Specialist-level Palliative Care Research Articles

Key factors for establishing and sustaining a successful palliative radiation oncology program: a survey of the Society for Palliative Radiation Oncology.

Dedicated palliative radiation oncology programs (PROPs) within radiation oncology (RO) practices have been shown to improve quality and decrease costs of radiation therapy (RT) in advanced cancer patients. Despite this, relatively few PROPs currently exist, highlighting an unmet need to understand characteristics of the few existing PROPs and the potential barriers and facilitators that exist in starting and maintaining a successful PROP. We sought to assess the attributes of existing PROPs, the facilitators and barriers to establishing these programs, and the resources needed to create and maintain a successful program. A 15-item online survey was sent to 157 members of the Society of Palliative Radiation Oncology (SPRO) in July 2019. Of the 157 members, 48 (31%) responded. Most practiced in an academic center (71% at main center and 15% at satellite) and 75% were from a larger group practice (≥6 physicians). Most (89%) believed the development and growth of a dedicated PROPs was either important (50%) or most important (39%) to the field of RO. Only 36% of respondents had a PROP, 38% wanted to establish one, and 13% were currently developing one. Of those with PROPs (N=16), 75% perceived an increase in the number of referrals for palliative RT since starting the program. A majority had an ability to refer to an outside palliative care specialist (64%), an outpatient RO service (53%), and specialized clinical processes for managing palliative radiotherapy patients (53%), with 41% having an inpatient RO consult service. Resources considered most essential were access to specialist-level palliative care, advanced practice provider support, a radiation oncologist with an interest in palliative care, having an outpatient palliative RO clinic, an emphasis on administering short radiation courses, and opportunities for educational development. Of those with a PROP or those who have tried to start one, the greatest perceived barriers to initiating a PROP were committed resources (83%), blocked out clinical time (61%), challenges coordinating management of patients (61%), and support from leaders/colleagues (61%). Perceived barriers to sustaining a PROP were similar. For those without a PROP, the perceived most important resources for starting one included access to palliative care specialist by referral (83%), published guidelines with best practices (80%), educational materials for referring physicians and patients (80%), educational sessions for clinical staff (83%), and standardized clinical pathways (80%). PROPs are not widespread, exist mainly within academic centers, are outpatient, have access to palliative care specialists by referral, and have specialized clinical processes for palliative radiation patients. Lack of committed resources was the single most important perceived barrier for initiating or maintaining a PROP. Best practice guidelines, educational resources, access to palliative care specialists and standardized pathways are most important for those who wish to develop a PROP. These insights can inform discussions and help align resources to develop, grow, and maintain a successful PROP.

Are We Consulting, Sharing Care, or Taking Over? A Conceptual Framework.

Primary- and specialist-level palliative care services are needed. They should work collaboratively and synergistically. Although several service models have been described, these remain open to different interpretations and deployment. This article describes a conceptual framework, the Consultation-Shared Care-Takeover (C-S-T) Framework, its evolution and its applications. An iterative process informed the development of the Framework. This included a symposium, literature searches, results from three studies, and real-life applications. The C-S-T Framework represents a spectrum anchored by the Consultation model at one end, the Takeover model at the other end, and the Shared Care model in the center. Indicators, divided into five domains, help differentiate one model from the other. The domains are (1) Scope (What aspects of care are addressed by the palliative care clinician?); (2) Prescriber (Who prescribes the treatments?); (3) Communication (What communication occurs between the palliative care clinician and the patient's attending clinician?); (4) Follow-up (Who provides the follow-up visits and what is their frequency?); and (5) Most responsible practitioner (MRP) (Who is identified as MRP?). Each model demonstrates strengths, limitations, uses, and roles. The C-S-T Framework can be used to better describe, understand, assess, and monitor models being used by specialist palliative care teams in their interactions with primary care providers and other specialist services. Large studies are needed to test the application of the Framework on a broader scale in health care systems.

Trends in Palliative Care Utilization in Deceased Veterans With Heart Failure.

Specialist-level palliative care in the final days does not allow time to alleviate symptoms and suffering. This analysis examined the change in the time from initial specialty-level palliative care to death among Veterans with heart failure. This retrospective cohort study examined Veterans with a diagnosis of heart failure (HF) who died between 2011 and 2021. We examined the decedents from each year as a separate cohort. The primary outcome was time from specialty-level palliative care (SPC) encounter to death in the year death occurred. Of the cohort (n = 232,079), 56.5% did not receive SPC. Specialist-level palliative care >90 days before death more than doubled from 10.1% (2011) to 26.2% (2021), and Specialist-level palliative care in the last day of life was cut from 2.5% to 0.9%. For Veterans with HF, specialist-level palliative care moved earlier in the disease course and has a substantial growth opportunity.

