Palliative Medicine Consultation Research Articles

PROVISION OF END OF LIFE (EOL) CARE TO PATIENTS WITH HEART FAILURE (HF) IN AN ACUTE HOSPITAL TRUST

BackgroundPatients with Heart Failure (HF) often have palliative care needs but access to appropriate palliative and end of life care is not always achieved. Following the appointment of a hospital...

PALLIATIVE AND END OF LIFE CARE IN PRISONS IN ENGLAND AND WALES – APPROACHES TAKEN TO IMPROVE INEQUALITIES

BackgroundThe End of Life Care Strategy (2008) states that healthcare providers, prisons and coronial services should develop strategies that enhance delivery of palliative and end of life care. The prison...

KETAMINE USE IN PALLIATIVE CARE WITHIN THE NORTH TRENT CANCER NETWORK (NTCN)

BackgroundKetamine is a potent analgesic with potentially serious adverse effects (eg dysphoria, bladder dysfunction), being used in palliative medicine. Its evidence base is limited and a recent RCT using the...

The Impact of Palliative Care Consultion in the Intensive Care Uniton 30 Day Hospital Readmission Rates (S768)

1.Define and explain the variables used to compare the groups in this study.2.Describe the results found in this study and explain limitations of the study. Our project expands on a previous study at our institution that assessed the effectiveness of integrating a palliative medicine (PM) consult service in the intensive care unit (Walker et al., JPM, in press). This study found a significant decrease in ICU length of stay for referred patients without a significant increase in mortality. Although palliative services were shown to be effective in the index hospitalization, we have not yet studied the long term impact of having a palliative plan of care at discharge. We sought to 1) Quantify the difference in 30- day readmission rates between patients in the medical ICU who received a PM consultation and agreed to a palliative plan of care at discharge versus those who did, and 2) Compare these groups for one year after index hospitalization discharge in terms of further readmissions, mortality, venue of death, and hospital costs. This study is a quasi-experimental cross-sectional study using the patients identified in the prior study that received a PM consultation in the ICU and survived discharge. We obtained readmission and billing data from MedStar electronic records database and death information from an online database. Our primary outcome measure was all-cause 30-day hospital readmission. Other variables of interest included mortality, number and costs of hospital readmissions over one year of follow-up. This study was considered exempt by IRB. Of 57 patients receiving a PM consultation, 45 agreed to a palliative plan of care at discharge. 30-day readmission rates were significantly lower in the group that agreed to a palliative plan of care (7% vs 75%, p<0.001). Most of the patients (92%) without palliative plans died within one year. PM consultations resulting in a palliative plan of care have a significant impact on 30-day readmission rates.

Managing Patients with Mechanical Circulatory Support Acrossthe Care Spectrum (SA521)

1.Review the role of palliative care for patients with mechanical circulatory support in the inpatient setting.2.Explore care challenges for patients with mechanical circulatory support in the outpatient setting (home, nursing home, hospice).3.Discuss end-of-life management of mechanical circulatory support across the care continuum. Mechanical circulatory support (MCS) is being utilized with increasing prevalence for patients with advanced heart failure. The use of MCS (eg, ventricular assist devices and total artificial hearts) presents opportunities for hospice and palliative medicine (PM) providers to optimize care. The goal of this session is to demonstrate how PM providers can support patients receiving MCS across the care spectrum—from preimplantation to patients living with MCS and those endoflife. In the preimplantation period (often in the inpatient setting), PM consultation is recommended. Determination of patients' goals and preferences is important before they make the decision for MCS. Additionally, PM providers can help with preparedness planning—an advance care plan specific to MCS recipients. Although many PM providers are familiar with this concept, details regarding how to approach this or how to utilize models are not well known. We will discuss approaches to MCS candidates and recipients in the inpatient setting, with emphasis on how to complete a preparedness plan and how to document this in the chart. Patients with MCS also face unique challenges as outpatients. After their initial discharge, most patients will live months to years with their device as outpatients, although frequent inpatient stays are not uncommon. We will discuss the role of PM in supporting these patients as outpatients, at home, and during transitions. Lastly, nursing homes and hospices are often uncomfortable with managing patients with MCS, or lack providers certified to provide care for these patients. This can lead to significant disparities in care for these patients, particularly when approaching the end of life. Inpatient and home hospices are often asked to care for patients with MCS, but may not have protocols in place to provide optimal care. We will discuss end-of-life management with emphasis on hospice and nursing home-based protocols for deactivation and comfort care.

