Specialist Palliative Care Referral Research Articles

Specialist Palliative Care Referral Practices Among Oncologists, Cardiologists, Respirologists: A Comparison of National Survey Studies.

Although patients with nonmalignant diseases have palliative care needs similar to those of cancer patients, they are less likely to receive specialist palliative care (SPC). Referral practices of oncologists, cardiologists, and respirologists could provide insight into reasons for this difference. We compared referral practices to SPC among cardiologists, respirologists, and oncologists, discerned from surveys (the Canadian Palliative Cardiology/Respirology/Oncology Surveys). Descriptive comparison of survey studies; multivariable linear regression analysis of association between specialty and referral frequency. Surveys for each specialty were disseminated to physicians across Canada in 2010 (oncologists) and 2018 (cardiologists, respirologists). The combined response rate of the surveys was 60.9% (1568/2574): 603 oncologists,534 cardiologists, and431 respirologists. Perceived availability of SPC services was higher for cancer than for noncancer patients. Oncologists were more likely to make a referral to SPC for a symptomatic patient with a prognosis of <one year. Cardiologists and respirologists were more likely to make a referral to services at a prognosis of <one month; and to refer earlier if palliative care was renamed supportive care.Cardiologists and respirologists had a lower frequency of referrals than oncologists, adjusting for demographic and professional characteristics (P < 0.0001 in both groups). For cardiologists and respirologists in 2018, perceived availability of SPC services was poorer, timing of referral later, and frequency of referral lower than among oncologists in 2010. Further research is needed to identify reasons for differences in referral practices and to develop interventions to overcome them.

CELPI: trial protocol for a randomised controlled trial of a Carer End of Life Planning Intervention in people dying with dementia

BackgroundDementia is a leading cause of death in developed nations. Despite an often distressing and symptom laden end of life, there are systematic barriers to accessing palliative care in older people dying of dementia. Evidence exists that 70% of people living with severe dementia attend an emergency department (ED) in their last year of life. The aim of this trial is to test whether a Carer End of Life Planning Intervention (CELPI), co-designed by consumers, clinicians and content specialists, improves access to end of life care for older people with severe dementia, using an ED visit as a catalyst for recognising unmet needs and specialist palliative care referral where indicated.MethodsA randomised controlled trial (RCT) enrolling at six EDs across three states in Australia will be conducted, enrolling four hundred and forty dyads comprising a person with severe dementia aged ≥ 65 years, and their primary carer.Participants will be randomly allocated to CELPI or the control group. CELPI incorporates a structured carer needs assessment and referral to specialist palliative care services where indicated by patient symptom burden and needs assessment. The primary outcome measure is death of the person with dementia in the carer-nominated preferred location. Secondary outcomes include carer reported quality of life of the person dying of dementia, hospital bed day occupancy in the last 12 months of life, and carer stress. An economic evaluation from the perspective of a health funder will be conducted.DiscussionCELPI seeks to support carers and provide optimal end of life care for the person dying of dementia. This trial will provide high level evidence as to the clinical and cost effectiveness of this intervention.Trial registrationACTRN12622000611729 registered 22/04/2022.

The PaCES (Palliative Care Early and Systematic) Project: Impact of individual components of a multi-faceted intervention on early referral to specialist palliative care.

199 Background: Early referral to specialist palliative care can improve, or maintain, symptom and quality of life outcomes that matter most to patients facing life-limiting illnesses. We tested a multifaceted oncologist-facing intervention (Palliative Care Early and Systematic) in the real-world setting of a busy outpatient cancer clinic for its ability to increase the proportion of patients who receive early specialist palliative care (defined as ≥ 90 days before death). Herein, we describe how each component of the multi-faceted intervention, intended to bridge cancer, primary, and palliative care, impacted early use of specialist palliative care among advanced colorectal cancer patients. Methods: Two intervention components were implemented in Calgary, Alberta, Canada’s tertiary cancer centre from January 2019 to June 2020: 1) Adult colorectal cancer patients were referred to a community-based Clinical Nurse Specialist if they failed, or could not receive, first-line chemotherapy, or had high symptom burden (indicated by an Edmonton Symptom Assessment System Revised score ≥ 7); 2) Medical oncologists sent templated ‘Shared Care’ letters to patients’ primary care providers to improve communication, collaboration and role clarity. Results: N = 209 eligible patients died during the intervention period, of whom 57% experienced early referral to specialist palliative care. The median days from referral to death was 130 (IQR: 53-359). Of the 209, 28 (13%) saw the Clinical Nurse Specialist and received Shared Care letters, and all (100%) had early specialist palliative care referral (median 240 days, IQR: 161-359). 21/209 (10%) saw the Clinical Nurse Specialist but had no Shared Care letter. Of these 21, 76% had early specialist palliative care referral (median 197 days, IQR: 96-251). 43/209 (21%) had a Shared Care letter but no interaction with the Clinical Nurse Specialist. Of these 43, 53% had early specialist palliative care referral (median 102 days, IQR: 53-257). 117/209 (56%) did not interact with the Clinical Nurse Specialist or have a Shared Care letter. Of these 117, 45% had early specialist palliative care referral (median 86 days, IQR: 40-204). Conclusions: The Clinical Nurse Specialist was associated with the greatest increase in early specialist palliative care referral; however, the Clinical Nurse Specialist and Shared Care letters combined were associated with even greater (100%) early specialist palliative care use.

