Palliative Interventions Research Articles

88 An audit of the quality of documentation during the end of life phase of older adults in acute hospital settings

Abstract Background End of Life Care (EoLC) is commonly provided to Older Adults presenting to acute stroke or medical services. Death is considered a ‘poor medical outcome’ but a ‘good death’ is of medical, cultural and spiritual significance for patients and families. Our audit aimed to examine how well medical staff document quality indicators of the EoLC phase of hospital care in a cohort of older adults who died on the geriatric and stroke medicine services. Methods Inclusion criteria were patients who died under the care of the Stroke or Acute internal Geriatric Medicine department between May to October 2022 aged >75. We collected data using the BMJ Support Palliative Care Journal ‘Guidance for completing End of Life Structured Judgement Review’. Data points included recognition of dying, communication with patients and their families, palliative interventions and pastoral care. Results 28 patients were identified with a diagnosis of stroke. 17 patients were identified from AIGM. Data described as Stroke vs AIGM. Recognition of dying was documented in 92.9% (26/28) vs 94.1% (16/17). DNAR was documented in 100% (26/26) vs. 100% (16/16). An escalation/de-escalation plan was documented in 84.6% (24/28) vs. 75% (13/17). Risk of dying was communicated to: the patient 3.6% (1/28) vs. 0% (0/12); family 75% (21/28) vs. 59% (10/17). Anticipatory medicine were: prescribed; 94.1% (26/28) vs. 92.9% (16/17); administered: 85.7% (24/28) vs. 82.4% (14/17); evaluated for effect; 78.6% (22/28) vs 70.6% (12/17). Documentation of spirituality: 17.9% (5/28) vs. 5.9% (1/17). Documentation of available chaplaincy service 17.9% (5/28) vs 5.9% (1/17). Patient’s wishes around dying documented: 7.1% (1/28) vs 0% (0/17). Palliative Care services were consulted in 14.3% (4/28) vs 29.4% (5/17). Conclusion Further improvement, via education and awareness, is needed around the documentation of EOLC by medical staff, particularly in regard to communication to families and referral to pastoral care services.

Pain and Palliative Management in Advanced Gastrointestinal Malignancies – How Are We Doing?

Aims: The aim of the study is to study the different methods and their efficacy in pain management in advanced gastrointestinal (GI) malignancies. Methods: The study included patients with advanced and inoperable GI malignancies. Demographic data, laboratory parameters and radiological investigations, baseline visual analog scale (VAS) score, and subjective global assessment (SGA) were recorded on the first contact along with details of medical, endoscopic, and palliative interventions as performed. Analgesic pain step ladder approach was followed for pain management. Follow-up to assess response was done using VAS score and SGA at the end of 3 months or death within this period. Results: Seventy-one patients were included. Most of them were elderly males. Out of 7 malignancies noted, hepatocellular carcinoma (HCC) was the most common tumor (41; 57.8%). Thirty-five patients (49.3%) had vascular invasion, while 29 (40.8%) had metastatic cancer. The most common vascular invasion was the portal vein (29; 40.8%). The liver was the most common metastatic site (12; 16.9%). The baseline mean VAS score was 5.13 ± 2.38 and the highest was in carcinoma gallbladder patients (8.0 ± 2.0). Most patients were having baseline SGA rating B (69%). Tramadol was the most commonly used analgesic (35.22%) followed by a combination of tramadol and fentanyl (26.76%). The most common palliation was transarterial chemoembolization in HCC (80.5%) and biliary self-expandable metallic stent in carcinoma pancreas (77.8%). There was a statistically significant reduction in VAS score in HCC (P < 0.001), carcinoma pancreas (P = 0.009), and colorectal cancer (P = 0.022). One-sixth patients moved from SGA rating B to rating A, 9.9% moved from SGA rating B to rating C, and 9.9% moved from SGA rating C to rating B. Conclusion: There was an improvement in quality of life at 3-month follow-up. There was significant pain improvement in the studied patients. However, almost one-third patients did not get adequate pain relief.

