Palliative Care Consultation Service Research Articles

Multidisciplinary Prognostication Using the Palliative Prognostic Score in an Australian Cancer Center.

CONTEXTAccurate prognostication is important in oncology and palliative care. A multidisciplinary approach to prognostication provides a novel approach, but its accuracy and application is poorly researched. In this study, we describe and analyze our experience of multidisciplinary prognostication in palliative care patients with cancer.OBJECTIVESTo assess our accuracy of prognostication using multidisciplinary team prediction of survival (MTPS) alone and within the Palliative Prognostic (PaP) Score.METHODSThis retrospective study included all new patients referred to a palliative care consultation service in a tertiary cancer center between January 2010 and December 2011. Initial assessment data for 421 inpatients and 223 outpatients were analyzed according to inpatient and outpatient groups to evaluate the accuracy of prognostication using MTPS alone and within the PaP score (MTPS-PaP) and their correlation with overall survival.RESULTSInpatients with MTPS-PaP group A, B, and C had a median survival of 10.9, 3.4, and 0.7 weeks, respectively, and a 30-day survival probability of 81%, 40%, and 10%, respectively. Outpatients with MTPS-PaP group A and B had a median survival of 17.3 and 5.1 weeks, respectively, and a 30-day survival probability of 94% and 50%, respectively. MTPS overestimated survival by a factor of 1.5 for inpatients and 1.2 for outpatients. The MTPS-PaP score correlated better than MTPS alone with overall survival.CONCLUSIONThis study suggests that a multidisciplinary team approach to prognostication within routine clinical practice is possible and may substitute for single clinician prediction of survival within the PaP score without detracting from its accuracy. Multidisciplinary team prognostication can assist treating teams to recognize and articulate prognosis, facilitate treatment decisions, and plan end-of-life care appropriately. PaP was less useful in the outpatient setting, given the longer survival interval of the outpatient palliative care patient group.

From Albania to Zambia: Travel Back to Country of Origin as a Goal of Care for Terminally Ill Patients

With unprecedented levels of international migration, physicians in the United States may care for terminally ill patients who have strong connections to their country of origin and such patients may desire to return in the final stages of life. In this study, we analyzed how often terminally ill patients cited travel to country of origin as a goal of care, how often travel occurred, and factors associated with successful travel. A retrospective chart review from January 1, 2005 through May 1, 2007. All foreign-born patients seen by a palliative care consultation service, including inpatient and outpatient consultations, in an urban safety-net health system in the United States. We determined whether patients expressed a desire to travel to their country of origin and the factors, including demographics and functional status associated with travel. Of 336 foreign-born patients, 129 (38%) expressed a desire to travel to their country of origin; 60 (47%) successfully returned to 24 unique countries. Countries to which the largest number of patients returned were Mexico (n=14), Poland (n=11), and the Philippines (n=7). Although patients with the best functional status were most likely to travel successfully, 16 (31%) who wanted to travel despite having the worst functional status (Eastern Cooperative Oncology Group [ECOG] score indicating confinement to bed or chair) traveled successfully. There were no deaths en route or flight diversions due to medical crisis; all trips were made on regularly scheduled commercial airline flights. A substantial proportion of patients in our cohort expressed a desire to return to their country of origin. We facilitated successful travel for nearly half of these patients. Our findings identify the need to include travel back to country of origin in the framework of planning care for terminally ill patients.

Perspectives on palliative care in a multisite oncology practice.

