Tertiary Palliative Care Research Articles

Tertiary Palliative Care Model in South Africa: A case of the Gauteng/Wits Centre for Palliative Care

Tertiary Palliative Care Model in South Africa: A case of the Gauteng/Wits Centre for Palliative Care

Effects of tertiary palliative care on the pattern of end-of-life care in patients with hematologic malignancies in Korea.

Patients with hematologic malignancies (HMs) often face challenges in accessing palliative care (PC) and receiving quality end-of-life (EOL) care. We examined factors associated with referrals to tertiary PC and the effects of tertiary PC on EOL care in patients with HMs. We included patients with HMs who were admitted to a university-affiliated hospital and died during hospitalization between January 2018 and December 2021. We investigated the receipt of PC consultations, patient characteristics, and EOL care indicators. Overall, 487 patients were included in the analysis, with 156 (32%) undergoing PC consultation. Sex, residence, disease status, and admission purpose were factors associated with the likelihood of PC consultation, and there has been an increasing trend in the frequency of consultations in recent cases. A higher proportion of patients who received PC completed advance statements and life-sustaining treatment documents. Patients who received PC had lower rates of aggressive EOL care, including chemotherapy and intensive care unit admission, than those who did not receive PC. Notably, PC reduced the number of blood transfusions. Tertiary PC aims to reduce aggressive EOL care through patient-centered goal-of-care discussions. Therefore, there is an imperative need for concerted efforts toward seamless integration of PC.

Tertiary Inpatient Palliative Care within Region-Wide Services: A Retrospective Examination of Psychosocial and Medical Demographics at Admissions

Palliative care offers symptom relief and improved quality of life. Tertiary palliative care units (TPCUs) focus on complex suffering under the care of specialist palliative physicians and interdisciplinary teams. The Intensive Palliative Care Unit (IPCU) is a TPCU integrated in well-developed region-wide palliative services in Calgary, Canada. We compared the population accessing the IPCU to published data from other Canadian sites. Methods: A retrospective chart review was conducted using 8 sample months over a 2-year period. We gleaned psychosocial and medical demographics alongside the self-reported symptom burden on the Edmonton Symptom Assessment System. Descriptive statistics were calculated. Results: Adults (n = 117) with cancer admitted to the IPCU were 5–10 years younger, had later-stage cancer, and had higher discharges to preferred locations than other published Canadian TPCUs. Up to two months before admission, most commonly reported symptoms were consistent with the outpatient literature although with higher reported intensity. Discussion: With more advanced disease, younger age, and elevated symptom burden before admission, the IPCU still discharged patients to preferred locations at higher rates than other sites. This may be due to integration in the region’s organized palliative care services. Conclusion: With proper integration, a TPCU may be able to improve quality of life and reduce deaths in hospitals.

Use of opioids by patients in oncology palliative care

Introduction: Pain is the most common symptom in oncology, affecting more than 80% of patients, with opioids being the drugs of choice for the treatment of moderate to severe pain, especially in cancer.Objective: To analyze the patterns of opioid consumption among a group of cancer patients presenting to a tertiary palliative care unit.Methods: Cross-sectional study of analysis of medical records and prescriptions of patients at the Oncological PCU of a public hospital in Brasília (DF), Brazil, between September 2021 and March 2022. Fisher’s exact test was used, followed by Bonferroni’s post hoc test for categorical variables, and Kendall’s tau correlation coefficient for continuous variables.Results: Study participants were on average 62 years old (SD ± 14.8), 52% were female and had a diagnosis of malignant neoplasms of the digestive system (40.9%), the genital system (27.6%), and others malignant neoplasms (31.5%). Participants were hospitalized for an average of 12.5 days (SD ± 18.7), most of them were using an opioid, with morphine being the most prevalent (81.9%), and drugs were delivered mostly through intravenous route (45.7%). There was a change in the routes of drug administration in 39.4% of the cases. Genital system neoplasms affected women the most.Conclusion: In regard to the use of opioids and pain control data collected at the studied OPCU were consistent with the recommended practices of PC, such as dose rotation and titration. The patients’ profile partially matches what is expected from the epidemiology of cancer in Brazil.

Symptom Clusters in Patients With Advanced Cancer: A Prospective Longitudinal Cohort Study to Examine Their Stability and Prognostic Significance.