Implementation of a Multi-Disciplinary Team and Quality of Goals of Care Discussions in Palliative Surgical Oncology Patients

BackgroundPalliative surgical oncology patients represent a unique group with complex needs who often require multidisciplinary input for the provision of timely and holistic care. The authors assembled a multi-disciplinary palliative intervention team and evaluated its association with the quality of discussions on goals of care (GOC) among advanced cancer patients undergoing palliative interventions.MethodsThis prospective cohort study analyzed advanced cancer patients undergoing palliative interventions at a single urban academic center from October 2019 to March 2022. In January 2021, a multi-disciplinary palliative surgical intervention (MD-PALS) team was assembled. All palliative surgical oncology patients were discussed at multi-disciplinary meetings and managed by members of the MD-PALS team. An interrupted time series (ITS) model was built to evaluate the association of MD-PALS implementation and the quality of GOC discussions as measured by a consensus-derived four-point GOC discussion quality score.ResultsThe study recruited 126 palliative surgical oncology patients: 44 in the pre-MD-PALS group and 82 in the post-MD-PALS group. The two groups did not differ significantly in baseline demographics, treatment, or postoperative and survival outcomes. Compared with the pre-MD-PALS group, the post-MD-PALS group had a significantly higher mean GOC discussion quality score (1.34 vs 2.61; p < 0.001). Based on the ITS model, the average quarterly GOC discussion quality score increased significantly among patients after implementation of the MD-PALS team (change = 1.93; 95 % confidence interval, 0.96–2.90; P = 0.003).ConclusionThe implementation of an MD-PALS team was associated with improvements in the quality of GOC discussions among palliative surgical oncology patients.

Qualitative evaluation of a palliative care case management intervention for patients with incurable gastrointestinal cancer (PalMaGiC) in a hospital department

PurposeGeneralist palliative care in hospital departments largely lacks an overall structure to fully manage the symptom burden and support needs of patients with incurable gastrointestinal cancer. Palliative care case management interventions show promising results in reducing healthcare use and enhancing quality of life. Less is known about these interventions and their potential to improve the quality of generalist palliative care in hospital departments. The aim of this study was to explore patients’ experience of a palliative care case management intervention (PalMaGiC) to acquire knowledge about its advantages and disadvantages and, if needed, adjust the intervention. MethodsQualitative semi-structured interviews with patients (n = 14) with incurable gastrointestinal cancers of the oesophagus, pancreas, colon, or rectum were conducted and analysed using content analysis. Participants in the study were affiliated with PalMaGiC, an intervention in a gastroenterology department based on symptom assessment, care planning, care coordination, and needs-based follow-up. ResultsParticipants perceived the intervention as filling a gap and as a secure lifeline in the healthcare system since it provided 24-h access, a designated specialist nurse, and a patient-healthcare alliance. Using a needs-based approach, PalMaGiC changed the participants’ focus from disease to quality of life. Participants requested more open dialog within complementary and alternative medicine, greater focus on promoting hope and using need assessment questionnaires differently in assessing symptoms and problems. ConclusionThe PalMaGiC intervention can potentially meet the needs of patients requiring palliative care in hospital departments, but further development of the content and personalised approach is needed.

Does It Matter Whether a Psychiatric Intervention Is "Palliative"?

Palliative interventions are intended to alleviate suffering and improve quality, not quantity, of life and are not intended to cure illness. In psychiatry, uncertainty about which interventions count as palliative stems from the fact that psychiatry generally prioritizes symptom management irrespective of diagnosis or specific pathophysiology of illness. This commentary on a case considers how distinctions between palliative and other psychiatric interventions might not be all that helpful in resolving clinical and ethical questions about which interventions are-and when they are-appropriate.

Charting the Path: Navigating Embryonic Development to Potentially Safeguard against Congenital Heart Defects.