Features and Outcomes of Patients Who Underwent Cardiac Device Deactivation

Little is known about patients who undergo cardiovascular implantable electronic device deactivation. To describe features and outcomes of patients who underwent cardiovascular implantable electronic device deactivation. Retrospective review of medical records of 150 patients at a tertiary academic medical center (Mayo Clinic, Rochester, Minnesota). EXPOSURE Cardiovascular implantable electronic device deactivation. Demographic and clinical data and information regarding advance directives, ethics consultations, palliative medicine consultations, and cardiovascular implantable electronic device deactivations. Of the 150 patients (median age, 79 years; 67% were male), 149 (99%) had poor or terminal prognoses. Overall, 118 patients (79%) underwent deactivation of tachycardia therapies only, and 32 (21%) underwent deactivation of bradycardia therapies with or without tachycardia therapies (6 patients [4%] were pacemaker-dependent). Half of the deactivation requests (51%) were made by surrogates. A majority of deactivations (55%) were carried out by nurses. Although 85 patients (57%) had advance directives, only 1 mentioned the device in the directive. Ethics consultations occurred in 3 patients (2%) and palliative medicine consultations in 64 (43%). The proportions of patients who died within 1 month of device deactivation were similar for those who underwent deactivation of tachycardia therapies only and those who underwent deactivation of bradycardia therapies with or without tachycardia therapies (85% vs 94%; P = .37). Most requests for cardiovascular implantable electronic device deactivation were for implantable cardioverter-defibrillator-delivered tachycardia therapies only. Many of these requests were made by surrogates. Advance directives executed by patients with these devices rarely addressed device management. Regardless of device therapy, most patients died shortly after device deactivation. Hence, a device deactivation decision may reflect the seriousness of a given patient's underlying illness. Patients with devices should engage in advance care planning to ensure that future care is consistent with their preferences.

Economic impact of hospitalisations among patients in the last year of life: An observational study

Background: Hospital admissions among patients at the end of life have a significant economic impact. Avoiding unnecessary hospitalisations has the potential for significant cost savings and is often in line with patient preference. Objective: To determine the extent of potentially avoidable hospital admissions among patients admitted to hospital in the last year of life and to cost these accordingly. Design: An observational retrospective case note review with economic impact assessment. Setting: Two large acute hospitals in the North of England, serving contrasting socio-demographic populations. Patients: A total of 483 patients who died within 1 year of admission to hospital. Measurements: Data were collected across a range of clinical, demographic, economic and service use variables and were collected from hospital case notes and routinely collected sources. Palliative medicine consultants identified admissions that were potentially avoidable. Results: Of 483 admissions, 35 were classified as potentially avoidable. Avoiding these admissions and caring for the patients in alternative locations would save the two hospitals £5.9 million per year. Reducing length of stay in all 483 patients by 14% has the potential to save the two hospitals £47.5 million per year; however, this cost would have to be offset against increased community care costs. Limitations: A lack of accurate cost data on alternative care provision in the community limits the accuracy of economic estimates. Conclusions: Reducing length of hospital stay in palliative care patients may offer the potential to achieve higher hospital cost savings than preventing avoidable admissions. Further research is required to determine both the feasibility of reducing length of hospital stay for patients with palliative care needs and the economic impact of doing so.