52 Background: The Institute of Medicine reported that many cancer patients do not receive palliative care to manage symptoms. It is possible that practitioners do not identify palliative care as an important component of high-quality cancer care, or do not know how to most efficiently utilize available palliative care consultative services. Methods: An anonymous electronic survey was sent to physicians, nurses, nurse practitioners, physician assistants, and social workers (n=99) in our multi-site, single-institution Cancer Center. Results: Sixty-five responses were received (66% response rate). Eighty-three percent of respondents reported working primarily in the outpatient setting. Fifty-nine percent reported their patients ‘rarely use the ER for pain management’ while 16% reported their patients ‘frequently require ER visits for pain management’. Ninety-two percent considered palliative care ‘an integral part of a multidisciplinary team’ while 6% reported palliative care consultation to be ‘cumbersome to consult and coordinate with’. The most common reason for consultation was end-of-life discussions (38%) followed by chronic pain management (33%). Seventy-seven percent reported consulting between 1 and 5 times per month, 14% between 6-10 times per month, and 5% greater than 11 times per month. Thirteen percent reported that they were able to manage patient symptoms adequately themselves. The average rating for convenience of consulting palliative care was 3.8/5. Fifty-eight percent reported the most effective means of communication with palliative care consultants was through the medical record, whereas 42% reported that most effective communication took place in person. Sixty percent reported a preference for palliative care practitioners from within the division of hematology/oncology. Conclusions: Our survey suggests that the majority of oncology practitioners value palliative care consultation and are willing to incorporate palliative care services into patient management. It is possible that practitioners overestimate their utilization of palliative care services and that optimizing the convenience of consultation and communication would result in better integration of palliative care for cancer patients.

Integration of oncology palliative care in a regional health care system.

34 Background: Early incorporation of palliative medicine in cancer care has been shown to be associated with improved symptom control, quality of life, and patient and family satisfaction however integration in the outpatient setting remains deficient nationwide. Regional healthcare systems carry the additional challenge of providing consistent quality care across a diverse geographic area. We performed a retrospective review of oncology palliative care utilization in a regional healthcare system following the implementation of a fully integrated model of palliative care. Methods: In 2012, Levine Cancer Institute (LCI) and Carolinas Palliative Care collaborated to establish palliative care access across its 12-site regional cancer center. This was a transition from a vendor service to a fully embedded clinic at multiple LCI locations. The new model offered full time outpatient multidisciplinary services in addition to an inpatient oncology palliative care consult service. Standardization of care and early integration were augmented by the creation of symptom management guidelines and tumor treatment pathways with built in recommendations for palliative/supportive care. Results: New oncology palliative care referrals increased from 150 annually to over 475 in the first 12 months. The top diagnoses were lung (16%), breast (11%), and head and neck cancer (7.2%) with pain and symptom management as the primary reason for consultation. Ten symptom management pathways have been published for regional utilization, enabling primary palliative care and serving as a trigger for palliative specialist consultation. A toolkit was created to identify operational needs, clinical tools, and staffing at each site. Conclusions: The growth of oncology palliative care utilization by 317% demonstrates the success of a fully embedded program. This multidisciplinary model is being standardized across regional sites to ensure access to primary and secondary palliative care. Additional clinic sites and the application of telemedicine for rural areas are in development. Future research is needed to document outcomes associated with palliative care integration across the cancer trajectory in a regional healthcare system.

Characteristics of patients referred to a community-based palliative care consultation service.