Increasing Goals-of-Care Documentation and its Impact on < 30 Days Readmissions for Patients with Medicare Fee-for-Service: Does Specialist-Level Palliative Care Matter? (QI114)

Increasing Goals-of-Care Documentation and its Impact on < 30 Days Readmissions for Patients with Medicare Fee-for-Service: Does Specialist-Level Palliative Care Matter? (QI114)

A Retrospective Study Analyzing a Palliative Care-Hospital Medicine Collaboration to Improve Quality of Care of Patients With Advanced Illness.

Palliative care seeks to improve outcomes for patients with advanced illness (AI). Advocacy exists for making it part of mainstream care for hospitalized patients with AI. To determine if a partnership between hospital-medicine and specialized palliative care would increase identification of AI patients with palliative care needs requiring palliative consultation. Secondary outcomes: Decreasing 30-day readmission, length of stay (LOS) and pain scores, increasing documentation reflecting goals and advanced care planning. Retrospective chart review of patients with AI admitted to a hospitalist-resident run unit divided into Care Models, "A" and "B," and analyzed over two ten-month periods, "1" and "2." Triggers for palliative needs were provided for "A." During biweekly rounding, needs were assessed and generalist vs. specialist level palliative care concepts were used for consultation. Quaternary-level teaching center in the New York Metropolitan area. 3,395 AI patients were analyzed, 1,707 from "1," and 1,688 from "2." Comparing care models and time frames, palliative care consultation increased in "A" (P-value = .0013, P-value = .0005). When investigating "A" in "1" to "2," CMI was higher. Comparing "B" between "1" and "2," found older age and lower LACE. When adjusting for confounders (LACE and CMI), our models did not show a difference. Data on discharge disposition was significant for subacute rehab but not for mortality. There were no differences between care models and time-periods for secondary outcomes. Our study demonstrated the demand for palliative care services integrated into hospital medicine and highlighted areas of focus for future studies.

Palliative care physicians’ motivations for models of practicing in the community: A qualitative descriptive study

Background: Internationally, both primary care providers and palliative care specialists are required to address palliative care needs of our communities. Clarity on the roles of primary and specialist-level palliative care providers is needed in order to improve access to care. This study examines how community-based palliative care physicians apply their roles as palliative care specialists, what motivates them, and the impact that has on how they practice. Design: A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care specialists. We asked participants to describe their care processes and the factors that influence how they work. Setting/participants: A qualitative descriptive study using semi-structured virtual interviews of community-based palliative care physicians in Ontario, Canada was undertaken between March and June 2020. At interview end, participants indicated whether their practice approaches aligned with one or more models depicted in a conceptual framework that includes consultation (specialist provides recommendations to the family physician) and takeover (palliative care physician takes over all care responsibility from the family physician) models. Results: Of the 14 participants, 4 worked in a consultation model, 8 in a takeover model, and 2 were transitioning to a consultation model. Different motivators were found for the two practice models. In the takeover model, palliative care physicians were primarily motivated by their relationships with patients. In the consultation model, palliative care physicians were primarily motivated by their relationships with primary care. These differing motivations corresponded to differences in the day-to-day processes and outcomes of care. Conclusions: The physician’s personal or internal motivators were drivers in their practice style of takeover versus consultative palliative care models. Awareness of these motivations can aid our understanding of current models of care and help inform strategies to enhance consultative palliative care models.

Primary and Specialist-Level Palliative Care during the spring 2020 COVID-19 Surge: A Single-Center Experience in the Bronx.