The role and timing of palliative medicine consultation for women with gynecologic malignancies: Association with end of life interventions and direct hospital costs

ObjectiveAggressive care interventions at the end of life (ACE) are reported metrics of sub-optimal quality of end of life care that are modifiable by palliative medicine consultation. Our objective was to evaluate the association of inpatient palliative medicine consultation with ACE scores and direct inpatient hospital costs of patients with gynecologic malignancies. MethodsA retrospective review of medical records of the past 100 consecutive patients who died from their primary gynecologic malignancies at a single institution was performed. Timely palliative medicine consultation was defined as exposure to inpatient consultation ≥30days before death. Metrics utilized to tabulate ACE scores were ICU admission, hospital admission, emergency room visit, death in an acute care setting, chemotherapy at the end of life, and hospice admission <3days. Inpatient direct hospital costs were calculated for the last 30days of life from accounting records. Data were analyzed using Fisher's Exact, Mann–Whitney U, Kaplan–Meier, and Student's T testing. Results49% of patients had a palliative medicine consultation and 18% had timely consultation. Median ACE score for patients with timely palliative medicine consultation was 0 (range 0–3) versus 2 (range 0–6) p=0.025 for patients with untimely/no consultation. Median inpatient direct costs for the last 30days of life were lower for patients with timely consultation, $0 (range 0–28,019) versus untimely, $7729 (0–52,720), p=0.01. ConclusionsTimely palliative medicine consultation was associated with lower ACE scores and direct hospital costs. Prospective evaluation is needed to validate the impact of palliative medicine consultation on quality of life and healthcare costs.

P158 A hospice motor neurone disease clinic: challenges and benefits of a new service

Background/contextThe Hospice in North Hampshire had offered support and care to MND patients but in an unstructured way. Close working between the Palliative Medicine and Neurology Consultants led to a...

Effectiveness of Integration of Palliative Medicine Specialist Services into the Intensive Care Unit of a Community Teaching Hospital

Collaboration between palliative medicine and the intensive care unit (ICU) represents best practice and offers important benefits. However, achieving effective collaboration between these two specialties can be challenging. Assess effectiveness of integrating palliative medicine specialists in the ICU. Retrospective chart review. Of 201 patients who qualified for palliative consultation using a palliative screening tool, 92 were referred and 109 were not referred for palliative medicine consultation. The number of screening criteria met was similar between the two groups. Palliative medicine consult volume increased significantly compared with preintegration (7.7±3.4 versus 4.4±2.8 consults per month, p=0.04). No significant difference in hospital mortality was found between the referred and unreferred groups (32/92 [35%] versus 26/109 [24%], p=0.09). ICU length of stay was significantly shorter in the referred group (7 versus 11 days, p<0.001). Referred patients were more frequently enrolled in hospice compared with unreferred patients (32/92 [37%] versus 3/109 [3%], p<0.001). ICU physicians referred patients significantly more often for dementia and ventilator withdrawal (13/16, p=0.003; 24/29, p<0.001, respectively) and significantly less often for ICU stay longer than 10 days (21 versus 49, p=0.001). Integrating palliative medicine specialists into intensive care was associated with a significant increase in use of palliative medicine services and a significant decrease in ICU length of stay for referred patients without a significant increase in mortality. The screening tool effectively identified patients at high risk of death. Given the high mortality rate of the unreferred patients, the criteria could be more widely adopted by ICU physicians to consider expanding palliative medicine referrals.

Integrating palliative care in lung cancer: an early feasibility study

The aim of this preliminary study was to evaluate the feasibility of conducting an effectiveness trial of early access to palliative care services for people with lung cancer through use of an integrated outpatient model. Newly diagnosed patients with lung cancer receiving palliative-intent treatment or best supportive care treatment were recruited over a 5-month period from one out-patient clinic in Scotland. Patients were offered a clinical review appointment with a palliative medicine consultant at two time points: baseline and 12 weeks later. Prior to each appointment patients completed three outcome measures addressing symptom severity, wellbeing, and health-care needs. One-to-one interviews were also conducted to explore patients' experiences of being involved in the study. Three patients participated in the study. The main reasons for low recruitment were patients' deteriorating condition and unwillingness to undertake extra hospital visits. However, qualitative data indicated that the participants found this extra layer of supportive care useful in identifying and managing their needs, as well as enabling future planning. Further testing is needed to ascertain the feasibility of conducting a trial of integrating early access to palliative care services into routine practice for people with lung cancer.

Results of timely palliative medicine consultation on end-of-life care outcomes for women with gynecologic malignancies

Objective: Quality of end-of-life care has recently been measured using distinct outcome variables that have been used to improve care. Many of these variables are related to aggressive care interventions in patients at the end of life (ACE). Our objective was to compare the ACE scores of patients with and without a timely palliative medicine consultation at the end of life. Our hypothesis was that an early palliative medicine consultation would result in lower ACE scores at the end of life.