132 Background: Home-based palliative care programs by multi-disciplinary providers improve patient and caregiver satisfaction, enhance symptom control, increase hospice use, and decrease acute care encounters. We launched a community-based consultation service to deliver high-quality palliative care to patients who are homebound or staying in various post-acute care facilities. The study described the characteristics of our patients, and determined the relationship between certain demographic features and outcomes. Methods: We conducted a restrospective chart review of patients seen on initial consultation and subsequent visits between January 1, 2011 and December 31, 2011. All patient encounters were done by 4 palliative care physicians. Data pertaining to demographics, diagnosis, hospice use, and death were obtained and analyzed. Results: A total of 221 patients were evaluated. The median age was 75 years, 61.1% were female, 51.1% had cancer, 79.1% were seen at home, and 57% possessed advance directives at initial consultation. Almost half (45.2%) of the referrals were made by primary care physicians. Majority (82.4%) of the referrals were for symptom management, while 37.6% were for goals of care discussion. Many patients had several reasons for consultation, as well as multiple symptoms, such as pain (65%), fatigue (54.8%), and dyspnea (22.6%). The mean number of follow-up visits was 0.62 + 1.08. During the study period, 33.5% of patients died, and 42.5% enrolled in hospice. Of the deaths, 48.7% occurred within 30 days of initial consultation, and 50.0% died at home. Age, gender, race and marital status were not related to hospice enrollment, death, and time and site of death. Patients with advance directives were more likely to enroll in hospice (50.0% vs 32.2%, p=0.009), while those seen at home were more likely to die at home rather than in a facility or hospital (61.0% vs 16.9% vs 22.0%, p<0.001). Conclusions: Patients referred to our community-based palliative care consultation service were mostly homebound older adults needing symptom management and goals of care discussion. Our program may have been helpful in providing quality end-of-life care by facilitating hospice enrollment and death at home.

Characteristics of a palliative care consultation service with a focus on pain in a German university hospital.

BackgroundA minority of patients with incurable and advanced disease receive specialised palliative care. Specialised palliative care services that complement the care of difficult and complex cases ought to be integrated with services that deliver general care for most patients. A typical setting in which this integrative concept takes place is the hospital setting, where patients suffering from incurable and advanced disease are treated in many different departments.The aim of the study is to investigate the profile and spectrum of a palliative care consultation service (PCCS) at a German university hospital with special reference to pain therapy.MethodsWe retrospectively analysed the PCCS documentation of three years.ResultsMost patients were referred from non-surgical departments, 72% were inpatients, and 28% were outpatients. 98% of the patients suffered from cancer. Counselling in pain therapy was one of the key aspects of the consultation: For 76% of all consulted patients, modifications of the analgesic regimen were recommended, which involved opioids in 96%. Recommendations on breakthrough-pain medication were made for 70% of the patients; this was an opioid in most cases (68%). The most commonly used opioid was morphine. For 17% of the patients, additional diagnostic procedures were recommended. Besides pain management palliative care consultation implied a wide range of recommendations and services: In addition to organising home care infrastructure, palliative care services supported patients and their families in understanding the life-limiting diseases. They also coordinated physical therapy and social and legal advice.ConclusionThis survey clearly shows that for a consultation service to support patients with incurable or advanced disease, a multi-disciplinary approach is necessary to meet the complex requirements of a needs-adapted palliative care in inpatient or outpatient settings. Timely integration of palliative expertise may support symptom control and may give the required advice to patients, their carers, and their families.

Qualitative inquiry: a method for validating patient perceptions of palliative care while enrolled on a cancer clinical trial.

BackgroundPalliative care is a vital component of patient-centered care. It has increasingly become central to the management and care of seriously ill patients by integrating physical, psychosocial, and spiritual supportive services. Through qualitative inquiry, this paper examines cancer patients’ perceptions of the process and outcomes of the pain and palliative care consultative services they received while enrolled in a clinical trial.MethodsA qualitative analysis of open-ended questions was conducted from a sub-sample of patients (n = 34) with advanced cancers enrolled in a randomized controlled trial exploring the efficacy of a palliative care consult service. Two open-ended questions focused on patient perceptions of continued participation on their primary cancer clinical trials and their perceptions of interdisciplinary communication.ResultsThree overarching themes emerged when asked whether receiving pain and palliative care services made them more likely to remain enrolled in their primary cancer clinical trial: patients’ past experiences with care, self-identified personal characteristics and reasons for participation, and the quality of the partnership. Four themes emerged related to interdisciplinary communication including: the importance of developing relationships, facilitating open communication, having quality communication, and uncertainty about communication between the cancer clinical trial and palliative care teams.ConclusionsOur findings suggest the importance of qualitative inquiry methods to explore patient perceptions regarding the efficacy of palliative care services for cancer patients enrolled in a cancer clinical trial. Validation of patient perceptions through qualitative inquiry regarding their pain and palliative care needs can provide insight into areas for future implementation research.Trial registrationNIH Office of Human Subjects Research Protection OHSRP5443 and University of Pennsylvania 813365

Utilization of Palliative Care Consultation Service by Surgical Services at University of New Mexico

Utilization of Palliative Care Consultation Service by Surgical Services at University of New Mexico

Two steps forward, one step back: changes in palliative care consultation services in California hospitals from 2007 to 2011.

