Palliative Doctors Research Articles

Identification of Nursing Outcomes and Quality Indicators for Home Health Care in Older Adults with End-Stage Cancer.

This study aimed to identify nursing outcomes and quality indicators for older adults with end-stage cancer receiving home health care. Nineteen experts and professional caregivers, including palliative doctors, nursing faculty, advanced practice nurses, and registered nurses, participated in the Delphi technique. Final medians and interquartile ranges were calculated. Seven components with 43 nursing outcomes and quality indicators for older adults with end-stage cancer were developed, encompassing physical pain relief, symptom management, physical well-being, complication prevention, psychosocial support, caregiver and family roles in end-of-life care, and advance care planning. The caregiver and family's role in end-of-life care had the most indicators, reflecting the significance of family involvement in Thailand's cultural context. Consistent implementation of these indicators is crucial, and correlational analysis of indicator scores can enhance their validity.

END-OF-LIFE HOSPITALIZATION SPENDING IN THE LAST SIX MONTHS OF LIFE AMONG CANCER PATIENTS

Abstract End-of-life care may constitute a vast proportion of health care expenditure globally. In the US, one-quarter of all medicare spending goes towards healthcare for people near the end of life. This is especially true for cancer patients. Our study aimed to estimate hospital spending in cancer patients in the last six months of life. Patients with cancer who died between June 2015 to December 2016 (n=653) were extracted from Singapore’s electronic medical records. A two-part model was used to estimate hospitalization spending. In the last month of life, we found that 85% of the patients did not have chemotherapy, 43% had good quality care, and 31% had palliative care. The average total hospitalization spending in the last six months of life was S$59,180. Further analysis by month from death revealed that spending increased sharply by 62%, from $7,591 in the sixth month of life to $12,315 in the last month of life. Decedents who received chemotherapy in the last month of life spent $6,925 more on hospitalization expenditure than those who did not ($17,915 vs $10,990). Among decedents seen by a palliative doctor, hospital expenditures in the last month were $8,745 higher compared to those who did not ($16,119 vs $7,374). The study depicted the huge hospitalization spending during the end-of-life for cancer patients in Singapore. Expenditure on end-of-life care can be further reduced with investment in community-based services and integrated care across the community and acute sectors, where hospital-to-home services and earlier palliative care can provide potential cost-effective solutions.

An online randomised controlled trial of prognosticating imminent death in advanced cancer patients: Clinicians give greater weight to advice from a prognostic algorithm than from another clinician with a different profession.

A second opinion or a prognostic algorithm may increase prognostic accuracy. This study assessed the level to which clinicians integrate advice perceived to be coming from another clinician or a prognostic algorithm into their prognostic estimates, and how participant characteristics and nature of advice received affect this. An online double-blind randomised controlled trial was conducted. Palliative doctors, nurses and other types of healthcare professionals were randomised into study arms differing by perceived source of advice (algorithm or another clinician). In fact, the advice was the same in both arms (emanating from the PiPS-B14 prognostic model). Each participant reviewed five patient summaries. For each summary, participants: (1) provided an initial probability estimate of two-week survival (0% 'certain death'-100% 'certain survival'); (2) received advice (another estimate); (3) provided a final estimate. Weight of Advice (WOA) was calculated for each summary (0 '100% advice discounting' - 1 '0% discounting') and multilevel linear regression analyses were conducted. NCT04568629. A total of 283 clinicians were included in the analysis. Clinicians integrated advice from the algorithm more than advice from another clinician (WOA difference=-0.12 [95% CI -0.18, -0.07], p< 0.001). There was no interaction between study arm and participant profession, years of palliative care or overall experience. Advice of intermediate strength (75%) was given a lower WOA (0.31) than advice received at either the 50% (WOA 0.40) or 90% level (WOA 0.43). The overall interaction between strength of advice and study arm on WOA was significant (p< 0.001). Clinicians adjusted their prognostic estimates more when advice was perceived to come from a prognostic algorithm than from another clinician. Research is needed to understand how clinicians make prognostic decisions and how algorithms are used in clinical practice.

