Practice Of Palliative Medicine Research Articles

#1377 Evaluation of state-wide health system implementation of renal supportive care shows substantial net benefits

Abstract Background and Aims In 2016, the New South Wales (NSW) Health system implemented a service to make the principles and practice of palliative medicine comprehensively available to patients receiving chronic kidney disease (CKD) care across NSW. Summative evaluation of the economic value that this multi-disciplinary State-wide RSC service provided following implementation was prospectively planned in the domains of patient experience and economic value. This abstract reports the first cost-benefit analysis of a RSC service. Method De-identified patient-level data was extracted from the NSW Renal Supportive Care Register (a linked dataset comprising admitted patient, non-admitted patient, emergency department episodes and death registrations). Data was compared between 2015/16, prior to implementation of the State-wide RSC service; and 2018/19, following settled operation of the service. A cost-benefit analysis model was constructed to estimate the economic value of the RSC service between 2015/16 and 2018/19; and the projected value to 2029/30 under different scenarios. Multivariate Cox regressions were estimated to measure survival benefits, and a polynomial regression model was employed to estimate the impact of RSC on the share of patients receiving dialysis. Results Considering the actual impact of the NSW RSC service; in 2015/16, 5% (n = 443) of all ESKD patients, (defined as receiving dialysis >3 months, non-dialysis conservative care or in receipt of a functioning transplant) received any RSC service. By 2018/19, 16% (n = 1460) of all ESKD patients had received RSC within NSW. The proportion of patients receiving RSC from a non-dialysis conservative care or dialysis context remained stable between 2015/16 and 2018/19 at 41% and 29% respectively. Patients receiving RSC were estimated to have increased survival by 3-21 weeks, depending on patient characteristics, compared to the scenario of no RSC service. Considering the projected value of ongoing RSC services; scenarios with different assumptions were modelled. Assuming that the proportion of patients receiving different ESKD modalities and the costs of care remained stable, the RSC service would deliver a net financial benefit to the commissioning health system (avoided costs of service minus RSC costs) of ${\$}$109 million Australian Dollars (AUD), with a return on investment of 212%, compared to the scenario of no RSC service. When the economic value for the whole NSW community from increased survival benefit was included, the projected value was ${\$}$275 million AUD, with return on investment of 535%. The projected economic value of RSC was modelled under scenarios of increasing access to the service by ESKD patients (Figure). Increasing RSC access from the achieved 16% to 20% of ESKD patients was projected to deliver maximal economic value, with a 3% fall in ESKD patients receiving dialysis, increasing survival benefit (${\$}$221 million AUD) and economic value ${\$}$94 million AUD. As access to RSC expands further, modelling indicates that additional dialysis substitution becomes less likely but benefits still accrue from survival up to a maximum viable rollout of 50% of the ESKD population receiving RSC, when survival benefits plateau. Conclusion Economic evaluation of this implementation of the Statewide RSC service across NSW Health shows it has been associated with both a net economic benefit and survival benefits four years after implementation. It is projected to provide an economic value of ${\$}$275 million AUD over ten years, which would increase with greater participation of ESKD patients suitable for RSC.

Palliative medicine from deontology

Palliative medicine is the medicine that accompanies the person in their process of dying for alleviate their unwanted suffering, is a medicine that offers comfort care to the patient and his family, a medicine that does not prolong life unnecessarily at the expense of suffering, but rather it widens it, it is a medicine that takes care of life. Medical deontology tells us how our good medical practice through the rules contained in the Code of Ethics. In this article I address the practice of palliative medicine taking into account medical deontology, focusing on two issues that generate controversy such as palliative sedation and euthanasia. I consider that the good practice of palliative medicine consists, not in intentionally causing the death of the patient, but neither in unnecessarily prolong his agony, but to alleviate his suffering until death comes.

Primary palliative care for surgeons: a narrative review and synthesis of core competencies.