The number of palliative care consultation services is growing, yet little is known about how program characteristics change over time. Compare changes in the characteristics of palliative care programs and palliative care consultation services in 2007 and 2011. We surveyed all hospitals in California in 2011 and compared palliative care program and palliative care consultation service characteristics with survey results from 2007. There were 41 new palliative care programs since 2007; 17 programs closed between 2007 and 2011. Hospital characteristics associated with the closure of a palliative care program included a hospital size of 1-149 beds versus 150 or more (p=0.03), for-profit status (p=0.001), and having no system affiliation (p=0.0001). The prevalence of palliative care consultation services was 33% in 2007 and 37% in 2011 (p=0.3). At both time periods nearly all palliative care consultation services (98%) were available onsite during weekday business hours and only half were available at other times (p=0.4). There was an increase (p=0.002) in nurse/physician full-time equivalent (FTE; 2007, mean=1.5; 95% confidence interval [CI]=1.3-1.7; 2011, mean=1.9; 95% CI=1.6-2.2) but fewer teams reported having social workers (58% versus 80%, p=0.002) and chaplains (58% versus 77%, p=0.0001) in 2011. Over half of the palliative care consultation services reported seeing less than 50% of patients who would benefit from a consultation (2007: 59%, 2011=50%, p=0.2), yet most also reported struggling to cope with patient volume (2007: 62%; 2011: 66%, p=0.5). Fewer than half of hospitals in California offer a palliative care program and many close over time. Making palliative care consultation services a condition of participation by insurers could make hospital palliative care consultation services universal. Mechanisms need to be established to improve staffing levels, maintain the interdisciplinary nature of palliative care consultation services, and accommodate demand for services.

Enhancing Communication in End‐of‐Life Care: A Clinical Tool Translating Between the Clinical Frailty Scale and the Palliative Performance Scale

To create a clinical tool to translate between the Clinical Frailty Scale (CFS), which geriatrics teams use, and Palliative Performance Scale (PPS), which palliative care teams use, to create a common language and help improve communication between geriatric and palliative care teams. Cross-sectional. Two academic health centers: inpatient palliative care and chronic care units, an outpatient geriatric clinic, and inpatient referrals to a palliative care consultation service. Older adults (≥65) aged 80.9±8.0, with malignant (51%) and nonmalignant (49%) terminal diagnoses (N=120). Each participant was assigned four scores: a CFS score each from a geriatric physician and nurse and a PPS score each from a palliative care physician and nurse. Interrater reliability of each measure was calculated using kappa coefficients. For each measure, the mean of physician and nurse scores was used to calculate every possible combination of CFS and PPS scores to determine the combination with maximum agreement. Interrater reliability of each measure was very high for the CFS (weighted κ=0.92) and PPS (weighted κ=0.80). The CFS-PPS score matching that achieved maximum agreement (weighted κ=0.71) was used to create a conversion chart between the two measures. This conversion chart is a reliable means of translating scores between the CFS and PPS and is useful for geriatric and palliative care teams collaborating in the care of elderly adults.