Advance Directives and Palliative Medical Care in Nursing Homes: A Study on Everyday Life and Relevance in Out-of-Hours Medical Care

The percentage of nursing home residents that have documented advance directives (AD) is increasing. However, there are no studies concerning the consideration of these directives within the out-of-hours primary care or the emergency service. There is also a lack of information on the differences in the attitudes of doctors on duty in various disciplines towards therapeutic options in palliative situations. In the context of research about the medical care of nursing home residents outside regular practice hours, the existence of AD and their consideration by the doctors on duty or emergency doctors was investigated (n=101). Furthermore, the attitudes of the doctors on duty (n=60) and of a reference group of palliative doctors (n=19) towards experience in palliative medicine, asking for AD of the patients and the approach in a fictive palliative case were recorded. 71% of the 82 residents had documented a living will. In 54% of the 101 cases, the doctors on duty and emergency doctorsmade enquiries about AD. In 92% of cases, the doctors followed the given directives. Significant differences between doctors on duty and emergency doctors could not be confirmed. Given a fictive palliative case, 92% of the doctors on duty and 95% of the reference group stated they would enquire about an AD. In acute palliative situations, general practitioners, internists and palliative physicians were more likely to use rapid-acting opioids and anxiolytics, were less likely to call the emergency doctor and were less likely to admit patients to hospital. This distinguishes them from other disciplines. In only 54% of all contacts between patient and doctors on duty or emergency doctors, enquiries were about an AD. That is why doctors need to be further sensitized on the issue of making enquiries about AD from unknown. Additionally, the patient's will should be visible in short form in the respective patient file. Arrangements made with foresight, early involvement of doctors with palliative experience (AAPV, SAPV) as well as increased palliative medical training could improve the care of nursing home residents.

The hospice as a learning space: a death education intervention with a group of adolescents

BackgroundThe denial of death in Western society deprives young people of the tools to derive meaning from experiences of death and dying. Literature shows that death education may allow them to become familiar with this topic without causing negative effects. This article describes the effects of a death education course with adolescents, wherein participants were given the opportunity to meet palliative doctors and palliative psychologists at school and in a hospice, where they were able to converse with the families of the dying.MethodsThis study used mixed methods and included an evaluation of a death education intervention with longitudinal follow-up of outcomes. The course involved 87 secondary school students (experimental group) aged between 16 and 20 years. We also recruited a control group of 76 similarly-aged students to observe differences. The variables we examined were: alexithymia, representation of death, value attributed to life and spirituality. These were measured with the following instruments: the Toronto Alexithymia Scale-20, the Testoni Death Representation Scale, the Personal Meaning Profile and the Spiritual Orientation Inventory, respectively. To better understand how the students perceived the experience, we asked the experimental group to answer some open-ended questions. Their answers were analysed through thematic analysis.ResultsThe study showed that death education and the hospice experience did not produce negative effects, but rather allowed students to decrease alexithymia, improving their ability to recognise and express emotions. Thematic analysis revealed that all participants perceived the experience as very positive.ConclusionsOur findings affirm that death education programs can be successfully implemented in high schools, and that they can usefully involve local hospices and palliative care professionals, especially physicians and psychologists.

Why oral palliative care takes a backseat? A national focus group study on experiences of palliative doctors, nurses and dentists.

AimPoor oral care among frail older people at the end of life endangers quality of life. However, only few dying people have access to oral palliative care services. Therefore, this study aimed to investigate oral palliative care practices and referral patterns for palliative patients in the Brunei healthcare settings.DesignAn exploratory qualitative study.MethodsFive focus groups were conducted among palliative care nurses (N = 7), palliative medicine doctors (N = 4), dentists (N = 6), oncologists (N = 4) and oncology nurses (N = 4). Verbatim was analysed using qualitative thematic analysis.ResultsAnalyses revealed four distinct themes emerging as current oral palliative care assessment and referral practice in the Brunei healthcare settings: “taking a back seat,” “opportunistic oral care,” “they refused and refused” and “challenging healthcare resources and oral palliative care.”

