Palliative Care Team Intervention Research Articles

Association between hospital palliative care team intervention volume and patient outcomes.

The benefits of palliative care in patients with advanced cancer are well established. However, the effect of the skills of the palliative care team (PCT) on patient outcomes remains unclear. Our aim was to evaluate the association between hospital PCT intervention volume and patient outcomes in patients with cancer. A retrospective cohort study was conducted using a nationwide inpatient database in Japan. Patients with cancer receiving chemotherapy and PCT intervention from 2015 to 2020 were included. The outcomes were incidence of hyperactive delirium within 30days of admission, mortality within 30days of admission, and decline in activities of daily living (ADL) at discharge. The exposure of interest was hospital PCT intervention volume (annual number of new PCT interventions in a hospital), which was categorized into low-, intermediate-, and high-volume groups according to tertiles. Multivariate logistic regression and restricted cubic-spline regression were conducted. Of 29,076 patients, 1495 (5.1%), 562 (1.9%), and 3026 (10.4%) developed delirium, mortality, and decline in ADL, respectively. Compared with the low hospital PCT intervention volume group (1-103 cases/year, n = 9712), the intermediate (104-195, n = 9664) and high (196-679, n = 9700) volume groups showed significant association with lower odds ratios of 30-day delirium (odds ratio, 0.79 [95% confidence interval, 0.69-0.91] and 0.80 [0.69-0.93], respectively), 30-day mortality (0.73 [0.60-0.90] and 0.59 [0.46-0.75], respectively), and decline in ADL (0.77 [0.70-0.84] and 0.52 [0.47-0.58], respectively). Hospital PCT intervention volume is inversely associated with the odds ratios of delirium, mortality, and decline in ADL among hospitalized patients with cancer.

Effectiveness of the integration of a palliative care team in the follow-up of patients with advanced chronic obstructive pulmonary disease: The home obstructive lung disease study

BackgroundAccess to palliative care for patients with end-stage chronic obstructive pulmonary disease (COPD) is still very poor. ObjectivesEvaluate our palliative care program for patients with advanced COPD by assessing whether the referral criteria for advanced COPD patients were adequate in identifying patients in end-of-life care and determine the results of the palliative care team's intervention MethodsThis was a prospective observational study of patients admitted to a multidisciplinary unit for advanced COPD. Data on sociodemographic variables, survival, symptomatology, quality of life, ACP, and health resource utilization were analyzed. ResultsEighty-three patients were included in this study. By the end of the follow-up period, 69 (83%) patients had died, mainly due to respiratory failure (96%). The median duration of survival from the start of follow-up was 4.27 months (95% confidence interval, 1.97–16.07). Most patients (94%) had a dyspnea level of 4. Sixty (72%) patients required opioids for dyspnea control. There were no significant differences in the quality of life of the patients during follow-up. Thirty (43%) patients died at home, 26 (38%) in a palliative care unit, and 13 (19%) in an acute care hospital. ACP was performed for 50 (72%) patients. Forty (57%) patients required palliative sedation during follow-up. Dyspnea was the reason for sedation in 34 (85%) patients. Hospital admissions and emergency room visits decreased significantly (p = 0.01) during follow-up. ConclusionsOur integrated model allows for adequate selection of patients, facilitates symptom control and ACP, reduces resource utilization, and favors death at home.

Clinical role and safety of tapentadol in patients with cancer: A single-center experience.

To evaluate real-world data on the use of tapentadol (TAP) in cancer patients. Single-center retrospective study. Curative/palliative. Patients who started TAP between October 2014 and December 2018 at our institution. The primary outcome was the reason for TAP initiation. Secondary outcomes included prescription duration, TAP cessation rate, reason for cessation, and adverse events (AEs). Since the palliative care team (PCT) tended to prescribe to cancer patients with intractable pain more often than patients in usual care, and also tended to prescribe opioids based on their characteristics, we decided to compare patients with and without PCT intervention. There were 175 patients who first received TAP during the study period, of whom 81 patients (46.3 percent) were male. The median age was 60 years. TAP was prescribed for opioid-naive patients in 45 (26 percent) cases and opioid switch in 130 (74 percent) cases. When comparing the PCT group (n = 121) and the non-PCT group (n = 54) using univariate analysis, the PCT group had a higher opioid switch rate (81.8 percent vs 57.4 percent, p < .001), higher proportion of patients with neuropathic pain (NP) (65.3 percent vs 16.7 percent, p < .001), and a higher proportion of patients with a history of nausea (41.3 percent vs 18.5 percent, p < .01). The cessation rate due to AEs was 8 percent overall. Palliative care physicians prescribed TAP for patients with NP or a history of nausea. Opioid-naive patients were preferred by oncologists. TAP has good tolerability in both groups, with a low dropout rate due to AEs.