The practice of palliative medicine has grown substantially over the last two decades and the data demonstrates that seriously ill and injured surgical patients as well as their loved one's benefit from the integration of palliative care into standard surgical management. This narrative review highlights the patient and family benefit of primary surgical palliative care (PSPC) for seriously ill or injured surgical patients and the need for primary palliative care (PPC) skill acquisition by surgeons. The review encourages surgeons to identify all aspects of suffering as a critical component of the care needs of surgical patients and families and to consider integrating mitigation strategies during surgical care. Identification of suffering has not been traditionally taught in surgical training or reinforced in surgical practice, therefore current surgical educational opportunities should incorporate such instruction to assist surgeons in training and in practice to acknowledge and treat suffering to improve and expand the quality and value of surgical care offered to seriously ill or injured surgical patients. Additionally, a patient-centered approach to surgical care necessitates engaging advanced communication skills to successfully ascertain a patient's and/or their surrogate decision maker's, substituted goals and values in the provision of surgical care to ensure that all the care delivered is aligned with each patient's preferences. A preliminary synthesis of core competencies to achieve these SPC objectives is presented.

Palliative medicine in intensive care unit during a pandemic.

The coronavirus disease-2019 (COVID-19) or severe acute respiratory distress syndrome coronavirus 2 (SARS-CoV-2) pandemic has changed the landscape of medical care. Efforts made to limit the spread of the deadly disease have impacted the specialty of palliative medicine in ways that could not have been completely predicted or appreciated. The consequences of these changes have been most evident in the care of COVID-19 patients and families within the intensive care unit. The policies meant to keep staff, patients, and families safe, greatly changed the way that palliative medicine could be provided. This article provides a more in-depth look at how the practice of palliative medicine adapted to such difficult and constantly changing times, particularly in aspects of family meetings, communication, paternalism, managing emotions, death, and grief. Despite the ongoing challenges presented by this virus, the specialty of palliative medicine may be well suited to adapt and flourish.

Translating Evidenced-Based Guidelines into Clinical Practice using Goal Setting and Palliative Program Dashboards (GP772)

• State sources of evidence-based palliative care guidelines• Describe methods of determining appropriate quality measures for individual practice• State potential outcomes/benefits of utilizing dashboards for guideline implementation. Palliative medicine practice is increasingly informed by evidence from clinical trials performed in academic medical centers. This evidence informs national practice guidelines, such as the National Consensus Project (NCP) and American Society of Clinical Oncology, aimed at improving quality of patient care. Translating these evidence-based guidelines into clinical practice is difficult due to resource limitations and lack of established models of palliative care delivery. This leads to gaps between published guidelines and clinical practice, particularly in the community setting. 1. State sources of palliative care guidelines 2. Describe methods of determining appropriate quality measures for individual practice 3. State potential outcomes/benefits of utilizing dashboards for guideline implementation Two palliative care programs, one academic and one community-based, translated guidelines into practice using interdisciplinary goal setting and creation of palliative care dashboards.The programs compared their practice to national guidelines to identify opportunities for improvement. Goals identified included implementation of opioid risk assessment, chemotherapy at end of life, 30-day readmissions, and frequency of palliative consultation for patients with advanced lung cancer. The outpatient Penn Medicine Lancaster General Health program, providing primarily Palliative Care in Oncology, used program dashboards to measure and encourage progress on identified goals, resulting in >50% improvement in measures such as palliative consultation for advanced cancers. Penn State Health Palliative Care implemented dashboard goals informed by NCP guidelines including psychosocial support and advance care planning completion. This led to >60% improvement in measured outcomes during the first year of implementation. Goal setting and creation of program dashboards can facilitate application of palliative guidelines.

Feasibility and Acceptability of Inpatient Palliative Care E-Family Meetings During COVID-19 Pandemic

Family meetings are fundamental to the practice of palliative medicine and serve as a cornerstone of intervention on the inpatient palliative care consultation service. The COVID-19 pandemic disrupted the structure and process of in-patient family meetings, owing to necessary but restrictive visitor policies that did not allow families to be present in the hospital. We describe implementation of telemedicine to facilitate electronic family (e-family) meetings to facilitate in-patient palliative care. Of 67 scheduled meetings performed by the palliative care service, only two meetings were aborted for a 97% success rate of scheduled meetings occurring. On a five-point Likert-type scale, the average clinician rating of the e-family meeting overall quality was 3.18 (SD, .96). Of the 10 unique family participants who agreed to be interviewed, their overall ratings of the e-family meetings were high. Over 80% of respondent families participants reported that they agreed or strongly agreed that they were able to ask all of their questions, felt comfortable expressing their thoughts and feelings with the clinical team, felt like they understood the care their loved one received, and that the virtual family meeting helped them trust the clinical team. Of patients who were able to communicate, 50% of family respondents reported that the e-family meeting helped them understand their loved one's thoughts and wishes.