Combination of Initial Palliative Prognostic Index and Score Change Provides a Better Prognostic Value for Terminally Ill Cancer Patients: A Six-Year Observational Cohort Study

ContextThe Palliative Prognostic Index (PPI) is among the most popular scores used to predict life expectancy in terminally ill patients worldwide. PPI assessed on the first day of palliative care might be inappropriate because the contribution from subsequent changes in a patient's condition are not taken into account. ObjectivesThe aim of this study is to determine the utility of sequential PPI assessments as a better prognostic tool for patients with terminal cancer. MethodsIn total, 2392 terminally ill cancer patients with initial and one-week PPI assessments under the palliative care consultation service between January 2006 and December 2011 at a single medical center in Taiwan were selected. Patients were categorized into initial PPI, Week 1 PPI, score change (initial PPI − Week 1 PPI; Δscore), and combined initial PPI and Δscore subgroups for survival analysis. ResultsOverall median survival was 32 days (range eight to 180 days), and 2183 patients (91.3%) died within 180 days of palliative care consultation service care. A significant difference in survival was observed among patient subgroups (P < 0.001). Subgroup survival analysis showed significant difference in patients with Δscores >0, 0, and <0 in each prognostic group categorized by initial PPI. The c-statistic for predicting life expectancy <30 days was significantly higher with the combined initial PPI and Δscore (c-statistic, 0.71; 95% CI, 0.694–0.731) than with the initial PPI (c-statistic, 0.63; 95% CI, 0.61–0.65), Week 1 PPI (c-statistic, 0.67; 95% CI, 0.652–0.690), or Δscore (c-statistic, 0.64; 95% CI, 0.62–0.66). ConclusionCombination of initial PPI and score change is more useful than initial PPI for identifying patients with poor outcomes in good prognostic groups and patients with better outcomes in poor prognostic groups.

Facility Characteristics and Quality of Lung Cancer Care in an Integrated Health Care System

In a national, integrated health care system, we sought to identify facility-level attributes associated with better quality of lung cancer care. Adherence to 23 quality indicators across four domains (Diagnosis and Staging, Treatment, Supportive Care, End-of-Life Care) was assessed through abstraction of electronic records from 4804 lung cancer patients diagnosed in 2007 at 131 Veterans Health Administration facilities. Performance was reported as proportions of eligible patients fulfilling adherence criteria. With stratification of patients by stage, generalized estimating equations identified facility-level characteristics associated with performance by domain. Overall performance was high for the older (mean age 67.7 years, SD 9.4 years), predominantly male (98%) veterans. However, no facility did well on every measure, and range of adherence across facilities was large; 9% of facilities were in the highest quartile for one or more domain of care, more than 30% for two, and 65% for three. No facility performed consistently well across all domains. Less than 1% performed in the lowest quartile for all. Few facility-level characteristics were associated with care quality. For End-of-Life Care, diagnosis and treatment within the same facility, availability of cancer psychiatry/psychology consultation services, and availability of both inpatient and outpatient palliative care consultation services were associated with better adherence. Quality of Veterans Health Administration lung cancer care is generally high, though substantial variation exists across facilities. With the exception of the salutary impact of palliative care consultation services on end-of-life quality of care, observed facility-level characteristics did not consistently predict adherence to indicators, suggesting quality may be determined by complex local factors that are difficult to measure.

Late referral to palliative care consultation service: length of stay and in-hospital mortality outcomes.

Palliative care services in the United States are increasing in their prevalence but continue to vary in their implementation, with different referral policies and timing of patient access to services. To better define a late referral and to understand the association of late referrals to palliative care with patient health outcomes, including postreferral length of hospital stay and in-hospital mortality. We performed a retrospective study using multiple linear and logistic regressions on 1,225 patients with pre-existing oncologic diagnoses who received a referral to Stanford Hospital's palliative care service. Those oncologic patients who were referred to palliative care in the first week following admission had significantly shorter lengths of stay after referral, as well as lower in-hospital mortality, compared with patients who were referred later than 1 week following admission. Regression analyses, adjusted for demographic variables, DNR status, and sickness, revealed that waiting 1 week or longer to refer a patient was associated with an overall increased length of stay of 2.70 days (P < .001). This increased to 3.40 days (P < .001) when patients who died in the hospital were removed from the data, suggesting that in-hospital mortality was not solely responsible for the trend. Waiting 1 week to refer was associated with increased odds of a patient's dying in the hospital vs being discharged alive by a factor of 3.04 (P < .001). This study was limited to analyzing inpatient palliative care consultation services with a emphasis on patients with metastatic solid tumors. We used a proxy for patient sickness burden but did not analyze outcomes specific to cancer stage or individual oncologic diagnosis separately. Our study suggests that late referrals may have a marked negative impact on health outcomes, which argues for the design and implementation of hospital policies that encourage early referral to palliative care for advanced cancer patients.