Palliative medicine consultation at the end-of life decreases inpatient hospital costs in women with gynecologic malignancies

Palliative medicine consultation at the end-of life decreases inpatient hospital costs in women with gynecologic malignancies

End-of-Life Care of Women With Gynecologic Malignancies: A Pilot Study

There are limited data regarding the end-of-life care for women with gynecologic malignancies. We set out to generate pilot data describing the care that women with gynecologic malignancies received in the last 6 months of life. Patient demographics, patterns of care, and utilization of palliative medicine consultation services were evaluated. One hundred patients who died of gynecologic malignancies were identified in our institutional database. Only patients who had received treatment with a gynecologic oncologist within 1 year of death were included. Medical records were reviewed for relevant information. Data were abstracted from the electronic medical record, and analyses were made using Student t test and Mann-Whitney U test with SPSS software. The mean age of patients was 60 years (range, 30-94 years). Racial/ethnic distribution was as follows: 38%, white; 34%, black; and 15%, Hispanic. Seventy-five percent of patients received chemotherapy within the last 6 months of life, and 30% received chemotherapy within the last 6 weeks of life. The median number of days hospitalized during the last 6 months of life was 24 (range, 0-183 days). During the last 6 months of life, 19% were admitted to the intensive care unit, 17% were intubated, 5% had terminal extubation, and 13% had cardiopulmonary resuscitative efforts. Sixty-four percent had a family meeting, 50% utilized hospice care, and 49% had palliative medicine consultations. There was a significant difference in hospice utilization when comparison was made between patients who had 14 days or more from consultation until death versus patients who had 14 days or less or no consultation, 21 (72%) versus 29 (41%), P = 0.004. Patients who were single were less likely to have a palliative medicine consultation, P = 0.005. End-of-life care for patients with gynecologic malignancies often includes futile, aggressive treatments and invasive procedures. It is unknown whether these measures contribute to longevity or quality of life. These pilot data suggest that factors for implementation of timely hospice referral, family support, and legacy building should include specialists trained in palliative medicine.

What is the extent of potentially avoidable admissions amongst hospital inpatients with palliative care needs?

BackgroundThere is clear evidence that the full range of services required to support people dying at home are far from being implemented, either in England or elsewhere. No studies to date have attempted to identify the proportion of hospital admissions that could have been avoided amongst patients with palliative care needs, given existing and current local services. This study aimed to examine the extent of potentially avoidable admissions amongst hospital patients with palliative care needs.MethodsA cross sectional survey of palliative care needs was undertaken in two acute hospitals in England. Appropriateness of admission was assessed by two Palliative Medicine Consultants using the following data collected from case notes: reasons for admission; diagnosis and co-morbidities; age and living arrangements; time and route of admission; medical and nursing plan on admission; specialist palliative care involvement; and evidence of cognitive impairment.ResultsA total of 1359 inpatients were present in the two hospitals at the time of the census. Of the 654 consenting patients/consultees, complete case note data were collected for 580 patients; the analysis in this paper relates to these 580 patients. Amongst 208 patients meeting diagnostic and prognostic criteria for palliative care need in two acute settings in England, only 6.7% were identified as ‘potentially avoidable’ hospitalisations. These patients had a median age of 84. Half of the patients lived in residential or nursing homes and it was concluded that most could have received care in this setting in place of hospital.ConclusionOur findings challenge assumptions that, within the existing configuration of palliative and end of life health and social care services, patients with palliative care needs experience a high level of potentially avoidable hospitalisations.

Hospital Outcomes for a Home-Based Palliative Medicine Consulting Service

There is a growing need for palliative care services located outside of hospitals. This study's objective was to evaluate a home-based, nonhospice, palliative medicine (PM) consultation practice within a fee-for-service environment. Hospital and emergency department (ED) utilization and cost data obtained from administrative records were analyzed with longitudinal analyses to compare use 18 months before and after service enrollment in a single patient group. Patients (N=369) with advanced complex illness (ACI) referred for home-based palliative consultation participated in the study. Consultation conducted by nurse practitioners included a multidimensional assessment with recommendations to outpatient physicians for symptom management and guidance to patient and family for goals of treatment and advanced care planning (ACP). Nurse practitioners were supported by a collaborating PM physician. Follow-up visits varied by need for symptom management and ACP. Total hospitalizations, total hospital days, total and variable costs, and probability of a 30-day readmission were significantly reduced in the 18-month period following program enrollment. However, probability of an ED visit was not reduced. While requiring replication with rigorous methods, preliminary results suggest a home-based PM practice may reduce hospital utilization for ACI patients.