Congenital heart diseases (CHDs) are structural or functional defects present at birth due to improper heart development. Current therapeutic approaches to treating severe CHDs are primarily palliative surgical interventions during the peri- or prenatal stages, when the heart has fully developed from faulty embryogenesis. However, earlier interventions during embryonic development have the potential for better outcomes, as demonstrated by fetal cardiac interventions performed in utero, which have shown improved neonatal and prenatal survival rates, as well as reduced lifelong morbidity. Extensive research on heart development has identified key steps, cellular players, and the intricate network of signaling pathways and transcription factors governing cardiogenesis. Additionally, some reports have indicated that certain adverse genetic and environmental conditions leading to heart malformations and embryonic death may be amendable through the activation of alternative mechanisms. This review first highlights key molecular and cellular processes involved in heart development. Subsequently, it explores the potential for future therapeutic strategies, targeting early embryonic stages, to prevent CHDs, through the delivery of biomolecules or exosomes to compensate for faulty cardiogenic mechanisms. Implementing such non-surgical interventions during early gestation may offer a prophylactic approach toward reducing the occurrence and severity of CHDs.

Radiofrequency ablation during stereoelectroencephalography: from diagnostic tool to therapeutic intervention. Illustrative case.

Radiofrequency thermocoagulation (RFTC) during intracranial stereoelectroencephalography (sEEG) was first described as a safe technique for creating lesions of epileptic foci in 2004. Since that time, the method has been applied as a diagnostic and/or palliative intervention. Although widely practiced in European epilepsy surgical programs, the technique has not been popularized in the United States given the lack of Food and Drug Administration (FDA)-approved technologies permitting safe usage of in situ sEEG electrodes for this purpose. The authors present a case report of a young female patient with refractory left neocortical temporal lobe epilepsy undergoing sEEG electrode implantation, who underwent sEEG-guided RFTC via a stereotactic temperature-sensing pallidotomy probe. Although used as a diagnostic step in her workup, the patient has remained seizure-free for nearly 18 months. The use of in situ sEEG electrodes for RFTC remains limited in the United States. In this context, this case highlights a safe alternative and temporizing approach to performing diagnostic sEEG-guided RFTC, using a temperature-sensing pallidotomy probe to create small, precise stereotactic lesions. The authors caution careful consideration of this technique as a temporary work-around solution while also highlighting the rising need for new FDA-approved technologies for safe RFTC through in situ temperature-sensing sEEG electrodes.

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.

Minimally invasive stabilization of pelvic metastatic bone disease: A review of an emerging technique.

Percutaneous pelvic stabilization is an emerging technique that provides mechanical stability to pathologic fractures of the pelvic ring and acetabulum. Variability exists in procedural technique among institutions; however, early case series consistently demonstrate an acceptable complication profile and significant improvement in patients' pain and function. This minimally invasive approach is less morbid than traditional, open acetabular and pelvic reconstructions. Therefore, this procedure is an encouraging palliative intervention for a growing patient population in need.

Surgical outcomes of open and laser interstitial thermal therapy approaches for corpus callosotomy in pediatric epilepsy.

Corpus callosotomy (CC) is a palliative surgical intervention for patients with medically refractory epilepsy that has evolved in recent years to include a less-invasive alternative with the use of laser interstitial thermal therapy (LITT). LITT works by heating a stereotactically placed laser fiber to ablative temperatures under real-time magnetic resonance imaging (MRI) thermometry. This study aims to (1) describe the surgical outcomes of CC in a large cohort of children with medically refractory epilepsy, (2) compare anterior and complete CC, and (3) review LITT as a surgical alternative to open craniotomy for CC. This retrospective cohort study included 103 patients <21 years of age with at least 1 year follow-up at a single institution between 2003 and 2021. Surgical outcomes and the comparative effectiveness of anterior vs complete and open versus LITT surgical approaches were assessed. CC was the most common surgical disconnection (65%, n = 67) followed by anterior two-thirds (35%, n = 36), with a portion proceeding to posterior completion (28%, n = 10). The overall surgical complication rate was 6% (n = 6/103). Open craniotomy was the most common approach (87%, n = 90), with LITT used increasingly in recent years (13%, n = 13). Compared to open, LITT had shorter hospital stay (3 days [interquartile range (IQR) 2-5] vs 5 days [IQR 3-7]; p < .05). Modified Engel class I, II, III, and IV outcomes at last follow-up were 19.8% (n = 17/86), 19.8% (n = 17/86), 40.2% (n = 35/86), and 19.8% (n = 17/86). Of the 70 patients with preoperative drop seizures, 75% resolved postoperatively (n = 52/69). No significant differences in seizure outcome between patients who underwent only anterior CC and complete CC were observed. LITT is a less-invasive surgical alternative to open craniotomy for CC, associated with similar seizure outcomes, lower blood loss, shorter hospital stays, and lower complication rates, but with longer operative times, when compared with the open craniotomy approach.