A phase III wait-listed randomised controlled trial of novel targeted inter-professional clinical education intervention to improve cancer patients\u2019 reported pain outcomes (The Cancer Pain Assessment (CPAS) Trial): study protocol

BackgroundVariations in care models contribute to cancer pain being under-recognised and under-treated in half of all patients with cancer. International and national cancer pain management guidelines are achievable with minimal investment but require practice changes. While much of the cancer pain research over the preceding decades has focused on management interventions, little attention has been given to achieving better adherence to recommended cancer pain guideline screening and assessment practices. This trial aims to reduce unrelieved cancer pain by improving cancer and palliative doctors’ and nurses’ (‘clinicians’) pain assessment capabilities through a targeted inter-professional clinical education intervention delivered to participants’ mobile devices (‘mHealth’).MethodsA wait-listed, randomised control trial design. Cancer and/or palliative care physicians and nurses employed at one of the six participating sites across Australia will be eligible to participate in this trial and, on enrolment, will be allocated to the active or wait-listed arm. Participants allocated to the active arm will be invited to complete the mHealth cancer pain assessment intervention. In this trial, mHealth is defined as medical or public health practice supported by mobile devices (i.e. phones, patient monitoring devices, personal digital assistants and other wireless devices). This mHealth intervention integrates three evidence-based elements, namely: the COM-B theoretical framework; spaced learning pedagogy; and audit and feedback. This intervention will be delivered via the QStream online platform to participants’ mobile devices over four weeks. The trial will determine if a tailored mHealth intervention, targeting clinicians’ cancer pain assessment capabilities, is effective in reducing self-reported cancer pain scores, as measured by a Numerical Rating Scale (NRS).DiscussionIf this mHealth intervention is found to be effective, in addition to improving cancer pain assessment practices, it will provide a readily transferable evidence-based framework that could readily be applied to other evidence practice gaps and a scalable intervention that could be administered simultaneously to multiple clinicians across diverse geographical locations. Moreover, if found to be cost-effective, it will help transform clinical continuing professional development. In summary, this mHealth intervention will provide health services with an opportunity to offer an evidence-based, pedagogically robust, cost-effective, scalable training alternative.Trial registrationAustralian New Zealand Clinical Trials Registry (ANZCTR), ACTRN12618001103257. Registered on 3 July 2018.

Palliative approach in outpatient care in Westphalia-Lippe--Follow-up study five years after inception of a structured home-based palliative care system

Since 2009, based on an agreement to implement palliative care for terminally ill patients at home in Westfalia-Lippe, family doctors and palliative doctors cooperate, supported by coordinators. Since 2009, this cooperation is evaluated, concerning supply structure, number of patients and their places of death. In Westfalia-Lippe, yearly approx. 91.000 patients die, approx. 19 % of them, 17.699 patients, were included in palliative care structures, compared to some 6 % in 2009/2010. Whereas in the first years about 70 % of the palliative patients died at home, 2014 this number increased to 75 %. Only 9 % of our patients 2014 died in a hospital (normal ward) - compared to about 13 % in 2009/2010. This applies both for urban and rural areas. The idea of home based, family doctor supported palliative care led to a significant strengthening of the general out-patient palliative care. The number of patients, integrated in our structures of palliative care in 2014 tripled compare to those of 2009/2010. Well trained and experienced coordinators are the essential guarantee of multidisciplinary and multiprofessional team-work. The results of the regional palliative care structures are different also after the agreement came in effect. Data for quality assurance should be periodically collected and evaluated in the future to develop the palliative care structures for outpatients.

Alexandrine Syndrome and Palliative Care: A Psychotic Reaction against Death: A Case Report