Criteria for Referral of Patients With Advanced Heart Failure for Specialized Palliative Care

BackgroundPatients with advanced heart failure have substantial supportive care needs. Specialist palliative care can be beneficial, but it is unclear who is most appropriate for referral and when patients should be referred. ObjectivesWe conducted a Delphi study of international experts to identify consensus referral criteria for specialist palliative care for patients with advanced heart failure. MethodsClinicians from 5 continents with expertise in the integration of cardiology and palliative care were asked to rate 34 disease-based, 24 needs-based, and 9 time-based criteria over 3 rounds. Consensus was defined a priori as ≥70% agreement. A criterion was coded as major if the experts endorsed that meeting that criterion alone was adequate to justify a referral. ResultsThe response rate was 44 of 46 (96%), 41 of 46 (89%), and 43 of 46 (93%) in the first, second, and third rounds, respectively. Panelists reached consensus on 25 major criteria for specialist palliative care referral. The 25 major criteria were categorized under 6 topics, including “advanced/refractory heart failure, comorbidities, and complications” (eg, cardiac cachexia, cardiorenal syndrome) (n = 8), “advanced heart failure therapies” (eg, chronic inotropes, precardiac transplant) (n = 4), “hospital utilization” (eg, emergency room visits, hospitalization) (n = 2), “prognostic estimate” (n = 1), “symptom burden/distress” (eg, severe physical/emotional/spiritual distress) (n = 6), and “decision making/social support” (eg, goals-of-care discussions) (n = 4). The majority (68%) of major criteria had ≥90% agreement. ConclusionsInternational experts reached consensus on a large number of criteria for referral to specialist palliative care. With further validation, these criteria may be useful for standardizing palliative care access in the inpatient and/or outpatient settings.

The PACES Study: A controlled before and after pragmatic trial of a cancer clinic–based intervention to increase early referral to specialist palliative care.

6501 Background: Early referral to specialist palliative care (SPC) can improve symptom and quality of life outcomes that matter most to cancer patients during the late stage of their illness. We tested a multifaceted oncologist-facing intervention (Palliative Care Early and Systematic) in the real-world setting of a busy cancer clinic for its ability to increase the proportion of patients who receive early SPC (defined as SPC ≥90 days before death). Methods: This is a pragmatic controlled before-and-after study performed in 18 outpatient cancer clinics in two tertiary cancer centers in neighboring metropolitan cities. The control city was chosen to match as closely as possible the intervention city for population size, characteristics, and health services availability. Adults deceased from colorectal cancer (CRC) between April 2017 to December 2020 residing in either the intervention or control city. Decedents who did not visit an oncologist in the year prior to death were excluded as they were unlikely to have received the intervention. Patients who died ≤120 days after diagnosis with CRC were excluded as providers would have had insufficient time to implement the intervention. In the baseline phase (April 2017 to December 2018) patients received usual care. In the intervention phase (April 2019 to December 2020), new clinical practice guidelines and resources were implemented to increase early SPC referrals by oncologists. These changes included: a) systematically screening patients attending treatment clinics for unmet PC needs and alerting the primary oncologist, b) addition of a community-based palliative clinical nurse specialist to handle increased referrals and enhance communication and co-management of patient needs among providers, and c) implementation of templated ‘shared care’ letters (all providers and patient) to improve awareness of patients’ needs. The primary outcome was the proportion of CRC decedents who received early SPC. Results: 695 decedents were included: 341 in the baseline phase (153 control, 188 intervention) and 354 in the intervention phase (145 control, 209 intervention). From baseline to intervention, in the intervention arm, the proportion of decedents who received early SPC increased from 45% to 57%; in the control arm the proportion decreased from 48% to 44% (17% difference in differences; 95%CI -2% to 32%; P=0.03). Conclusions: A multifaceted intervention aimed at increasing oncologists’ awareness of their patients’ appropriateness for early SPC increased by 17% the proportion of patients receiving early SPC as compared to controls. Additional research is needed to determine if in a real-world clinical setting further increasing the proportion of patients receiving early PC beyond 57% is feasible, and to understand the role of screening and alerting for oncologists.