Chemotherapy use in end-of-life digestive cancer patients: a retrospective AGEO observational study

BackgroundThe use of chemotherapy (CT) near the end-of-life (EOL) is an important issue in oncology since it could degrade quality of life. CT near EOL is still poorly studied, with no dedicated study in gastrointestinal (GI) cancer patients. AimTo analyze in GI cancer patients the factors associated with the use of CT within 3- and 1-month before patients’ death. Methods and participantsAll consecutive patients who died from a GI cancer in 10 French tertiary care hospitals during 2014 were included in this retrospective study. Clinical, demographical and biological data were collected and compared between patients receiving or not CT within 3- and 1-month before death. Variables associated with overall survival (OS) was also determined using of univariate and multivariate analyses with a Cox model. ResultsFour hundred and thirty-seven patients with a metastatic GI cancer were included in this study. Among them, 293 pts (67.0%) received CT within 3-months before death, and 121 pts (27.7%) received CT within 1-month before death. Patients receiving CT within 3-months before death were significantly younger (median age: 65.5 vs 72.8 years, p < 0.0001), with a better PS (PS 0 or 1: 53.9 vs 29.3%, p < 0.0001) and a higher albumin level (median: 32.8 vs 31.0 g/L, p = 0.048). Similar results were found for CT within 1 month before death. Palliative care team intervention was less frequent in patients who received CT in their last month of life (39.7% vs 51.3%, p = 0.02). In multivariate analysis, median OS from diagnosis was shorter in the group receiving CT within 1-month before death (HR = 0.59; 95% CI [0.48–0.74]). ConclusionIn GI-cancer patients, CT is administered within 3- and 1-month before death, in two and one third of patients, respectively. Patients receiving CT within 1-month before death, had more aggressive disease with poor OS. Palliative care team intervention was associated with less administration of CT in the last month of life. These results highlight the need to better anticipate the time to stop CT treatment in the end-of-life and the importance of an active collaboration between oncology and palliative care teams.

End-of-Life Aspects in a Hematopoietic Stem Cell Transplantation Unit: The Integration of Palliative Care Group in the Transplant Process

Topic Significance & Study Purpose/Background/Rationale Patients submitted to Hematopoietic Stem Cell Transplantation (HSCT) are affected by a burden of symptoms arising from conditioning treatment, clinical complications such infections, bleeding disorders, leading to physical and psychological suffering. The understanding of how hematological patients are managed in the end-of-life may provide improvement in the quality of care since it seems hematological patients have less access to palliative care (PC) when compared to solid tumors. The aim of this study was evaluate the end-of-life scenario of our patients that died after HSCT followed or not by PC team and try to improve the care practice of this patients Methods, Intervention, & Analysis We retrospectively analyzed patients submitted to HSCT who died between January, 2010 and July, 2018 in a single private hospital in Sao Paulo, Brazil. It was recorded cause of death: if TRM (Transplant related Mortality) or relapse/ disease progression (DP) related; the local of death ICU (intensive care unit) or regular room and PC team intervention. For statistical analysis was used Chi-square and likelihood ratio test. Findings & Interpretation A total of 460 patients received HSCT in this period. 345 (75%) adults and 115 (25%) pediatrics. Among them 125 (27,1%) died 101 (80%) adults and 24 (20%) children. In the pediatric population 15 (62.5%) died due TRM and all died in the ICU, PC team followed just one (7%) patient. Nine (37.5%) died due DP, and just one (4%) patient was followed by PC team, and died in regular room free of invasive therapy. In the adult population 55 (54,5%) died due TRM, the PC team followed 10 (18%), of them and; 8 (14.5%) died in ICU. Forty-six (45.5%) of patients died by DP and, 26 patients (56.5%) were followed by PC team, and 16 (35%) died in regular room. Twenty patients were not followed by CP team and 17 (37%) out 20 died in the ICU. In the adult population patients who were followed by PC team have less chance of being transferred to ICU (p Discussion & Implications Our mortality rate is similar to literature, but few patients were followed by PC team. A new practice was established in January 2018 and PC team starts evaluating all adult patients undergoing HSCT. The first visits was in the pre transplant evaluation and then followed by weekly visits during admission period interfering in symptoms management, with this we hope to increase the quality of the assistance offered in the final stage of life. In respect to pediatric patients we are in the process of evaluating our gaps for service implementation. When the PC team is introduced we observed an improved management of patients, family and health team with a decrease of transfers for ICU, giving better quality at the end of life.