Background: Palliative care disclosure and death-facing can be traumatic for patients with advanced cancer. Some of them can suffer a psychotic breakdown that must be differentiated from a terminal delirium. Objectives: To describe a psychiatric side effect from a palliative care announcement called the Alexandrine syndrome. Methods: To illustrate this, we report the case of a patient with no past psychiatric history who, a few days after his palliative state has been announced, presented a major behavioral disorder with violence and paranoiac delusions, heteroagressivity against caregivers and autoagressivity, that could not be explained by a somatic origin. Results: With this case report, we would like to point out the importance of an unreported palliative clinical situation which cannot be explained by an organic substratum. An intense fear of death expressed by the patient with an outburst of defense mechanisms can lead to a brief psychiatric decompensation without any preexisting state of psychosis. Conclusion: The hypothesis of an Alexandrine syndrome should be considered in palliative care in advanced cancer patients experiencing massive anxiety when facing death. This infrequent diagnosis should especially be hypothesized when a patient presents a feature with sudden or recent profound mental disorder following an oncologist consultation with palliative state disclosure. Physical and psychological consequences must not be neglected for patients, as well as disturbing occurrences for the medical team involved. Therefore, oncologists and palliative doctors should be aware of this possibility. Collaboration between psychiatrists and palliative and oncologic teams is recommended to better manage this psychiatric situation.

Effect of palliative doctor in medical oncology team on patient outcomes.

122 Background: Advanced cancer patients have a high symptom burden and not infrequently have unplanned hospital admissions. In our institution, PM services are provided via a separate consult team rather than an integrated palliative oncology team. Sometimes, PM doctors join the oncology team as integrated members for a few months each as part of their PM fellowship training program. This study aims to explore the effect of this PM doctor. Methods: Patients admitted under the lung and gastrointestinal (GI) oncology teams from June 2013 to June 2014 were studied as this cohort of patients had a higher symptom burden and were more likely to benefit from PM input. The following information for each month was obtained from the computer system: hospital length of stay, formal referrals for a PM consult, 30-day, 60-day and 90-day mortality, and place of death. 2-sample T test was used to compare outcomes when there was a PM doctor in the oncology team for at least half of the month versus when there was not. Results: See table below. The presence of a PM doctor reduced the monthly percentage of formal referrals for PM consults but did not have clinically significant effects on other outcomes. Conclusions: PM doctors were there to learn oncology rather than provide a PM service. However, a reduction of PM referrals suggests that they were still able to meet some of the PM needs of the patients admitted. A new model of PM service provision whereby a PM healthcare professional is integrated within the oncology team warrants further study. [Table: see text]

USE OF KETAMINE FOR INTRACTABLE PAIN IN TERMINALLY ILL PATIENTS

BackgroundThere is insufficient evidence from controlled clinical studies to support the use of Ketamine in refractory cancer pain. This has lead to lack of confidence and inconsistent clinical use of...

The role of dentist in palliative care team

The palliative doctor gives the ‘touch of God’ as he/she takes care of the terminally ill patient. The oncologist encounters great difficulties in managing oral cavity problems of these patients. A trained dental doctor can help other doctors in dealing with these situations. But the general dental surgeon does not have enough idea about his part in these treatments. The community is also unaware of the role that a nearby dentist can play. Adequate training programs have to be conducted and awareness has to be created. A trained dentist will be a good team mate for the oncologist or radiotherapist or other doctors of the palliative care team. In this paper, a brief attempt is made to list a few areas in which a palliative care dentist can help other members of the palliative care team and also the patient in leading a better life.

Palliative care professionals’ perceptions of nutrition and hydration at the end of life

The provision of medically administered nutrition and hydration (MNH) for the terminally ill patient is a controversial issue and there has been much debate in the literature concerning this sensitive subject. This article reports on a qualitative research study that explores palliative care nurses' and doctors' perceptions and attitudes to patient nutrition and hydration at the end of life. Participants were from an urban and rural palliative care service. Three main discourses were identified: carers' distress at the non-provision of MNH; palliative care doctors' and nurses' position that terminal dehydration lessened the burden of suffering for dying patients; and polarisation between the acute care setting and the palliative care setting. Overlaying these three main discourses are contesting discourses involving cure vs comfort, and acute care vs palliative care. Importantly, the findings of this study reveal that palliative doctors and nurses believe that medically assisted nutrition and hydration at the end stage of life rarely benefits patients, and as long as adequate mouth care is given, patients do not suffer. However, family members do experience emotional distress in dealing with this situation. In caring for dying people, the nurse's and doctor's role is one of education and communication, involving a team approach to manage this difficult issue.