Patients with Congestive Cardiac Failure Referred to Specialist Palliative Care.

Congestive cardiac failure is a chronic, progressive condition with a significant symptom burden. There is limited data available regarding the palliative care requirements of the heart failure population. To characterise patients with a primary diagnosis of congestive cardiac failure referred to a specialist palliative care (SPC) service in Ireland. A retrospective chart review of patients with congestive cardiac failure admitted to the specialist palliative care unit or reviewed by the community palliative care team over 2 years was carried out, utilising a data collection template. 57 patient charts were included. 54% (n = 31) were female. Mean age was 81 [60 - 97] years. GP's referred 42% (n = 24), Cardiologists 39% (n = 22) and other hospital consultants 19% (n = 11). The commonest symptom reported was dyspnoea (n = 47). Time from referral to death ranged from less than one month (n =22) to greater than one year (n = 3). 14 patients were discharged from the service due to lack of SPC needs. Place of death was distributed between home, hospice, nursing home and acute hospital. Patients with congestive cardiac failure experience high symptom burden. More than 50% of patients that died while receiving SPC input had been referred less than 1 month prior, while almost a quarter of all referrals resulted in patient discharge. This highlights the importance of further education regarding indication for specialist palliative care referral and the benefits of early referral in this patient cohort when appropriate.

Palliative radiotherapy delivery by a dedicated multidisciplinary team facilitates early integration of palliative care: A secondary analysis of routinely collected health data

BackgroundEarly integration of Specialist Palliative Care (SPC) with oncological care improves quality of life (QOL) of patients with advanced cancer; however, patients tend to access SPC late in their disease trajectory, if at all. Routine referral of all patients to SPC would quickly overwhelm available resources, suggesting a need for widespread accessibility of generalist PC competencies. This has been increasingly facilitated by dedicated palliative radiotherapy (PRT) clinics, such as the multidisciplinary Palliative Radiation Oncology (PRO) program at the Cross Cancer Institute (CCI). Our objectives were to estimate the proportion of patients dying with breast cancer seen in consultation for PRT, and the interaction between PRT delivery and SPC referral. MethodsThis secondary analysis of routinely collected health data examined female adults with breast cancer who died between 04/01/2013 and 03/31/2014, and had advanced disease while under the care of a CCI oncologist. Alberta Cancer Registry, electronic medical records, and Edmonton Zone Palliative Care Program data were linked. During the study period, referrals for SPC, and setting of assessment for PRT, were at the attending physicians’ discretion. Clinical data were abstracted including summaries of intervals between PRT and SPC consultations, as well as from consults to death. Kaplan-Meier survival estimates, independent samples median tests, t tests of proportions, independent t tests and Chi-square tests compared groups. ResultsOf 194 patients, median age at cancer diagnosis was 59 years (range 24-95yrs), median one-way distance from the CCI was 18.8km, and overall median survival (MS) was 4.4 years. 130/194 (67.0%) and 110/194 (56.7%) were assessed for PRT and by SPC respectively; 22/194 (11.3%) saw neither prior to death. Median time between first PRT consultation and death was 11.7 months (interquartile range 3.7-22.2 mos). Median time between first SPC consult and death was 2.9 mos (IQR 1-6.2 mos). 65.6% of those who never had PRT ultimately required SPC involvement, versus 52.3% of those receiving PRT. Of the 68/130 who had both, 91.2% were seen for PRT first, a median of 7.9 mos prior to seeing SPC. Patients who had SPC consultation without previous PRT were seen by PC a median 1.5 mos prior to death (IQR 0.6-4.9 mos). Patients seen for PRT outside of the PRO clinic had SPC consultation a median of 3.3 mos before death (IQR 1.2-6.2 mos), versus those seen by the PRO clinic team, who were referred a median of 6.2 mos prior (IQR 2.4-8.1 mos). ConclusionsFewer advanced breast cancer patients who received PRT ultimately required SPC consultation, but those who did were referred earlier in their disease course, especially if PRT assessment and delivery had taken place in the setting of a dedicated multidisciplinary team.