Inpatient Palliative Care Consultation for Women with Gynecologic Malignancies

Objective: Recommendations to improve end-of-life cancer care include integration of palliative care into standard cancer care. There is limited information regarding palliative care for ethnic and racial minority women with gynecologic malignancies. The purpose of this study was to determine the impact of clinical, socio-demographic, and provider factors on palliative medicineconsultation. Methods: After IRB approval, patients with gynecologic malignancies who received a palliative medicine consultation from January 1, 2008 until June 1, 2010 were identified. Abstracted data included demographics, reason/s for consultation, and outcomes. Results were described and comparison made using Fisher’s Exact Test, Student’s T analysis, and Kaplan-Meier time to event analysis with SPSS software. Results: 84 patients were referred for palliative medicine consultation. Ethnic/racial distribution was Black (37%), White (39%), and Hispanic (16%). The reason/s for consultation included pain (45%), goals of care (46%), and bowel obstruction (4%), dyspnea (4%). Median number of days from the initial consultation until death by Kaplan-Meier time to event analysis, which is a proxy metric for timely consultation was 35 days [Range 0-1005 days].Younger patients (<60) were less likely to be DNR (p=0.03, 60% verses 79.5%) or referred to hospice (p=0.02, 9% versus 33%). “Goals of care” was the consultation reason in 61% of patients of medical sub-specialists vs. 26% of Gynecologic Oncologists (p=0.003). 28% of patients from medical sub-specialists died in the hospital verses 8% of gynecologic oncologist referred patients (p=0.02). Conclusions: These data suggest that there may be barriers to the implementation of palliative medicine for women with gynecologic malignancies. Providers may be influenced by patient age as well as their own specialty background. Reasons for the barriers to access in these women need to be further explored.

The Use of Skype in a Community Hospital Inpatient Palliative Medicine Consultation Service

Skype™, an Internet-based communication tool, has enhanced communication under numerous circumstances. As telemedicine continues to be an increasing part of medical practice, there will be more opportunities to use Skype and similar tools. Numerous scenarios in the lay literature have helped to highlight the potential uses. Although most commonly used to enhance physician-to-patient communication, there has been limited reported use of Skype for patient-to-family communication, especially in end of life and palliative care. Our inpatient Palliative Medicine Consultation Service has offered and used this technology to enhance our patients' quality of life. The objective was to provide another tool for our patients to use to communicate with family and/or friends, especially under circumstances in which clinical symptoms, functional status, financial concerns, or geographic limitations preclude in-person face-to face communication.

The Effects of the Palliative Medicine Consultation on the DNR Status of African Americans in a Safety-Net Hospital

To examine the effectiveness of palliative medicine consultation on completion of advance directives/do-not-resuscitate (DNR) orders by racial/ethnic minorities. A sample of 1999 seriously ill African American and Hispanic inpatients was obtained from the Palliative Medicine Consultation database (n = 2972). Associations between race/ethnicity and diagnosis and documentation of DNR status on admission and discharge were examined. Cancer was the primary diagnosis, 34.5%. Among patients with a consultation, 98% agreed to discuss advance directives; 65% of African Americans and 70% of Hispanics elected DNR status. Inpatient deaths were 46%; 74% of decedents agreed to DNR orders. Discharged patients referred to hospice were 29%. Palliative medicine consultations resulted in timely completion of DNR orders and were positively associated with DNR election and hospice enrollment.

The primary care palliative care programme in Auckland, New Zealand: an update

The PCPCP has been implemented amongst GP teams in Procare, a Primary Health Organisation (PHO) in Auckland, New Zealand. Implementation began two years ago and in that time 412 patients...