Decision support training for advanced cancer family caregivers: Study protocol for the CASCADE factorial trial

BackgroundPatients with advanced cancer face numerous decisions when diagnosed and often receive decision support from family caregivers. The CASCADE (CAre Supporters Coached to be Adept DEcision partners) factorial trial intervention aims to train caregivers in skills to provide effective decision support to patients and identify most effective intervention components. MethodsThis is a 2-site, single-blind, 24 factorial trial to test components of the CASCADE decision support training intervention for family caregivers of patients with newly-diagnosed advanced cancer delivered by specially-trained, telehealth, palliative care lay coaches over 24 weeks. Family caregivers (target N = 352) are randomly assigned to one of 16 combinations of four components with two levels each: 1) psychoeducation on effective decision partnering principles (1 vs. 3 sessions); 2) decision support communication training (1 session vs. none); 3) Ottawa Decision Guide training (1 session vs. none) and 4) monthly follow-up (1 call vs. calls for 24 weeks). The primary outcome is patient-reported decisional conflict at 24 weeks. Secondary outcomes include patient distress, healthcare utilization, caregiver distress, and quality of life. Mediators and moderators (e.g., sociodemographics, decision self-efficacy, social support) will be explored between intervention components and outcomes. Results will be used to build two versions of CASCADE: one with only effective components (d ≥ 0.30) and another optimized for scalability and cost. DiscussionThis protocol describes the first factorial trial, informed by the multiphase optimization strategy, of a palliative care decision-support intervention for advanced cancer family caregivers and will address the field's need to identify effective components that support serious illness decision-making.Trial registration:NCT04803604

P-239 Effectiveness and safety of palliative surgical interventions for bowel obstruction in advanced staged colorectal cancer: A systematic review and network meta-analysis

P-239 Effectiveness and safety of palliative surgical interventions for bowel obstruction in advanced staged colorectal cancer: A systematic review and network meta-analysis

Physician-Reported Experience and Usability of the MyPal Platform: A Palliative Care Digital Health Intervention.

There is a lack of research focusing on the physician-end, their experiences, and their perception of usability with an eHealth intervention. The aim of this study was to evaluate physician satisfaction, and perception of usability following the use of the MyPal platform, a digital health intervention to foster palliative care for hematological cancer patients. Participants were healthcare professionals active in the project's multinational randomized clinical trial evaluating the impact of the MyPal platform. A post-study electronic questionnaire was administered comprised of; 2 standardized questionnaires (PSSUQ, UEQ) and a feature satisfaction questionnaire, and an open ended question. All questionnaire scores were relatively high and the platform was more than marginally accepted by all participants.