Assisting People With Their Living, Not Their Dying: Health Professionals' Perspectives of Palliative Care and Opioids in ILD.

Interstitial lung disease (ILD) is a debilitating and life-limiting condition, requiring multi-disciplinary care. While guidelines recommend early specialist palliative care referral to improve symptoms and quality of life, few patients access such care towards the end-of-life. This study aimed to explore clinicians' perspectives regarding specialist palliative care and opioids to understand barriers to optimal care and guide clinical practice improvement initiatives. A cross-sectional, exploratory, qualitative study was undertaken with Australian respiratory clinicians caring for people with ILD (n = 17). In-depth, semi-structured interviews were audio-recorded, transcribed verbatim and coded. Thematic analysis was undertaken to extrapolate recurring ideas from the data. Four themes were identified: 1) understanding how to improve patient care and support, 2) the need to dispel stigmatized beliefs and misconceptions, 3) the importance of trusted relationships and good communication and 4) the challenges of navigating the health-care system. Participants discussed the need to implement early specialist palliative care and symptom palliation to alleviate symptoms, provide emotional support and augment quality of life. Participants described challenges accessing palliative care and opioids due to stigmatized beliefs amongst patients and clinicians and difficulties navigating the health-care system. Trusted therapeutic relationships with patients and strong inter-disciplinary partnerships with collaborative education and communication were perceived to improve patients' access to symptom palliation. Specialist palliative care and opioids were believed to improve patients' quality of life, however, many barriers can make accessing such care challenging. To address these issues, multi-disciplinary collaboration, high-quality communication and trusted therapeutic relationships are crucial throughout the ILD illness journey.

Do screening tools assess palliative care needs and 12-month mortality in patients admitted to hepatology in-patient wards?

BackgroundMany liver patients have unmet palliative care needs, but liver clinicians are unclear whom to refer to specialist palliative care (SPC). The Supportive and Palliative Care Indicator Tool (SPICT) and...

Attitudes and practices towards palliative care in chronic heart failure: a survey of cardiovascular nurses and physicians

Background Heart failure is a chronic condition with various implications for individuals and families. Although the importance of implementing palliative care is recommended in best practice guidelines, implementation strategies are less clear. Aims This study sought to; (1) determine Australian and New Zealand cardiovascular nurses and physicians’ end of life care attitudes and specialist palliative care referral in heart failure and; (2) determine self-reported delivery of supportive care and attitudes towards service names. Methods An electronic survey was emailed to members of four peak bodies and professional networks. Participants were also recruited through social media. Paper-based versions of the survey were completed by attendees of the 66th Cardiac Society of Australia and New Zealand Annual Scientific Meeting, August 2018. Findings There were 113 completed responses included in the analyses. Participants were nurses (n = 75), physicians (n = 32) and allied health professionals (n = 4). Most (67%) reported they were comfortable with providing end of life care; however, fewer respondents agreed they received support for their dying patients and one-third experienced a sense of failure when heart failure progressed. Most (84–100%) participants agreed they would refer a heart failure patient later in the illness trajectory. There was a more favourable attitude towards the service name ‘supportive care’ than to ‘palliative care’. Conclusion Comfort with end of life discussions is encouraging as it may lead to a greater likelihood of planning future care and identifying palliative care needs. Peer support and supervision may be useful for addressing feelings of failure. The use of needs-based assessment tools, adopting the service name ‘supportive care’ and further research focusing on primary palliative team-based approach is required to improve palliative care access. Impact statement Cardiovascular nurses and physicians are comfortable providing end of life care, but referrals to palliative care in the later stages of heart failure persists.

Referral criteria to specialist palliative care for patients with dementia: A systematic review.