End-of-life care for cancer patients in Japanese acute care hospitals: A nationwide retrospective administrative database survey.

End-of-life (EOL) cancer care in Japanese acute care hospitals has not been well described. We aimed to assess the aggressiveness of EOL care and examine common treatments administered to cancer patients using a health administrative database. Subjects are adult cancer patients who died at acute care hospitals between April 2011 and March 2014. Data from the Japanese Diagnosis Procedure Combination database were analysed to measure the aggressiveness of care (chemotherapy, intensive care unit [ICU] admission and cardiopulmonary resuscitation [CPR]) and describe procedures and prescriptions administered in the last 14 and 30 days of life, disaggregated by hospital case volume: high, intermediate and low volumes. Of 248,978 cancer decedents, 170,024 died in high-, 70,231 in intermediate- and 8,723 in low-volume hospitals. Aggressive treatment in the last 14 days of life included chemotherapy (9.4%, 7.3%, and 5.4%, respectively), ICU admission (3.0%, 2.0%, and 2.4%) and CPR (5.8%, 6.4%, and 8.3%). Opioids were administered to 66.0%, 59.0% and 49.4% patients, while Palliative Care Team intervention was performed for 8.5%, 2.2% and 2.0% of patients, respectively in the last 30 days. In high-volume hospitals, radiotherapy and certified outpatient chemotherapy fees were more frequent. Catecholamines and hyperalimentation were more frequently administered in low-volume hospitals. This is the first study to assess EOL care among Japanese acute care hospitals. More frequent use of chemotherapy at high-volume hospitals may reflect a well-established cancer treatment system. The approach for low-volume hospitals might improve the EOL care for all cancer patients in Japan.

Discrepancies between Reasons of Palliative Care Team Consultation and Palliative Care Team Activities.

Palliative care team (PCT) is a common type of palliative care services. However, distress in cancer patients may be underestimated by hospital staff. Reasons for PCT consultation may be inconsistent with patients' actual needs. We aimed to examine the proportions of discrepancy between the reasons for PCT consultation and actual PCT activities. We performed an observational study based on datasets of PCT activities at Kindai University Hospital. Differences in the proportion between reasons for PCT consultation and actual PCT activities were calculated. Datasets of 368 hospitalized cancer patients for whom the PCT performed interventions were analyzed. The average patient age was 61 years. Hepatobiliary and pancreatic cancer were the most common primary sites (20%) followed by blood (12%) and lung (11%). Pain management was the most frequent reason for PCT consultation (67%) and PCT activities (65%). Delirium was more likely to be treated by the PCT, but less likely to be listed as a reason for consultation. The need for support for family and for decision making was less often recognized by hospital staff. Cancer-related fatigue (CRF) and depression were more likely listed as reasons for consultation, but less likely to receive PCT intervention. Delirium and the need for family and decision-making support were underrecognized by hospital staff. PCT intervention for CRF and depression was often withheld because of very late referral. Appropriate timing of PCT consultations is important. Providing educational opportunities for hospital staff to comprehensively assess patient's multidimensional distress is needed.

