-B) and a clinical practice questionnaire developed and validated to access impact of ELNEC on clinical practice. Quantitative and qualitative data were assessed using Statistical package for social sciences and thematic analysis respectively. The 18-month follow-up PCQN and FATCOD-B scores were compared with the pre-ELNEC (baseline) and immediate post-ELNEC scores. Results: Out of 108 nurses, 69 responded with a response rate of 63.8%. The mean follow-up PCQN score was 9.03 ± 2.58; significantly higher than the pre-ELNEC (8.45 ± 1.88) but lower than the immediate post-ELNEC scores (10.2 ± 1.88). Attitudes toward end-of-life care declined over time but remained positive in the end-of-life care value and care of the dying. Thematic analysis of responses to open questions revealed that ELNEC motivated nurses to work in palliative care and care for patients with chronic life-limiting illnesses (n = 52, 75.3%), improved their nursing practice (n = 60, 86.9%), and helped enhance their communication skills (n = 51, 73.9%). Participants (n = 55, 79.7%) emphasized on regular palliative care training to reinforce their knowledge and skills. Conclusion: Compared with baseline, ELNEC leads to long-term improvement in practicing nurses' palliative care knowledge, clinical practice, communication skills and motivates them to work in palliative care.

Palliative care and COVID-19: acknowledging past mistakes to forge a better future.

COVID-19 induces complex distress across physical, psychological, and social realms and palliative care (PC) has the potential to mitigate this suffering significantly. To describe the clinical characteristics and outcomes of COVID-19 patients with an indication of PC, compared to patients who had no indication, in different pandemic waves. This retrospective multicenter observational cohort included patients from 40 hospitals, admitted from March 2020 to August 2022. Patients who had an indication of palliative care (PC) described in their medical records were included in the palliative care group (PCG), while those who had no such indication in their medical records were allocated to the non-palliative care group (NPCG). Out of 21,158 patients, only 6.7% had indication for PC registered in their medical records. The PCG was older, had a higher frequency of comorbidities, exhibited higher frailty, and had a higher prevalence of clinical complications and mortality (81.4% vs. 17.7%, p < 0.001), when compared to the NPCG. Regarding artificial life support, the PCG had a higher frequency of dialysis (20.4% vs. 10.1%, p < 0.001), invasive mechanical ventilation (48.2% vs. 26.0%, p < 0.001) and admission to the intensive care unit (53.6% vs. 35.4%, p < 0.001). These differences were consistent across all three waves. A low proportion of patients received PC. Patients in PCG were more fragile, had more clinical complications, and had a higher mortality. On the contrary to our expectations, they received more artificial life support in all three waves. Taken together, these findings suggest that decisions regarding PC indication were made too late, within a context of end-of-life and therapeutic failure.

Palliative Care Clinical Trials in Underrepresented Ethnic and Racial Minorities: A Narrative Review.

Introduction: A growing number of patients with serious illness who would benefit from palliative care are part of ethnoracial minority groups. Nevertheless, large disparities in provision of palliative services exist for minoritized populations. Furthermore, there is a relative dearth of palliative care research focused on minority groups and how best to provide high-quality, culturally tailored palliative care. The aim of this narrative review is to summarize the existing literature regarding palliative care clinical trials in underrepresented minority populations, describe methodological approaches, and provide guidance on future palliative care-focused clinical trials. Methods: We used the Scale for the Assessment of Narrative Review Articles (SANRA) and Cochrane's guidelines on conducting reviews. We used PubMed and Clinicaltrials.gov to review published, full-text articles or protocols (1950-2022), and limited to palliative care interventions focused on ethnoracial minority populations. We included randomized clinical trials (RCTs), including pilot and feasibility trials, protocols of RCTs, and studies that report RCT methodology. Two reviewers independently assessed eligibility. Results: Our search yielded 585 publications; of these, 30 met the full-text review criteria and 16 studies met our criteria for inclusion. We deemed nine articles as having low risk of bias and four as having high risk of bias. Discussion: Commonly used methodologic approaches for clinical trials in underrepresented minority populations included the following: the use of written and visual materials that were no higher than a sixth-grade reading level, the use of patient and lay health navigators, bilingual and multicultural study staff and study materials, race-concordant staff, the option of in-person and virtual visits that accommodated the patient and family's schedule, recruitment from faith communities, and the use of community-engaged research principles. Future palliative care clinical trials should expand on the strategies described in this article, adopt effective strategies currently used in nonpalliative care interventions, and innovate around the principles of community-engaged research.