A clinical case of successful palliative endovascular treatment of a patient with a single ventricle, mitral valve atresia, an intact atrial septum and persistent cardinal vein

BackgroundTreatment of newborns with univentricular hemodynamics in combination with an anomaly of pulmonary venous return has the worst correction results in modern cardiac surgical papers. According to the data obtained by different authors, postoperative mortality in this cohort of patients varies from 41.7 to 53%. The presence of the venous outflow tract obstruction, as well as the serious condition of a newborn, is one of the main factors that increase the risk of death in the postoperative period.Case presentationThis article reveals a clinical case of a patient with a combined heart disease prenatally diagnosed in the form of a functionally single ventricle with a double outlet of the main vessels from it, mitral valve atresia, an intact atrial septum and an anomaly of venous return, when the blood outflow from the left atrium was carried out through a single fetal communication such as stenotic cardinal vein. In order to stabilize the patient's condition, the newborn urgently underwent stenting of the stenotic section of the cardinal vein. However, due to the lack of positive dynamics in the postoperative period, the child underwent repeated endovascular intervention and stenting of the intraoperatively created interatrial communication was performed. Taking into account the absence of obstruction of the outflow tract to the pulmonary artery, it was necessary to perform an open surgical intervention in a short time such as pulmonary artery banding.ConclusionsThus, palliative endovascular intervention in critically ill neonates with univentricular hemodynamics and anomalous pulmonary venous return can be considered as a method of choice that can become a new safer strategy for managing infants in order to stabilize the condition before the main stage of surgical intervention comes.

Nurses' practices and their influencing factors in palliative care.

In 2017, the Chinese government launched a pilot project in palliative care, in which Shanghai was a pioneer. Nurses play a key role in palliative care services as they are the main providers improving the quality of services for patients and their families. However, little is known about practices and influencing factors in the field of palliative care from a nursing perspective in China. This is an original empirical study that has meticulously analyzed the interrelationship and intensity between practices and other factors among nurses in the initial stage of palliative care in primary healthcare institutions in Shanghai, China. A descriptive-correlational study design was used to sample 2,829 eligible palliative care nurses by purposive sampling survey in 225 healthcare institutions in Shanghai, China. Descriptive analyses were performed using IBM SPSS 24.0 software. Structural equation modeling was applied to analyze the data by AMOS 20.0. Data were collected using the well-designed Knowledge, Attitudes, and Practices of Hospice Care (KAPHC) scale. The final model showed a good model fit. Self-efficacy directly influenced practices (β = 0.506, P < 0.01) and indirectly influenced practices (β = 0.028, P < 0.01) through intention. Subjective norm directly influenced practices (β = 0.082, P < 0.01) and indirectly influenced practices (β = 0.030, P < 0.01) through intention. Intention (β = 0.152, P < 0.01) and knowledge (β = 0.068, P < 0.01) directly influenced practices. Perceived susceptibility (β = -0.027, P < 0.01), perceived benefits (β = -0.017, P < 0.01), and perceived barriers (β = -0.014, P < 0.01) indirectly influenced practices through intention. This study provided evidence of the associations of knowledge, perceived susceptibility, benefits, barriers, subjective norm, self-efficacy, intention, and practices among nurses concerning palliative care and interventions improving their actual work practices. Our findings revealed that self-efficacy, intention, and subjective norms greatly influenced practices. It is imperative to take interventions that focus precisely on self-efficacy, intention, and subjective norms to improve nurses' practices.

Improving outcomes for people with a primary malignant brain tumour and their carers through early palliative interventions

This publication is the Russian translation of the Plain Language Summary (PLS) of the Cochrane Systematic Review: Byrne A, Torrens-Burton A, Sivell S, et al. Early palliative interventions for improving outcomes in people with a primary malignant brain tumour and their carers. Cochrane Database Syst Rev. 2022;1(1):CD013440. DOI: 10.1002/14651858.CD013440.pub2

Minimally Invasive Image-Guided Procedures for Benign Liver Lesions

AbstractAs access to affordable high-resolution medical imaging has improved, so too has the identification of benign hepatic lesions. Advanced imaging techniques and applications often allow characterization of these lesions so as to differentiate benign and malignant lesions without the need for biopsy. Patients with benign liver lesions are usually asymptomatic; however, a palliative intervention may be indicated if a benign liver lesion is symptomatic. This article reviews the characteristic imaging features of benign liver lesions, the indications for minimally invasive intervention, and the specific procedures for minimally invasive, nonsurgical intervention, and the procedural expectations, effectiveness, and periprocedural care.