Resource utilization and end‐of‐life care in a US hospital following medical emergency team‐implemented do not resuscitate orders

Medical emergency teams frequently implement do not resuscitate orders, but little is known about end-of-life care in this population. To examine resource utilization and end-of-life care following medical emergency team-implemented do not resuscitate orders. Retrospective review. Single, tertiary care center. Consecutive adult inpatients requiring a medical emergency team activation over 1 year. Changes to code status, time spent on medical emergency team activations, frequency of palliative care consultation, discharges with hospice care. None. We observed 1156 medical emergency team activations in 998 patients. Five percent (58/1156) resulted in do not resuscitate orders. The median time spent on activations with a change in code status was longer than activations without a change (66 vs 60 minutes, P = 0.05). Patients with a medical emergency team-implemented do not resuscitate order had a higher inpatient mortality (43 vs 27%, P = 0.04) and were less likely to be discharged with hospice at the end of life than patients with a preexisting do not resuscitate order (4 vs 29%, P = 0.01). There was no difference in palliative care consultation in patients with a preexisting do not resuscitate versus medical emergency team-implemented do not resuscitate order (20% vs 12%, P = 0.39). Despite high mortality, patients with medical emergency team-implemented do not resuscitate orders had a relatively low utilization of end-of-life resources, including palliative care consultation and home hospice services. Coordinated care between medical emergency teams and inpatient palliative care services may help to improve end-of-life care.

Integrating Palliative Care into Critical Care

Many terminally ill patients experience an increasing intensity of medical care, an escalation frequently not consistent with their preferences. In 2009, formal palliative care consultation (PCC) was integrated into our medical intensive care unit (ICU). We hypothesized that significant differences in clinical and economic outcomes exist between ICU patients who received PCC and those who did not. We reviewed ICU admissions between July and October 2010, identified 41 patients who received PCC, and randomly selected 80 patients who did not. We measured clinical outcomes and economic variables associated with patients' ICU courses. Patients in the PCC group were older (average 64 years, standard deviation [SD] 19.2 vs 55.6 years, SD 14.5; P = .021) and sicker (median Acute Physiology and Chronic Health Evaluation IV score 85.5, interquartile range [IQR] 60.5-107.5 vs 60, IQR 39.2-74.75; P < .001) than the non-PCC controls. PCC patients received significantly more total days of ICU care on average (8 days, IQR 4-15 vs 4 days, IQR 2-7; P < .001), had more ICU admissions, and were more likely to die during their ICU stay (64.3% vs 12.5%, P < .001). Median total hospital charges per patient attributable to ICU care were higher in the PCC group than in the controls (US$315,493, IQR US$156,470-US$486,740 vs US$116,934, IQR US$54,750-US$288,660; P < .001). After we adjusted for ICU length of stay, we found that median ICU charges per day per patient did not differ significantly between the groups (US$37,463, IQR US$27,429-US$56,230 vs US$41,332, IQR US$30,149-US$63,288; P = .884). Median time to PCC during the ICU stay was 7 days (IQR 2-14.5 days). Patients who received PCC had higher disease acuity, longer ICU lengths of stay, and higher ICU mortality than controls. "Trigger" programs in the ICU may improve utilization of PCC services, improve patient comfort, and reduce invasive, often futile end-of-life care.