Introduction:The COVID-19 pandemic surge necessitated a rapid increase in provision of goals of care communication for patients with respiratory failure and high risk of death. We aimed to describe the outcomes and incidence of code status changes for mechanically ventilated patients in an acute care hospital after deploying strategies to enhance primary palliative care, including provision of goals of care communication scripts to front-line physicians.Methods:This is a retrospective cohort study including all patients admitted with COVID-19 disease and requiring mechanical ventilation during a 2-week period in March and April of 2020.Results:Of the 440 total patients, 327 (74.3%) died. 162 patients received a documented attempt at cardiopulmonary resuscitation (CPR) and only 4 (2.5%) of them survived. No patient above the age of 64 survived a CPR attempt. On admission, 404 patients (92.8%) were Full Code. 165 patients (37.5%) had a code status change. Almost half of the patients (n = 219) had a palliative care consult. Patients with a palliative care consult were more likely to have a code status change (56.6% v. 18.6%, χ2 = 68.0, p < 0.01).Discussion:Mechanically ventilated patients had a high mortality, and CPR did not result in survival to discharge in patients over 65. Palliative care specialists are needed to guide goals of care discussions during the COVID-19 pandemic, as there are numerous barriers to equipping primary care teams to lead such discussions. The COVID-19 pandemic has underscored the vital role of palliative care in disaster response.

The Creation of a Psychiatry-Palliative Care Liaison Team: Using Psychiatrists to Extend Palliative Care Delivery and Access During the COVID-19 Crisis

ContextDuring the course of March and April 2020, New York City experienced a surge of a 170,000 coronavirus disease 2019 (COVID-19) cases, overwhelming hospital systems and leading to an unprecedented need for palliative care services. ObjectivesTo present a model for rapid palliative care workforce expansion under crisis conditions, using supervised advanced psychiatry trainees to provide primary palliative services in the acute care and emergency setting. MethodsIn response to the New York City COVID-19 surge, advanced psychiatry trainees at New York-Presbyterian Columbia University Irving Medical Center were rapidly trained and redeployed to a newly formed psychiatry-palliative care liaison team. Under the supervision of consultation-liaison psychiatrists (who also served as team coordinators), these trainees provided circumscribed palliative care services to patients and/or their families, including goals-of-care discussions and psychosocial support. Palliative care attendings remained available to all team members for more advanced and specialized supervision. ResultsThe psychiatry-palliative care liaison team effectively provided palliative care services during the early phase and peak of New York City's COVID-19 crisis, managing up to 16 new cases per day and provided longitudinal follow-up, thereby enabling palliative care specialists to focus on providing services requiring specialist-level palliative care expertise. ConclusionBy training and supervising psychiatrists and advanced psychiatry trainees in specific palliative care roles, palliative care teams could more effectively meet markedly increased service needs of varying complexity during the COVID-19 crisis. As new geographic regions experience possible COVID-19 surges in the coming months, this may serve as a model for rapidly increasing palliative care workforce.

Gaps in Provision of Primary and Specialty Palliative Care in the Acute Care Setting by Race and Ethnicity

ContextPrevious research has identified a large unmet need in provision of specialist-level palliative care services in the hospital. How much of this gap is filled by primary palliative care provided by generalists or nonpalliative specialists has not been quantified. Estimates of racial and ethnic disparities have been inconsistent. ObjectivesThe objective of this study was to 1) estimate primary and specialty palliative care delivery and to measure unmet needs in the inpatient setting and 2) explore racial and ethnic disparities in palliative care delivery. MethodsThis was a cross-sectional, retrospective study of 55,658 adult admissions to two acute care hospitals in the Bronx in 2013. Patients with palliative care needs were identified by criteria adapted from the literature. The primary outcomes were delivery of primary and specialist-level palliative care. ResultsIn all, 18.5% of admissions met criteria for needing palliative care. Of those, 18% received specialist-level palliative care, an estimated 30% received primary palliative care, and 37% had no evidence of palliative care or advance care planning. Black and Hispanic patients were not less likely to receive specialist-level palliative care (adjusted odds ratio [OR] black patients = 1.18, 95% CI 0.98, 1.42; adjusted OR Hispanic patients = 1.24, 95% CI 1.04, 1.48), but they were less likely to receive primary palliative care (adjusted OR black patients = 0.41, 95% CI 0.20, 0.84; adjusted OR Hispanic patients = 0.48, 95% CI 0.25, 0.94). ConclusionEven when considering primary and specialty palliative care, hospitalized patients have a high prevalence of unmet palliative care need. Further research is needed understand racial and ethnic disparities in palliative care delivery.

Integrating contemplative and spiritual care in outpatient palliative care: A pilot study.