Stereo-EEG localization of midline onset seizures on scalp EEG

PurposeThe objective of this study was to describe the sEEG-defined seizure onset zone (SOZ), seizure semiology, presurgical evaluations, surgical intervention and outcome in patients with midline onset noninvasive phase I monitoring. MethodsA single center sEEG database was reviewed to identify patients with seizures onset predominantly involving midline electrodes (FZ, CZ, PZ, OZ) on scalp EEG. Data abstracted included clinical factors, seizure semiology graded into lobar segmentation, imaging and electrographic findings, sEEG plan, interventions, and outcome. ResultsTwelve patients were identified (8 males, median age of sEEG 28 years) out of 100 cases of sEEG performed from January 2015-September 2019. “Frontal lobe” seizure semiology was the most common. sEEG-defined SOZ were frontal (5), diffuse (1), multifocal (1), frontal and insular (1), frontal and cingulate (1), insular (1), cingulate (1), and mesial temporal (1). CZ and/or FZ scalp EEG changes were present for all patients with SOZ involving the frontal, cingulate, and insular regions. PZ/OZ scalp involvement was present in one patient with mesial temporal SOZ. Four patients underwent a definitive resective or ablative surgery, and the remaining patients underwent a palliative intervention. Of those with follow-up information available, 8/11 had seizure reduction by ≥ 50%, including 4 with an Engel I outcome. No clinical factors were associated with outcome. ConclusionsSOZ for midline onset seizures from noninvasive phase I monitoring was most commonly in the frontal, cingulate, and insular regions. A complex cortical network between these regions may explain overlap in semiology and scalp EEG findings. While the number rendered seizure-free was limited, a significant proportion experienced a reasonably favorable outcome justifying use of sEEG to identify surgical options in these patients.

Impact of Palliative Interventions on Survival of Patients with Unresected Pancreatic Cancer: Review of the 2010-2016 National Cancer Database.

Palliative interventions (PI) are offered to patients with pancreatic cancer with the aim of enhancing quality of life and improving overall survival (OS). The purpose of this study was to determine the impact of PI on survival amongst patients with unresected pancreatic cancer. Patients with stage I-IV unresected pancreatic adenocarcinoma were identified using the 2010-2016 National Cancer Database. The cohort was stratified by PI received: palliative surgery (PS), radiation therapy (RT), chemotherapy (CT), pain management (PM), or a combination (COM) of the preceding. Kaplan-Meier method with log-rank test was used to compare and estimate OS based on the PI received. A multivariate proportional hazards model was utilized to identify predictors of survival. 25,995 patients were identified, of which 24.3% received PS, 7.7% RT, 40.8% CT, 16.6% PM, and 10.6% COM. The median OS was 4.9months, with stage III patients having the highest and stage IV the lowest OS (7.8 vs 4.0months). Across all stages, PM yielded the lowest median OS and CT the highest (P < .001). Despite this, the stage IV cohort was the only group in which CT (81%) accounted for the largest proportion of PI received (P < .001). Although all PI were identified as positive predictors of survival on multivariate analysis, CT had the strongest association (HR .43; 95% CI, .55-.60, P = .001). PI offers a survival advantage to patients with pancreatic adenocarcinoma. Further studies to examine the observed limited use of CT in earlier disease stages are warranted.

Sun Stroke: Physiological Mechanism and Palliative Intervention

Sun stroke is a high-emergency clinical condition consisting of a cascade of six prominent symptom groups with failed gravity and intramuscular routes of IM and IV administration, gut constriction and grave prognosis. 2% KCl + 5% NaCl +2% CaOH with diluted milk as vector is proposed. Institutional framework is absent. Nurses are called upon. Keywords: Sun stroke, Oral administration, 2% KCl + 5% NaCl +2% CaOH, Panacea.