Education About Palliative Care in the Intensive Care Unit: Rediscovering Opportunity

Underlying palliative care is a philosophy that aligns patients' health care with what they deem most important. For patients in the final stages of life, this often includes the desire to avoid burdensome and high-intensity care. In the intensive care unit (ICU), where we see the highest acuity of illness, often there are many competing priorities. The principles of palliative care are vital in refocusing our attention on what matters most to the patient and his or her family. Because of the value of these principles, there is increasing interest in finding ways to improve education in palliative care and to integrate palliative care education into the ICU. To achieve this goal, 3 models for incorporating palliative care in the ICU have been proposed: the integrative model (education in primary palliative care skills for ICU clinicians); the consultative model (access to palliative care specialists); and the mixed model that uses both of these approaches simultaneously.1,2 It is increasingly clear that a mixed model, in which the education and deployment of palliative care specialists is combined with the education of all clinicians in basic principles of palliative care, is the optimal approach to address the diverse range of palliative care needs in the ICU.2

Impact of critical care medicine training programs' palliative care education and bedside tools on ICU use at the end of life.

Intensive care unit (ICU) use at the end of life is rising. Little research has focused on associations among critical care fellows' training, institutional support, and bedside tools with ICU use at the end of life. We evaluated whether hospital and critical care medicine program interventions were associated with ICU use in the last 6months of life for patients with chronic illness. Our observational, retrospective study explored associations between results from a survey of critical care program directors and hospital-level Medicare data on ICU use in the last 6months of life. Program directors evaluated quality of palliative care education in their critical care fellowships and reported on the number of bedside tools and the presence or absence of an inpatient palliative care consultation service. For the 89 hospitals and 71 affiliated training programs analyzed, there were statistically significant relationships between 2 of the explanatory variables-the quality of palliative care education and the number of bedside tools-in ICU use. Each level of increased educational quality (1-5 Likert scale) was associated with a 0.57-day decrease in ICU days, whereas, for each additional, evidence-based bedside tool, there was a 0.31-day decrease. The presence of an inpatient palliative care program was not a significant predictor of ICU use. We found that the quality of palliative care training in critical care medicine programs and the use of bedside tools were independently associated with reduced ICU use at the end of life.

Bridging the gap: a palliative care consultation service in a hematological malignancy-bone marrow transplant unit.

There is often a lack of collaboration between hematological malignancy-bone marrow transplantation (HM-BMT) units and palliative care (PC) services. In this paper, we describe a quality improvement project that sought to close this gap at a tertiary care hospital in Pittsburgh, Pennsylvania, from August 2006 to May 2010. Through a needs assessment, didactic lectures, clinical consultation, and the informal presence of PC clinicians, the team created a palliative care service in HM-BMT unit of the Western Pennsylvania Hospital in Pittsburgh. The following data were collected for each consult: referral reason, daily pain assessments, whether or not a "goals of care" conversation took place, and hospice enrollment. Lastly, satisfaction surveys were administered. During the program, 392 PC consultations were provided to 256 unique patients. Of these 256 patients, the PC clinicians documented the first goals of care conversations in 67% of patients (n = 172). Of the 278 consults referred for pain, 70% (n = 194) involved reports of unacceptable or very unacceptable pain at baseline. Sixty-six percent (n = 129) of these 194 consults involved reports of pain that was acceptable or very acceptable within 48 hours of consultation. In addition, the hospice referral rate grew from a pre-implementation rate of 5% to 41% (n = 67) of 165 patients who died during the period of program implementation. Lastly, hematological oncologists reported high levels of satisfaction with the program. The main limitation of this project is that it was a single institution study. The successful integration of a PC team into a hematological malignancy unit suggests great potential for positive interdisciplinary collaboration between these two fields.