The caregiver’s perspective on end-of-life inpatient palliative care: a qualitative study

Introduction Understanding patient and caregiver experience is key to providing person-centered care. The palliative care approach includes holistic assessment and whole-person care at the end of life, that also involves the patient’s family and loved ones. The aim of this study was to describe the way that family caregivers experienced patients’ deaths during their loved ones’ last hospital admission, comparing inpatient palliative care (PCU) and non-palliative care (Non-PCU) units. Methods A qualitative case study approach was implemented. Family caregivers of terminally ill patients admitted to the Infanta Elena Hospital (Madrid, Spain) between 2016 and 2018 were included using purposeful sampling. Eligible caregivers were first-degree relatives or spouses present during the patient’s last hospital admission. Data were collected via in-depth interviews and researchers’ field notes. Semi-structured interviews with a question guide were used. A thematic inductive analysis was performed. The group of caregivers of patients admitted to the PCU unit and the group of caregivers of patients admitted to Non-PCU were analyzed separately, through a matrix. Results In total 24 caregivers (12 from the PCU and 12 from Non-PCU units) were included. Two main themes were identified: caregivers’ perception of scientific and technical appropriateness of care, and perception of person-centred care. Scientific appropriateness of care was subdivided into two categories: diagnostic tests and treatment, and symptom control. Perception of person-centred care was subdivided as: communication, emotional support, and facilitating the farewell process. Caregivers of patients admitted to a PCU unit described their experience of end-of-life care as positive, while their Non-PCU unit counterparts described largely negative experiences. Conclusions PCU provides a person-centered approach to care at the end of life, optimizing treatment for patients with advanced disease, ensuring effective communication, establishing a satisfactory professional relationship with both patients and their loved ones, and facilitating the farewell process for family caregivers.

Views and experiences of opioid access amongst palliative care providers and public representatives in a low-resource setting: A qualitative interview study.

Opioids (e.g. morphine) are affordable, effective interventions for cancer-related pain. However, equity of access to this key medication remains a global challenge, particularly in low- and middle-income countries. We aimed to explore views of palliative care providers and public-representatives about opioid analgesia access in two States in India. We conducted a qualitative study using semi-structured interviews. Transcribed audio-recordings were subjected to thematic analysis using a Framework Approach. Palliative care providers and public-representatives were purposively sampled from services reporting consistent opioid availability and prescribing (≥4kg per annum) from Karnataka and Kerala. Twenty participants (doctors (10), nurses (4), pharmacists (2), service managers (2) and public-representatives (2) were interviewed. Three themes were identified: 1) Attitudes and awareness: opioid treatments are perceived as end-of-life (last days/weeks) interventions; fears of addiction and misunderstanding of pain management goals limit access. 2) Expected and unexpected inequities: patients/carers from lower socioeconomic strata accept doctor recommendations if opioids are affordable, more educated patients/families have reservations about opioids, delay access and perceive expensive medicines as better. Non-palliative care specialist doctors have negative entrenched views and require specialist training. 3) Experiential learning-positive experiences can positively alter attitudes (e.g., participants in Kerala report improved attitudes, awareness and understanding influenced by exposure and community awareness, but experience can also reinforce perceptions as end-of-life care. Entrenched negative views are reinforced by poor experiences while positive experiences improve attitudes. To promote access, opioid prescribing must be needs-based rather than prognosis-based. Addressing the lack of training for non-palliative care workforce would help overcome a major barrier.

End-of-Life Care in the Last Three Months before Death in Older Patients with Cancer in Belgium: A Large Retrospective Cohort Study Using Data Linkage

This study aims to describe end-of-life (EOL) care in older patients with cancer and investigate the association between geriatric assessment (GA) results and specialized palliative care (SPC) use. Older patients with a new cancer diagnosis (2009–2015) originally included in a previous multicentric study were selected if they died before the end of follow-up (2019). At the time of cancer diagnosis, patients underwent geriatric screening with Geriatric 8 (G8) followed by GA in case of a G8 score ≤14/17. These data were linked to the cancer registry and healthcare reimbursement data for follow-up. EOL care was assessed in the last three months before death, and associations were analyzed using logistic regression. A total of 3546 deceased older patients with cancer with a median age of 79 years at diagnosis were included. Breast, colon, and lung cancer were the most common diagnoses. In the last three months of life, 76.3% were hospitalized, 49.1% had an emergency department visit, and 43.5% received SPC. In total, 55.0% died in the hospital (38.5% in a non-palliative care unit and 16.4% in a palliative care unit). In multivariable analyses, functional and cognitive impairment at cancer diagnosis was associated with less SPC. Further research on optimizing EOL healthcare utilization and broadening access to SPC is needed.

The systemic challenges of non-palliative care professionals caring for end-of-life patients: A lived experience study.

The aims of this study are to identify the challenges faced by non-palliative care professionals (NPCPs) in caring for end-of-life patients; determine how these challenges interact with and influence each other systemically; and advance the theories and practices for supporting NPCPs in the provision of quality end-of-life care beyond the boundaries of palliative medicine. A constructivist phenomenological research design with an Interpretive-Systemic Framework of inquiry was adopted. Thirty-five physicians, 35 nurses, and 35 Medical Social Workers who play critical roles in caring for end-of-life patients and belonging to the 9 major medical disciplines of Cardiology, Geriatric, Intensive Care Medicine, Internal Medicine, Nephrology, Neurology, Oncology, Respiratory Medicine, and Surgery were recruited through purposive snowball sampling from 3 major public hospitals. Framework analysis revealed 5 themes and 17 subthemes that illuminate the individual, relational, cultural, institutional, and structural challenges that NPCPs faced in rendering end-of-life care. These challenges influence each other within the health-care ecosystem, serving to perpetuate or heighten care obstacles. This is the first known study exploring the systemic challenges of NPCPs spanning 9 major medical disciplines and encompassing 3 professional stakeholders responsible for the care for end-of-life patients, thus ensuring perspective inclusivity across the health-care system. Recommendations that consider the complexity of the interactions between these systemic challenges are presented in detail.