Tetrahydrocannabinol and Cannabidiol Use in an Outpatient Palliative Medicine Population.

Palliative medicine physicians are challenged by lack of guidance regarding effectiveness and dosing of cannabis products in the setting of their emerging popularity. The aim of this study was to describe early patterns of tetrahydrocannabinol (THC) and cannabidiol (CBD) use in Florida following passage of the state's first medical marijuana law. We describe here the perceived benefits, side effects, and beliefs expressed by patients in a single outpatient academic palliative medicine practice. A cross-sectional survey was performed of a sequential convenience sample of patients who presented to an outpatient academic palliative medicine clinic over a 3-month period. In all, 24% (14/58) of respondents reported THC use, with half using THC on a daily basis. Patients reported improvements in pain, appetite, and nausea. In all, 71% (10/14) began using THC after the diagnosis of their chronic illness, and the most common form of usage was vaping. In all, 24% (14/58) of patients reported CBD use. Patients reported improvements in pain, and the most common form of usage was topical application. None of the patients had used CBD prior to the onset of their chronic illness. In all, 21% (3/14) of THC users and 21% (3/14) of CBD users thought that their substance was helping to cure their illness. Individual reported side effects in both groups were minimal. Approximately a quarter of outpatient palliative care patients use THC or CBD, often on a daily basis. Palliative care providers should be aware of the frequency, diverse usage, and beliefs behind cannabis product use in this patient population.

The Practice of Palliative Medicine in Developing Countries—Part Three (SA500)

The Practice of Palliative Medicine in Developing Countries—Part Three (SA500)

The Practice of Palliative Medicine in Developing Countries—Part Two (FR430)

•Learn how physicians in specific countries provide palliative care to their patient populations often with limited resources.•Recognize specific cultural and political challenges to developing palliative care clinical, educational and research programs.•Describe roles of different health care providers practicing palliative care and how they meet the needs of their local populations. Please join AAHPM's International Scholars for a panel discussion. Each scholar will present for 10-15 minutes on the state of the practice of palliative care in their home country, with an emphasis on the roles of physicians, nurses, and other healthcare providers; the status of education and research in the field; and the unique challenges facing patients and providers. There will be time allotted after each presentation to field questions and dialogue from the audience. Prepare to be educated and inspired by these accomplished individuals who are leading and advancing the field of hospice and palliative medicine in their countries of origin.

The Practice of Palliative Medicine in Developing Countries—Part One (TH330)

•Learn how physicians in specific countries provide palliative care to their patient populations often with limited resources.•Recognize specific cultural and political challenges to developing palliative care clinical, educational, and research programs.•Describe roles of different healthcare providers practicing palliative care and how they meet the needs of their local populations. Please join AAHPM's International Scholars for a panel discussion. Each scholar will present for 10–15 minutes on the state of the practice of palliative care in their home country, with an emphasis on the roles of physicians, nurses, and other healthcare providers; the status of education and research in the field; and the unique challenges facing patients and providers. There will be time allotted after each presentation to field questions and dialogue from the audience. Prepare to be educated and inspired by these accomplished individuals who are leading and advancing the field of hospice and palliative medicine in their countries of origin.

The Practice of Palliative Medicine in Developing Countries—Part One (TH330)

•Learn how physicians in specific countries provide palliative care to their patient populations often with limited resources.•Recognize specific cultural and political challenges to developing palliative care clinical, educational and research programs.•Describe roles of different health care providers practicing palliative care and how they meet the needs of their local populations. Please join AAHPM’s International Scholars for a panel discussion. Each scholar will present for 10-15 minutes on the state of the practice of palliative care in their home country, with an emphasis on the roles of physicians, nurses, and other healthcare providers; the status of education and research in the field; and the unique challenges facing patients and providers. There will be time allotted after each presentation to field questions and dialogue from the audience. Prepare to be educated and inspired by these accomplished individuals who are leading and advancing the field of hospice and palliative medicine in their countries of origin.