Patients with dementia often have significant symptom burden and a progressive course of functional deterioration. Specialist palliative care referral may be helpful, but it is unclear who and when patients should be referred. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with dementia. We searched Ovid MEDLINE, Ovid Embase, Ovid PsycInfo, Cochrane Library, PubMed, and CINAHL databases for articles from inception to December 3, 2019, related to specialist palliative care referral for dementia. Two investigators independently reviewed the citations for inclusion, extracted the referral criteria, and categorized them thematically. Of the 1788 citations, 59 articles were included in the final sample. We identified 13 categories of referral criteria, including 6 disease-based and 7 needs-based criteria. The most commonly discussed criterion was "dementia stage" (n=43, 73%), followed by "new diagnosis of dementia" (n=17, 29%), "medical complications of dementia" (n=12, 20%), "prognosis" (n=11, 19%), and "physical symptoms" (n=11, 19%). Under dementia stage, 37/44 (84%) articles recommended a palliative care referral for advanced dementia. Pneumonia (n=6, 10%), fall/fracture (n=4, 7%), and decubitus ulcers (n=4, 7%) were most commonly discussed complications to trigger a referral. Under prognosis, the time frame for referral varied from <2 years of life expectancy to <6months. 3 (5%) of articles recommended "surprise question" as a potential trigger. This systematic review highlighted the lack of consensus regarding referral criteria for palliative care in patients with dementia and the need to identify timely triggers to standardize referral.

A Multicenter Retrospective Review of Systemic Anti-Cancer Treatment and Palliative Care Provided to Solid Tumor Oncology Patients in the 12 Weeks Preceding Death in Ireland.

Systemic anti-cancer treatment (SACT) can improve symptoms and survival in patients with incurable cancer but there may be harmful consequences. Information regarding the use of SACT at the end-of-life and its impact on patients has not been described in Ireland. The study aimed to quantify and describe the use of SACT at end-of-life. The primary outcome of interest was the number of patients who received treatment in the last 12, 4 and 2 weeks of life. Secondary outcomes included the frequency of admissions and procedures, location of death, and timing of specialist palliative care (SPC) referral. Retrospective review. Fisher exact testing was used for analyses. Patients were included if they died between January 2015 and July 2017 and received at least 1 dose of treatment for a solid tumor malignancy. Five hundred and eighty two patients were included. Three hundred and thirty eight (58%), 128 (22%) and 36 (6%) received treatment in the last 12, 4 and 2 weeks of life respectively. Patients who received chemotherapy in the last 12 weeks of life were more likely to be admitted to hospital, undergo a procedure, and die in hospital than those who did not (P < 0.001 for all). Median time of SPC referral before death was shorter in those patients who received chemotherapy than those who did not (61 v129 days, p = 0.0001). Patients who received chemotherapy had a higher likelihood of hospital admission, invasive procedure, and in-hospital death. They were less likely to have been referred early to SPC services.

Referral Practices of Cardiologists to Specialist Palliative Care in Canada

BackgroundPatients with heart failure have palliative care needs that can be effectively addressed by specialist palliative care (SPC). Despite this, SPC utilization by this patient population is low, suggesting barriers to SPC referral. We sought to determine the referral practices of cardiologists to SPC. MethodsCardiologists across Canada were invited to participate in a survey about their referral practices to SPC. Associations between referral practices and demographic, professional, and attitudinal factors were analyzed using multiple and logistic regression. ResultsThe response rate was 51% (551 of 1082). Between 35.1% and 64.2% of respondents were unaware of referral criteria to local SPC services. Of the respondents, 29% delayed SPC referral because of prognostic uncertainty, and 46.8% believed that SPC prioritizes patients with cancer. In actual practice, nearly three-fourths of cardiologists referred late. Referral frequency was associated with greater availability of SPC services for patients with nonmalignant diseases (P = 0.008), a higher number of palliative care settings accepting patients receiving continuous infusions or pursuing acute care management (P < 0.001), satisfaction with services (P < 0.001), and less equation of palliative care with end-of-life care (P < 0.001). Early timing of referral was associated with greater availability of SPC services for patients with nonmalignant diseases and less equation of palliative care with end-of-life care. ConclusionsThe findings suggest that barriers to timely SPC referral include an insufficiency of services for patients with nonmalignant diseases especially in the outpatient setting, the perception that SPC services do not accept patients receiving cardiology-specific treatments, and a misperception about the identity of palliative care.

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer.

Integration of specialist palliative care into routine oncologic care improves patients' quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of "palliative care" and "hospice care" in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines. We reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of "palliative care" and "hospice care," the definitions for these terms if available, and the recommended timing for these services. We identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care. "Palliative care" was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines. Integration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.