Therapeutic futility in cancer patients at the time of palliative care transition: An analysis with a modified version of the Medication Appropriateness Index

Background: Palliative Care professionals are often confronted with therapeutic futility, consisting in inappropriate strategies that do not add any advantage to the patient and may actually increase adverse events. Scientific literature concerning this issue is lacking. This article is one of the first to study therapeutic futility specifically at the time of transition to the palliative care setting. Aim: To study the phenomenon of pharmacologic therapeutic futility at the time of transition of a cancer patient to palliative care. Design: The pharmacological prescriptions at the time of the first appointment at an oncological palliative care unit during a time period of 2 months were prospectively collected and characterized using the Medication Appropriateness Index. Participants: The sample comprised 71 patients with a mean age of 68.2 years. Results: The most common pharmacological groups were analgesics (n = 121; 19.2%), psychoactive drugs (n = 89; 14.1%), and antihypertensives (n = 51; 8.1%). A total of 61 patients (85.9%) consumed 5 drugs or more at the time of the first appointment. The mean number of daily medications decreased significantly after the palliative care team intervention, from 7.15 to 5.73 (p < 0.05). The principal causes of inappropriateness were absence of indication for the drug (23.0% “inappropriate”), the drugs’ adverse interactions (11.1%), and inadequate dosage (9.9%). After the first consultation in the palliative care setting, 28.2% of the drugs were suspended. Conclusion: This article tried to evaluate the main causes of therapeutic futility at the palliative care transition. The principal causes of inappropriateness were absence of clinical indication, clinically significant drug–disease/comorbidity interactions, and incorrect dosage/posology.

Does a palliative care consult decrease the cost of caring for hospitalized patients with dementia?

Advanced dementia (AD) is a terminal disease. Palliative care is increasingly becoming of critical importance for patients afflicted with AD. The primary objective of this study was to compare pharmacy cost before and after a palliative care consultation (PCC) in patients with end-stage dementia. A secondary objective was to investigate the cost of particular types of medication before and after a PCC. This was a retrospective study of 60 hospitalized patients with end-stage dementia at a large academic tertiary care hospital from January 1, 2010 to October 1, 2011, in order to investigate pharmacy costs before and after a PCC. In addition to demographics, we carried out a comparison of the average daily pharmacy cost and comparison of the proportion of subjects taking each medication type (cardiac, analgesics, antibiotics, antipsychotics and antiemetics) before and after a PCC. There was a significant decrease in overall average daily pharmacy cost from before to after a PCC ($31.16 ± 24.71 vs. $20.83 ± 19.56; p < 0.003). There was also a significant difference in the proportion of subjects taking analgesics before and after PCC (55 vs. 73.3%; p < 0.009), with a significant average daily analgesic cost rise from pre- to post-PCC: $1.36 ± 5.07 (median = $0.05) versus. $2.35 ± 5.35 (median = $0.71), respectively, p < 0.011; average daily antiemetics cost showed a moderate increase from pre- to post-PCC: $0.08 ± 0.37 (median = $0) versus $0.23 ± 0.75 (median = $0), respectively, p < 0.047. Our findings indicate that PCC is associated with overall decreased medication cost in hospitalized AD patients. Additionally, receiving a PCC was related to greater use of pain medications in hospitalized dementia patients. Our study corroborates the benefits of palliative care team intervention in managing elderly hospitalized dementia patients.

Effect of integrated palliative care on the quality of end-of-life care: retrospective analysis of 521 cancer patients

ObjectiveTo examine the impact of oncologist awareness of palliative care (PC), the intervention of the PC team (PCT) and multidisciplinary decision-making on three quality indicators of end-of-life (EOL) care.SettingCochin Academic...

Evaluation of factors that intervention of palliative care team contributes to quality-of-life improvement of Japanese patients with advanced cancer.