This study's purpose was to assess symptom cluster (SC) stability during disease progression and determine their strength of association with survival in patients with advanced cancer . Consecutively eligible patients with advanced cancer not receiving cancer-specific treatment and referred to a Tertiary Palliative Care Clinic were enrolled in a prospective cohort study. At first consultation (D0) and in subsequent consultations at day 15 (D15) and day 30 (D30), patients rated 9 symptoms through the Edmonton Symptom Assessment System scale (0-10) and 10 others using a Likert scale (1-5). Principal components factor analysis with varimax rotation was used to determine SCs at each consultation. Of 318 patients with advanced cancer, 301 met eligibility criteria with a median age of 69 years (range 37-94). Three SCs were identified: neuro-psycho-metabolic (NPM), gastrointestinal, and sleep impairment, with some variations in their constitution over time. Exploratory factor analysis accounted for 40% of variance of observed variables in all SCs. Shorter median survival was observed continuously for NPM cluster (D0 23 vs. 58 days, P < .001; D15 41 vs. 104 days, P=.004; D30 46 vs. 114 days, P = .002), although the presence of 2 or more SCs on D0 and D15 also had prognostic significance (D0: 21 vs. 45 days, P = .005; D30: 50 vs. 96 days, P = .040). In a multivariable model, NPM cluster (D0 hazard ratio estimate: HR 1.64; 95%CI, 1.17-2.31; P = .005; D15 HR: 2.51; 95%CI, 1.25-5.05; P = .009; D30 HR: 3.9; 95%CI, 1.54-9.86; P = .004) and hospitalization (D0 HR: 2.27; 95%CI, 1.47-3.51; P < .001; D15 HR: 2.43; 95%CI, 1.18-5.01; P = .016; D30 HR: 3.41; 95%CI, 1.35-8.62; P = .009) were independently and significantly associated with worse survival. Three clinically relevant SCs were identified, and their constitution had small variations, maintaining a stable set of nuclear symptoms through disease progression. Presence of the NPM cluster and hospitalization maintained their prognostic value over time.

Otolaryngology consultations requested by palliative care services: a five-year analysis

Introduction: Otolaryngologists are required to possess the knowledge, skills, and confidence necessary to manage consultations requested by palliative care services. However, the inclusion of palliative care needs in otolaryngology residency training is limited. The goal of this study was to enhance awareness of otolaryngologists' palliative care knowledge and skills by evaluating otolaryngology consultations requested by tertiary palliative care services between 2016 and 2021. Methods: This retrospective cross-sectional study included patients who consulted the otolaryngology department from the palliative care service of Kutahya Health Sciences University between January 1, 2016 and September 31, 2021. A total of 80 otolaryngology consultations were requested between 2016 and 2021. Patients were evaluated for age, gender, diagnosis of palliative admission, reason for consultation, date of consultation, interventions, and additional investigations. Results: There were 27 female patients (33.7%) and 53 male patients (66.2%). The mean age was 65.0 (range: 22-97) years. It was found that the volume of consultations did not increase significantly over a five-year period (p=0.502) and 78.8 % of consultations were requested during working hours (08:00-16:00). In addition, the response time (minutes) for consultations during working hours (08:00-16:00) was significantly lower than outside working hours (16:01-07:59) (p&amp;lt;0.001). The reasons for requesting a consultation and the procedures performed were significantly different between patients under and over 65 years of age (p=0.019 and p=0.008, respectively). Conclusions: This is the first study to evaluate otolaryngology consultations requested by a tertiary palliative care service. Awareness of these consultations may provide guidance for the assessment and management of patients in palliative care services. Keywords: consultation, otolaryngology, tracheotomy, palliative care

End-of-Life Health Resource Utilization for Limited English-Proficient Patients With Advanced Non-Small-Cell Lung Cancer.

Limited English-proficient (LEP) patients with non-small-cell lung cancer (NSCLC) may receive less palliative care services and more likely to receive aggressive end-of-life (EoL) care. Goals of this retrospective cohort study are to compare access to community palliative home care (CPHC), do not resuscitate (DNR) form completion, place of death, and health resource utilization at EoL between English-proficient (EP) and LEP patients with NSCLC in Vancouver, Canada. All patients with advanced NSCLC referred in 2016 and received medical care were included. Patients were classified as LEP if seen with a medical interpreter. Descriptive statistics and univariate and multivariate analyses were used to compare the outcomes between the two groups. One hundred eighty-six patients were referred, 66% EP. Rates of CPHC referral and DNR form completion were the same for both groups (84% and 92%, P = 1.00). LEP patients received earlier access to CPHC (15 v 10 weeks before death, P = .039). Rates of ER visits within 6 months and 30 days of death were 0.89 for EP patients and 0.7 for LEP patients, P = .374, and 0.1 for EP patients and 0.13 for LEP patients, P = .244. Hospitalization rates within 6 months and 30 days of death were 1.4 for EP patients and 1.59 for LEP patients, P = .640, and 0.67 for EP patients and 0.81 for LEP patients, P = .091. EP patients were more likely to have a home death (26% v 14%), whereas LEP patients died in acute care (23% v 14%) or a tertiary palliative care unit (24% v 19%). This was not statistically significant (P = .335). LEP patients had better median overall survival (8.5 v 5.4 months, P < .001), but when controlled by age, mutation, and EP status, only receipt of palliative-intent systemic therapy was statistically significant. EP and LEP patients with NSCLC have similar referral rates to CPHC, DNR form completion, and EoL health resource utilization. The measured EoL variables did not demonstrate significant disparities between EP and LEP patients.

Telehealth in outpatient delivery of palliative care: A qualitative study of patient and physician views.