Use of the Electronic Medical Record (EMR) to Improve Delirium Screening and Recognition (S773)

Objectives 1. Describe the AMPATH Oncology Institute Palliative Care Service and the clinical demographics of the patient case-mix index at Moi Teaching and Referral Hospital in Eldoret, Kenya. 2. Describe the clinical and educational role of a global health palliative care elective through the AMPATH Oncology Institute on the training of US-based hospice and palliative care fellows. Background. Dying patients in Sub-Saharan Africa (SSA) suffer greatly and unnecessarily and would benefit from consultation by more palliative care clinicians knowledgeable about global health (GH) challenges. In response to this need, the AMPATH Oncology Institute (AOI) at Moi Teaching and Referral Hospital (MTRH) in Eldoret, Kenya created a palliative care consultation service, and through its U.S. academic partners established clinical training electives for HPM fellows. Research Objectives. We evaluated clinical data from the AOI Palliative Care Service to explore the training impact of an 8-12 week global health elective on HPM fellows. Methods. Palliative care service data was prospectively collected in 2012-13, and included patient demographics, diagnosis, mortality rate, reason for consultation, and treatment interventions. We conducted descriptive, univariate analyses. Results. During a four month study period, 240 pediatric and adult patients were seen in the inpatient oncology (49%) and outpatient (51%) settings. Median age was 52 years and 51% were female. Eighteen percent of the consultation patients died while on service. Pain (76%), constipation (57%), and dehydration (16%) were the most common reasons for consultation requests. Opiates were prescribed for pain in 61% of cases. Counseling for psychological and spiritual distress was provided to 57% of patients and 52% of families. The most common adult malignancies were breast, cervical, and esophageal cancer as well as sarcoma. Pediatric diagnoses were primarily ALL and NHL. Conclusions. The AOI Palliative Care service clinical volume and case-mix index provides a strong clinical experience for US palliative care fellows rotating in Kenya, and demographic, patient volume, and clinical case mix appear on par with domestic clinical experiences needed to meet ACGME training requirements. Implications for research, policy, or practice. The implication of this clinical training for US-based palliative care fellows would be to allow for work in a resource limited setting and exposure to cross cultural aspects of bio-psychosocial-spiritual palliative care.

Testing the feasibility and effects of a self-management support intervention for patients with cancer and their family caregivers to reduce pain and related symptoms (ANtiPain): Study protocol of a pilot study

Despite effective treatment options, more than 40% of cancer patients receive inadequate pain management. Our previous pilot study resulted in substantial adaptations of a cancer pain self-management intervention, the German PRO-Self? Plus Pain Control Program originally developed in the United States. This program will be implemented into clinical practice at the Medical Center-University of Freiburg. The purpose of this multiple methods pilot study is to test the implementation regarding feasibility and effects in clinical practice. In a randomized, wait-list controlled pilot study, adult oncology in-patients of a palliative care consultation service with pain >3/10 will be recruited. The intervention will be performed by a specialized advanced practice nurse with an in-hospital visit and, after discharge, via phone calls and visits. The follow-up will be personalized according to a clinical algorithm that factors in pain intensity, satisfaction with pain management, and patient adherence. The intervention includes structured and tailored components and is based on three key strategies: information, skill building and nurse coaching. The specific aims of this study are threefold: 1) to test the feasibility of the study and intervention procedures; 2) to establish effect sizes of main outcome variables (e.g. decrease pain intensity, reduce the number of patients with pain as main symptom) for subsequent power calculation; 3) to explore participants’ experiences with pain self-management support and their view of burden and benefit from study participation in a qualitative substudy. During the study period, which includes three data collection time points (T0 before, T1 one week and T2 six weeks after discharge), data will be collected via field notes of study nurses and questionnaires of patients. The results of this pilot study will build the basis for a larger comparative effectiveness study in which long term outcomes of a cancer pain self-management intervention in clinical practice will be evaluated.