e19517 Background: Quality of life (QOL) has not been evaluated in Japanese patients with advanced cancer by EORTC QLQ C-15 PAL, which was developed to measure QOL in palliative care. The patient characteristic that relates to EORTC QLQ C-15 PAL score is not known. Thus, we investigated the factor that related to EORTC QLQ C-15 PAL domain score change before and after the palliative care team (PCT) intervention. Methods: We executed the prospective study to the in-patient who had hoped for the PCT intervention. Patients were asked to complete the self-administered questionnaires according to EORTC QLQ C-15 PAL on before and day 7 of PCT intervention. We analyzed the QOL domain score changing and its correlation to clinical and physiological variables such as age, gender, performance status (PS), and baseline domain scoring in the multivariate stepwise linear regression and bootstrap analysis. Results: Thirty-five patients were recruited, and of those 26 completed the questionnaires and 9 were withdrawn from the trial due to discharge. Median age was 58.5 (range: 22-81), Male: Female = 19:7, PS 0:1:2:3:4 = 2:11:6:7:0, lung cancer = 17 (65%). In the multivariate analysis, the stepwise protocol detected significant baseline valuables which influence each QOL domain. Physical function (r(2)=0.56); baseline physical function scores (coefficient -0.70, [95%CI -1.03, -0.38], p<0.001), gender (male) (38.1, [19.4, 56.7], p<0.001). Emotional function (r(2)=0.70); baseline emotional function score (-0.62, [-0.86, -0.38], p<0.001), gender (male) (15.7, [0.21, 31.27], p=0.047), age (-0.61, [-1.11, -0.11], p=0.018), PS (2-4) (24.75, [10.69, 38.82], p=0.002). Global QOL (r(2)=0.46); baseline global QOL score (-0.7, [-1.02, -0.38], p<0.001). Conclusions: We observed significant associations of factors, such as baseline score, age, gender (male) and PS (2-4) with increased QOL domain score after PCT intervention. The rise of the baseline score and the age of the patient were suggested that a negative factor in the QOL improvement.

Predictors of Symptom Severity and Response in Patients With Metastatic Cancer

We examined determinants of symptom severity and response to treatment among 150 patients with cancer participating in a phase II trial of a palliative care team intervention. Patients completed a modified Edmonton Symptom Assessment Scale (ESAS) at baseline and 1 week. Women had a worse baseline ESAS Distress Score (EDS; P = .003) and Total Distress Score (TDS; P = .005); differences were particularly marked for anxiety and appetite. Performance status was inversely associated with EDS, TDS, well-being, appetite, and fatigue (Kruskal-Wallis, all P < .005). Multivariate analysis of covariance (ANCOVA) showed that symptom improvement was independently predicted by worse baseline EDS score and female gender. Performance status, gender, and baseline symptom severity should be accounted for in trials of palliative care interventions; inclusion criteria based on symptom severity should also be considered.

Improving cancer patients' pain: the impact of the hospital specialist palliative care team

Pain is reported to occur in the majority of patients with advanced cancer and is one of the main reasons for referral to a hospital specialist palliative care team. Yet despite this, there is a paucity of research into the impact the hospital specialist palliative care team has on pain control in patients. A non-equivalent control group design using a quota sample investigated 100 cancer patients who had been admitted to hospital for symptom control. Fifty patients received specialist hospital palliative care team intervention compared with 50 patients receiving traditional care. Outcome was assessed using the Palliative Care Assessment (PACA) tool on three occasions. There was no difference between the groups on the initial assessment and the results indicated that all cancer patients admitted to hospital had a significant improvement in their pain control. However, the patients who had the additional input of the palliative care team demonstrated a statistically significant greater improvement than the control group (P<0.001). Potential explanations are made for the results including the enhanced knowledge and skills of the hospital specialist palliative care team.

Hospital based palliative care teams improve the insight of cancer patients into their disease

It is reported that cancer patients want as much information as possible about their diagnosis and prognosis. This input regarding patients' insight into their disease is undoubtedly a major part of providing optimal palliative care. Despite this, there is little information regarding the impact of hospital based palliative care teams. An evaluation study comprising a nonequivalent control group design, using a quota sample, investigated 100 cancer patients who had been admitted to hospital for symptom control. Fifty patients received hospital palliative care team intervention compared with 50 patients receiving traditional care. Outcome was assessed using the Palliative Care Assessment tool (PACA) assessment tool on three occasions that measured the patients self-reported understanding of their illness. A supplementary qualitative approach that included 31 semistructured interviews with doctors and nurses to explore their perception of the impact of the palliative care team was also undertaken. The results indicated that cancer patients admitted to hospital for symptom control demonstrated an improvement in their insight to their diagnosis. Those patients who had the additional input of the palliative care team had a significantly greater improvement in their insight scores (reported by the doctors and nurses as being invaluable for the patients). Potential explanations are made for these results including enhanced communication skills of the palliative care team are explored.