A Qualitative Study Exploring Patient, Family Carer and Healthcare Professionals' Direct Experiences and Barriers to Providing and Integrating Palliative Care for Advanced Head and Neck Cancer.

Objectives:To report on direct experiences from advanced head and neck cancer patients, family carers and healthcare professionals, and the barriers to integrating specialist palliative care.Methods:Using a naturalistic, interpretative approach, within Northwest England, a purposive sample of adult head and neck cancer patients was selected. Their family carers were invited to participate. Healthcare professionals (representing head and neck surgery and specialist nursing; oncology; specialist palliative care; general practice and community nursing) were recruited. All participants underwent face-to-face or telephone interviews. A thematic approach, using a modified version of Colazzi’s framework, was used to analyze the data.Results:Seventeen interviews were conducted (9 patients, 4 joint with family carers and 8 healthcare professionals). Two main barriers were identified by healthcare professionals: “lack of consensus about timing of Specialist Palliative Care engagement” and “high stake decisions with uncertainty about treatment outcome.” The main barrier identified by patients and family carers was “lack of preparedness when transitioning from curable to incurable disease.” There were 2 overlapping themes from both groups: “uncertainty about meeting psychological needs” and “misconceptions of palliative care.”Conclusions:Head and neck cancer has a less predictable disease trajectory, where complex decisions are made and treatment outcomes are less certain. Specific focus is needed to define the optimal way to initiate Specialist Palliative Care referrals which may differ from those used for the wider cancer population. Clearer ways to effectively communicate goals of care are required potentially involving collaboration between Specialist Palliative Care and the wider head and neck cancer team.

1611P - Specialist palliative care (SPC) in haematological malignancy: Establishing practices in a UK tertiary cancer centre (TCC)

BackgroundInternational consensus supports early integration of SPC in oncological disease. Haematological malignancies differ in nature from solid site tumours. Remitting and relapsing trajectories, late salvage treatments, and divergent outcomes make for difficult prognostication and traditional markers of ‘good’ end of life care may not translate well to this group. However, disease is often incurable and physical and psychological symptom burden high, making SPC input essential. The authors propose an integrated care model to achieve this, utilising predefined triggers to identify unmet need and to guide SPC involvement from time of diagnosis. Such a service, “Triggers”, has been successfully developed for other cancer groups at the TCC. Through improved understanding of current practices we plan to tailor this service to meet the unique needs of the haematology patient group. MethodsA retrospective audit of electronic records was completed for patients dying of haematology malignancy in the 12 months to 31/3/18. Data relating to SPC referral, DNAR documentation, active interventions, place of death and diagnosis sub-type was collected. ResultsOf 108 patients identified, 67 died in hospitals, including 43 at the TCC. Of 26 deaths within 30 days of discharge from the TCC, 100% of those with a previous SPC referral (16) died in the community while 80% of those without (10) died in a local hospital.Table1611PTableTotals / RangeMedianDeaths in year ending 31/3/19108Documented referrals to SPC72/108Time from Diagnosis to death0 – 23 years3 yearsTime from SPC referral to death0 – 10 years6 daysFor Tertiary Centre in-patient deaths only:Number of TCC in-patient deaths43Chemotherapy in last 30 days25/43Blood transfusion in last 30 days38/432 days pre deathPlatelets in last 30 days34/433 days pre deathTPN in last 30 days11/434 days pre deathTime from DNAR record to death0 – 30 days3 days pre death ConclusionsHaematological intervention remains frequent up until death but SPC involvement is relatively delayed. Later SPC input is expected to limit effective relationship building and advance care planning and the data shows differences in place of death for those with and without SPC referral. Results suggest an opportunity to support patient-centred care through the development of an integrated service with early SPC accessibility and a consultative survey is underway to ascertain how this might best be achieved. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

Palliative care specialists\u2019 perceptions concerning referral of haematology patients to their services: findings from a qualitative study