What Characteristics are Important to Acute Care Health Professionals in Australia when Choosing a Palliative Care Prognostic Tool

Prognostic tools can aid acute care health professionals in the recognition of dying and identify when a patient should transition from active treatment to palliative care. The recognition of dying has important implications not only for the patient, but also for their family and others involved in providing care. Several prognostic tools are used in the Australian acute care setting, however they are not yet routine practice. Identifying what characteristics are important to acute care health professionals when choosing a palliative care prognostic tool may inform how the tools are presented and could increase their utilization by non-palliative care specialists. This survey found that the Supportive and Palliative Care Indicators Tool (SPICT) and Surprise Question are the most commonly known prognostic tools and are used in several clinical areas within the acute care setting. Acute care health professionals prefer validated prognostic tools which are easy to use, and are designed to be administered with the patient, substitute decision maker and the clinical team. The survey also identified the need for palliative care prognostic tools to be included within undergraduate teaching programs, further increasing the awareness and utilization of prognostic tools by health professionals working within the acute care setting.

The impact of palliative care consultation on reducing antibiotic overuse in hospitalized patients with terminal cancer at the end of life: a propensity score-weighting study.

A substantial number of hospitalized patients with terminal cancer at the end-of-life phase receive antibiotics, even with imminent death. We evaluated the impact of palliative care consultation on antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase. We identified adult patients with metastatic solid cancer who died at a tertiary medical centre in Seoul, Republic of Korea, following at least 4 days of hospitalization (January 2018-December 2020). Patients were divided into palliative and non-palliative care consultation groups. Propensity score-weighted, multivariable logistic regression analysis was used to compare the proportion of patients receiving antibiotics within 3 days before death between the two groups. Among 1143 patients analysed, 940 (82.2%) received antibiotics within 3 days before death. The proportion of patients receiving antibiotics was significantly lower (propensity score-weighted P < 0.001) in the palliative care consultation group (344/468; 73.5%) than in the non-palliative care consultation group (596/675; 88.3%). The decrease in the proportion of patients receiving antibiotics in the palliative care consultation group was significant for a carbapenem (42.4% versus 22.4%; P < 0.001), a glycopeptide (23.3% versus 11.1%; P < 0.001) and a quinolone (30.5% versus 19.4%; P = 0.012). In the multivariable logistic regression analysis, receiving palliative care consultation (adjusted OR 0.46, 95% CI 0.33-0.65; P < 0.001) was independently associated with reduced antibiotic use during the end-of-life phase. Palliative care consultation may reduce aggressive antibiotic use in hospitalized patients with terminal cancer during the end-of-life phase.

Association of Patient-Centered Elements of Care and Palliative Care Among Patients With Advanced Lung Cancer.

Palliative care (PC) is associated with improved quality of life, survival, and decreased healthcare use at the end of life among lung cancer patients. However, the specific elements of palliative care that may contribute to these benefits are unclear. To evaluate the associations of PC and its setting of delivery with prescriptions of symptom management medications, advance care planning (ACP), hospice enrollment, and home health care (HHC) receipt. Retrospective, cohort study of patients with advanced stage (IIIB/IV) lung cancer in the Veterans Health Administration (VA) diagnosed from 2007-2013; with follow-up through 2017. Propensity score methods were used with inverse probability of treatment weighting and logistic regression modeling, adjusting for patient and tumor characteristics. Among 23142 patients, 57% received PC. Compared to non-receipt of PC, PC in any setting (inpatient or outpatient) was associated with increased prescriptions of pain medications (Adjusted Odds Ratio (aOR) = 1.63, 95% CI: 1.45-1.83), constipation regimen with pain medications (aOR = 2.04, 95% CI: 1.63-2.54), and antidepressants (aOR = 1.78, 95% CI: 1.52-2.09). PC was also associated with increased ACP (aOR = 1.52, 95% CI: 1.37-1.67) and hospice enrollment (aOR = 1.39, 95% CI:1.31-1.47), and decreased HHC (aOR = 0.79, 95% CI: 0.70-.90) compared to non-receipt of PC. Receipt of PC in outpatient settings was associated with increased prescriptions of pain medications (aOR = 2.54, 95% CI: 2.13-3.04) and antidepressants (aOR = 1.76, 95% CI: 1.46-2.12), and hospice enrollment (aOR = 2.09, 95% CI: 1.90-2.31) compared to receipt of PC in inpatient settings. PC is associated with increased use of symptom management medications, ACP, and hospice enrollment, especially when delivered in outpatient settings. These elements of care elucidate potential mechanisms for improved outcomes associated with PC and provide a framework for a primary palliative care approach among non-palliative care clinicians.