The Practice of Palliative Medicine in Developing Countries—Part One (SA500)

•Learn how physicians in specific countries provide palliative care to their patient populations often with limited resources.•Recognize specific cultural and political challenges to developing palliative care clinical, educational and research programs.•Describe roles of different health care providers practicing palliative care and how they meet the needs of their local populations. Please join AAHPM’s International Scholars for a panel discussion. Each scholar will present for 10-15 minutes on the state of the practice of palliative care in their home country, with an emphasis on the roles of physicians, nurses, and other healthcare providers; the status of education and research in the field; and the unique challenges facing patients and providers. There will be time allotted after each presentation to field questions and dialogue from the audience. Prepare to be educated and inspired by these accomplished individuals who are leading and advancing the field of hospice and palliative medicine in their countries of origin.

The Practice of Palliative Medicine in Developing Countries—Part One (FR430)

The Practice of Palliative Medicine in Developing Countries—Part One (FR430)

Building a Supportive Oncology Practice that Impacts Emergency Department Visits, Hospice Utilization, and Hospital Admission.

Palliative care remains underutilized despite evidence supporting its value. Multiple professional organizations have endorsed broader and earlier access to palliative care, yet barriers exist that impede successful implementation of palliative care. We report on development of an ambulatory palliative medicine practice (Supportive Oncology) embedded within an academic cancer center. An incremental strategy was used to ensure the sustainability of the practice. A needs assessment of oncologists gauged perceptions of unmet patient needs, attitudes toward palliative care, reasons for referrals, and vision of a relationship with palliative care. Clinical outcomes included practice volume, healthcare utilization, and hospice enrollment. Key themes identified included diverse palliative care needs, variable reasons for referral, and lack of consensus on palliative care's role as a consultant or comanagement model. Supportive oncology visits were associated with a 12% reduction in emergency department visits and a 39% decrease in the cost of each visit. Percentage of hospice enrollment 30 days before death exceeded the national average, and was twice the local average. Providing ambulatory palliative care simultaneously with disease-directed oncologic care improves healthcare value. Despite regional variations in hospital culture and patient populations, the model described here can be adapted in a variety of settings. More research is needed to identify the optimal model of ambulatory palliative care delivery, including type and structure of integration, needs of patients, and level of generalist-level palliative care provided by oncologists.

The Practice of Palliative Medicine in Developing Countries—Part Two (FR430)

The Practice of Palliative Medicine in Developing Countries—Part Two (FR430)

The Practice of Palliative Medicine in Developing Countries—Part Three (SA511)

The Practice of Palliative Medicine in Developing Countries—Part Three (SA511)

The Practice of Palliative Medicine in Developing Countries—Part One (TH330)

The Practice of Palliative Medicine in Developing Countries—Part One (TH330)

The Liverpool Care Pathway: discarded in cancer patients but good enough for dying nursing home patients? A systematic review

BackgroundThe Liverpool Care Pathway (LCP) is an interdisciplinary protocol, aiming to ensure that dying patients receive dignified and individualized treatment and care at the end-of-life. LCP was originally developed in 1997 in the United Kingdom from a model of cancer care successfully established in hospices. It has since been introduced in many countries, including Norway. The method was withdrawn in the UK in 2013. This review investigates whether LCP has been adapted and validated for use in nursing homes and for dying people with dementia.MethodsThis systematic review is based on a systematic literature search of MEDLINE, CINAHL, EMBASE, and Web of Science.ResultsThe search identified 12 studies, but none describing an evidence-based adaption of LCP to nursing home patients and people with dementia. No studies described the LCP implementation procedure, including strategies for discontinuation of medications, procedures for nutrition and hydration, or the testing of such procedures in nursing homes. No effect studies addressing the assessment and treatment of pain and symptoms that include dying nursing home patients and people with dementia are available.ConclusionLCP has not been adapted to nursing home patients and people with dementia. Current evidence, i.e. studies investigating the validity and reliability in clinically relevant settings, is too limited for the LCP procedure to be recommended for the population at hand. There is a need to develop good practice in palliative medicine, Advance Care Planning, and disease-specific recommendations for people with dementia.

The Practice of Palliative Medicine in Developing Countries—Part Two (FR430)

The Practice of Palliative Medicine in Developing Countries—Part Two (FR430)

The Practice of Palliative Medicine in Developing Countries—Part Three (SA511)

The Practice of Palliative Medicine in Developing Countries—Part Three (SA511)