247 Background: Spiritual support is associated with better outcomes in cancer care and at the end of life (1, 2). Consensus guidelines advocate for incorporating spiritual care in the provision of specialist level palliative care (3). Contemplative care practices and chaplaincy interventions have the potential for mitigating existential distress, cultivating prognostic awareness, and fostering spiritual approaches to grieving and coping with advanced cancer. We present the results of a pilot program demonstrating the feasibility and impact of integrating a contemplative care chaplain in an outpatient palliative care program in a culturally diverse patient population in a large, academic cancer center. Methods: Case series and descriptive analysis. A description of 10 cases seen by a contemplative care chaplain in our outpatient palliative care clinic in the Herbert Irving Comprehensive Cancer Center (HICCC) at Columbia University will be presented. A descriptive analysis using a chaplaincy-centered model of assessment will highlight the domains of suffering and subjective integration of psychosocial and spiritual concepts. Results: Patients were generally in favor of meeting with and sharing their feelings openly with the chaplain. Patients’ describe important domains pertinent to their well being: meaning, family integration, spiritual practices, existential concerns, prognostic awareness. Subjective transformation and integration of the following constructs: “healing,” “gratitude,” “anger,” “hope,” “fear” were possible with only a few patient encounters. None of the patients were opposed to an initial visit and assessment. In only one case, the family requested not having further visits due to strong emotional reactions that came up. Conclusions: Preliminary results from a novel, pilot program integrating contemplative and spiritual care in an outpatient palliative care program suggest that it is a feasible intervention and should be considered in other cancer centers. Further studies will need to qualify and quantify the additional value and impact of spiritual care integrated in ambulatory palliative care services.

Hospice Enrollment After Referral to Community-Based, Specialist-Level Palliative Care: Incidence, Timing, and Predictors

ContextReferral to community-based palliative care may increase the likelihood of hospice enrollment. ObjectivesThis retrospective cohort study evaluated the incidence, timing, and predictors of hospice enrollment after referral to a community-based palliative care program. MethodsData from 1505 homebound patients referred to community-based palliative care during 2010–2013 were analyzed using multivariate linear and logistic regression. ResultsMean (SD) age was 70.4 (16.7) years; 58.8% were women, and race/ethnicity was diverse (white 32.9%, black 29.8%, Hispanic 28.6%, Asian 5.4%). Patients received palliative care services for a mean (SD) of 10.2 (10.2) months (median 6.9; range 0.03–52.2 months). A total of 362 patients (24.1%) were enrolled in hospice after receiving palliative care services for a mean (SD) of 4.8 (6.8) months (median 7.9; range 0.09–25.7 months). The median hospice length of stay was approximately twice as long as other patients enrolled in hospice during the same period. The probability of hospice enrollment increased with shorter duration of palliative care, cancer diagnosis, poorer performance status, and a lower likelihood of poverty. Similarly, significant predictors of a shorter duration of palliative care services before hospice enrollment included both sociodemographic and clinical factors. ConclusionAlmost one-quarter of patients were enrolled in hospice while receiving community-based palliative care, and hospice length of stay was relatively long for those who did. Both sociodemographic and clinical characteristics were associated with hospice-related outcomes. Studies are needed to further explore predictors and outcomes of hospice enrollment from palliative care.

Hospice Admission Following Community-Based, Specialist-Level Palliative Care: Incidence, Timing and Predictors (S716)

•Understand the rate of hospice conversion during long-term interdisciplinary, community-based palliative care, and describe the sociodemographic and clinical factors that predict this conversion.•Understand sociodemographic and clinical factors that may predict hospice referral timing after community-based, specialist-level palliative care using statistical evidence. Community-based palliative care is emerging to support seriously ill homebound patients. Timely referral to hospice is a key objective. Interdisciplinary palliative care models may provide repeated opportunities to facilitate appropriate hospice admission. We conducted a retrospective cohort analysis of a large sample to explore hospice utilization after enrollment in one such model. To evaluate the incidence and timing of hospice conversion after enrollment in a palliative care program. Patients (n=1505) were enrolled during 2010-2013 in a community-based, ‘high-touch’ model of specialist palliative care that included home visits by an MD/NP and social worker, telephonic outreach by an RN specialist, and access to 24/7 on-call care. Data entered into an electronic medical record at the time of service were extracted for this analysis. Outcomes included hospice admission (yes/no) and duration of palliative care enrollment, and covariates included sociodemographics, diagnosis, Karnofsky Performance Status (KPS), referral source, and insurance status. The sample had a mean age of 71.6 years (SD=14.5) and was 58.7% women, 32.9% White, 29.8% Black, and 28.5% Hispanic. The mean length of stay (LOS) in the palliative care program was 310 days; median was 210 (range 1-1589). A total of 334 patients (22.2%) were admitted to hospice. In multivariate analysis, predictors of hospice admission were shorter LOS in palliative care (p<0.001), cancer diagnosis (p<0.001), lower KPS (p<0.001), and lower poverty level (p=0.03). The only significant predictor of a longer LOS was higher KPS (p<0.01). During months of care by a ‘high-touch’ palliative care model, about one-fifth of patients were admitted to hospice, and relevant predictors of this outcome included cancer diagnosis, lower performance status, and higher socioeconomic status.