BackgroundHaematological malignancies (leukaemias, lymphomas and myeloma) are complex cancers that are relatively common, affect all ages and have divergent outcomes. Although the symptom burden of these diseases is comparable to other cancers, patients do not access specialist palliative care (SPC) services as often as those with other cancers. To determine the reasons for this, we asked SPC practitioners about their perspectives regarding the barriers and facilitators influencing haematology patient referrals.MethodsWe conducted a qualitative study, set within the United Kingdom’s (UK’s) Haematological Malignancy Research Network (HMRN: www.hmrn.org), a population-based cohort in the North of England. In-depth, semi-structured interviews were conducted with 20 SPC doctors and nurses working in hospital, community and hospice settings between 2012 and 2014. Interviews were digitally audio-recorded, transcribed and analysed for thematic content using the ‘Framework’ method.ResultsStudy participants identified a range of barriers and facilitators influencing the referral of patients with haematological malignancies to SPC services. Barriers included: the characteristics and pathways of haematological malignancies; the close patient/haematology team relationship; lack of role clarity; late end of life discussions and SPC referrals; policy issues; and organisational issues. The main facilitators identified were: establishment of inter-disciplinary working patterns (co-working) and enhanced understanding of roles; timely discussions with patients and early SPC referral; access to information platforms able to support information sharing; and use of indicators to ‘flag’ patients’ needs for SPC. Collaboration between haematology and SPC was perceived as beneficial and desirable, and was said to be increasing over time.ConclusionsThis is the first UK study to explore SPC practitioners’ perceptions concerning haematology patient referrals. Numerous factors were found to influence the likelihood of referral, some of which related to the organisation and delivery of SPC services, so were amenable to change, and others relating to the complex and unique characteristics and pathways of haematological cancers. Further research is needed to assess the extent to which palliative care is provided by haematology doctors and nurses and other generalists and ways in which clinical uncertainty could be used as a trigger, rather than a barrier, to referral.

A palliative approach for heart failure end-of-life care.

Purpose of reviewThe current review discusses the integration of guideline and evidence-based palliative care into heart failure end-of-life (EOL) care.Recent findingsNorth American and European heart failure societies recommend the integration of palliative care into heart failure programs. Advance care planning, shared decision-making, routine measurement of symptoms and quality of life and specialist palliative care at heart failure EOL are identified as key components to an effective heart failure palliative care program. There is limited evidence to support the effectiveness of the individual elements. However, results from the palliative care in heart failure trial suggest an integrated heart failure palliative care program can significantly improve quality of life for heart failure patients at EOL.SummaryIntegration of a palliative approach to heart failure EOL care helps to ensure patients receive the care that is congruent with their values, wishes and preferences. Specialist palliative care referrals are limited to those who are truly at heart failure EOL.

Impact of Oncologists' Attitudes Toward End-of-Life Care on Patients' Access to Palliative Care.

It is unclear how oncologists' attitudes toward end-of-life (EOL) care affect the delivery of care. The present study examined the association between oncologists' EOL care attitudes and (a) timely specialist palliative care referral, (b) provision of supportive care, and (c) EOL cancer treatment decisions. We randomly surveyed 240 oncology specialists at our tertiary care cancer center to assess their attitudes toward EOL care using a score derived from the Jackson et al. qualitative conceptual framework (0 = uncomfortable and 8 = highly comfortable with EOL care). We determined the association between this score and clinicians' report of specialist palliative care referral, provision of supportive care, and EOL cancer treatment decisions. Of the 182 respondents (response rate of 76%), the median composite EOL care score was 6 (interquartile range, 5-7). A higher EOL score was significantly associated with solid tumor oncology (median 7 vs. 6 for hematologic oncology; p = .003), a greater willingness to refer patients with newly diagnosed cancer to specialist palliative care (median, 7 vs. 6; p = .01), greater comfort with symptom management (median, 6 vs. 5; p = .01), and provision of counseling (median, 7 vs. 4; p < .001) but not with cancer treatment decisions. We observed a gradient effect, with higher scores associated with a greater proportion of patients referred to palliative care (score 0-4, 27%; 5, 31%; 6, 32%; 7, 35%; and 8, 45%; p = .007). Greater comfort with EOL care was associated with higher rates of specialist palliative care referral and self-reported primary palliative care delivery. More support and education are needed for oncologists who are less comfortable with EOL care. In the present survey of oncology specialists, most reported that they were comfortable with end-of-life (EOL) care, which was in turn, associated with greater provision of primary palliative care and higher rates of referral to specialist palliative care. The results of the present study highlight the need for more support and education for oncologists less comfortable with EOL care because their patients might receive lower levels of both primary and secondary palliative care.

Palliative care for cirrhosis: a UK survey of health professionals’ perceptions, current practice and future needs

ObjectiveTo determine the knowledge and practice patterns of a UK cohort of relevant healthcare professionals (HCPs) about delivering palliative care in cirrhosis, and to inform priorities for future research.DesignAn on-line...