The Serendipitous Survey: A Look at Primary and Specialist Palliative Social Work Practice, Preparation, and Competence.

Health professionals have begun to identify competencies needed for primary and specialist levels of palliative care practice, but little attention has been given to how these skills are acquired. The authors electronically surveyed a wide range of health social workers and educators to investigate their reported levels of preparation, training, and self-assessed competence to provide palliative and end-of-life care. Two health social work surveys were developed: one for educators and one for practitioners and students. The study used an electronic snowball sampling method with eight national social work listservs to capture a wide range of settings where health social workers may teach or practice. The survey was completed by 1149 self-identified health care social workers, 35% of whom identified as a specialist in palliative care. Health social work clinicians report competence in many skills related to palliative care and the psychosocial determinants of health, having developed these skills primarily through interprofessional and peer collaboration. A representative sample of social workers practicing in health care identify high competence in essential aspects of palliative care. This speaks to an existing pool of clinicians who, if practicing to the top of their licenses, have the potential to provide primary palliative care and contribute to the person-family centered care called for in the Institute of Medicine (IOM) report. Few programs exist to prepare social workers to work as specialists in palliative or end-of-life settings, and respondents identified key areas of practice that need to be integrated into graduate education to ensure that students, practitioners, and educators are better prepared to maximize the impact of health social work. Further research is needed to better understand how to prepare and train specialist-level palliative care social workers.

Unrelieved Pain and Suffering in Patients With Advanced Cancer

Even with specialist-level palliative care, cancer pain can be difficult to treat especially when the pain is complicated by profound suffering. It is paramount to consider not only the patients' biochemical factors but also their psychosocial and spiritual/existential influences. A multidimensional approach with knowledge of the risk factors for poor pain control is important to prevent, detect, and manage risk factors for intractable pain, including psychosocial distress, addictive behavior, and delirium in patients with terminal cancer. We present 3 cases of patients with advanced cancer with intractable bone pain whose hospital courses were complicated by severe psychosocial distress and delirium. We also propose an algorithm of multidimensional approach to unrelieved pain and suffering in patients with advanced cancer.

Nurse Practitioner-Based Models of Specialist Palliative Care at Home: Sustainability and Evaluation of Feasibility

Patients with serious medical problems who live at home may not be able to access specialist-level palliative care when the need develops. Nurse practitioner (NP)-based models may be able to increase the availability of specialist care in the community. The aim of this study was to evaluate the financial sustainability and feasibility of two NP-based models in an urban setting. In one model, an NP was linked with a social worker (SW) to create a new palliative home care team (PHCT-NP-SW), which would provide consultation and direct care to referred homebound elderly patients with advanced illnesses. In a second model, an NP was assigned to a hospice program (Hospice-NP) for the purpose of enhancing the reach and impact of a home care team. The revenue generated by each model was compared with direct costs; the PHCT-NP-SW model also was evaluated for its feasibility and impact on patient-level outcomes. Over a two-year period, the NP in the PHCT-NP-SW model made 350 visits and followed 114 patients at home. Annualized revenue through reimbursement from patient billing offset less than 50% of the NP's salary costs. In contrast, the Hospice-NP model led to a 360% increment in hospice referrals, yielding sufficient new revenue to support this position indefinitely after only seven months. The PHCT-NP-SW model provided numerous interventions that yielded a significant decline in symptom distress during the initial two weeks after referral (P=0.003), 100% compliance with advance care planning, 21% admission rate to hospice, access to other community services, and crisis management. Nonetheless, lack of funding led to closure of this model after the two years. This experience suggests that a PHCT-NP-SW model is not sustainable in this urban environment through reimbursement-based revenue, whereas a Hospice-NP model for hospice can be sustainable based on the growth of hospice census. The PHCT-NP-SW model appears to offer benefits, and additional efforts are needed to establish the funding mechanisms to sustain such programs, create mixed models of hospice and nonhospice funding, or provide a basis for sustainability through cost reduction.