The COVID-19 pandemic has widened the funded use of telehealth in Australia to support telehealth delivery to all patients in any setting. Increasing the use and experience of telehealth brings to light unique insights into the advantages and challenges of this new model of healthcare delivery This study aimed to qualitatively explore the experiences of both palliative care physicians and patients setting, including their views on its future role in healthcare. This qualitative study was conducted across three metropolitan tertiary palliative care centers in Victoria, Australia between November 2020 and March 2021. Purposive sampling identified 23 participants (12 physicians and 11 patients). Semi-structured interviews focused on the last telehealth consultation, thoughts and impressions of telehealth, and the possibility of telehealth remaining in palliative care. A thematic approach was adopted to code and analyze the data. Telehealth transformed the ways physicians and patients in this study perceived and engaged with outpatient palliative care across the entire continuum of care. Four key themes were identified: (1) access to care; (2) delivery of care; (3) engagement with care; and (4) the future. This study provides novel data bringing together the perspective of patients and physicians, which confirms the utility of telehealth in palliative care. Its convenience enables more frequent review, enables reviews to occur in response to lower levels of concern, and adds toward enhancing the continuity of care across and between settings. Moving forward, support seemed strongest for a hybrid model of telehealth and face-to-face consultations guided by key parameters relating to the level of anticipated complexity.

Palliative care virtual ward: early evaluation of a novel model of care to support patients with complex symptom management known to a UK tertiary hospital specialist palliative care team

Palliative care virtual ward: early evaluation of a novel model of care to support patients with complex symptom management known to a UK tertiary hospital specialist palliative care team

The effects of ketamine on pain control in stage IV cancer patients receiving palliative care

Background: We evaluated the effects of intravenous ketamine on cancer pain in stage IV cancer patients receiving palliative care.Methods: In total, 253 stage IV cancer patients with cancer pain hospitalized at a single tertiary hospital palliative care unit were included. The ketamine group contained 112 patients receiving ketamine, and the control group comprised 141 non-ketamine users. To evaluate the odds ratios (ORs) for favorable pain control, optimal pain control, and opioid-sparing effect among ketamine users, we used multivariable logistic regression adjusted for age and objective prognosis score. Differences in the visual analog scale (VAS) score, oral morphine equivalents, inter-dose frequency, and inter-dose amount were compared between both groups at the time of ketamine introduction (T0), after 24 hours (T1), and after 48 hours (T2) using repeated-measures analysis of covariance.Results: The ketamine group was more likely to show favorable pain control (OR, 3.84; 95% confidence interval [CI], 1.76–8.37) and an optimal response (OR, 3.99; 95% CI, 1.73–9.22) than the control group. Compared to the control group, the ketamine group showed a higher VAS score at T0, but a more evident VAS score reduction at T1 and T2 (pint&lt;0.001). The ketamine group was less likely than the control group to experience depressive mood (OR, 0.31; 95% CI, 0.10–0.92), but had a higher risk of delirium (OR, 2.06; 95% CI, 1.12–3.91).Conclusion: Our findings suggest that ketamine can effectively reduce refractory cancer pain in stage IV cancer patients.

C-reactive protein and white blood cell count are adverse prognostic markers for patients with advanced cancer on parenteral nutrition in a palliative care unit setting: A retrospective cohort study

Background: Parenteral nutrition is controversial in patients with advanced cancer. Nevertheless, this treatment is common practice near the end of life. Aim: We aimed to identify factors which were associated with the outcome of patients on parenteral nutrition at an academic tertiary palliative care unit. Design: In this retrospective cohort study patients were assigned to two groups according to parenteral nutrition treatment. Inferential statistics were used to assess whether the dynamics of laboratory variables over 2 weeks of parenteral nutrition were associated with survival. Setting/Participants: Patients admitted to the Department of Palliative Medicine at the Medical University of Vienna between 2016 and 2018 were included in this study. Results: Of 443 patients, 113 patients received parenteral nutrition. Patients had a lower body mass index, lower levels of bilirubin, γ-glutamyltransferase, alkaline phosphatase, and were of younger age compared to patients which did not receive parenteral nutrition. No difference in survival as measured from admission to death was found when comparing the two groups. Levels for γ-glutamyltransferase, alkaline phosphatase, and C-reactive protein significantly increased during 2 weeks of parenteral nutrition. Among patients with parenteral nutrition, an increase in C-reactive protein or white blood cell count levels was associated with lower survival. Conclusion: Patients who responded with an increase of C-reactive protein or white blood cell count during 2 weeks after reinitiation or start of parenteral nutrition had a worse survival. Our findings might support clinicians and patients in their decision to forgo parenteral nutrition in a palliative care setting.

‘We couldn't have managed without your team’: A collaborative palliative care response to the COVID‐19 pandemic in residential aged care

The global COVID‐19 pandemic has challenged healthcare, aged care and palliative care provision in ways previously unimaginable. In Australia, this has been felt particularly amongst our most vulnerable members of society, those residing in residential aged care. Currently representing the majority (75%) of COVID‐19 deaths and health‐care worker infections, this vulnerable sector has borne the greatest impact. A collaborative response comprising a tertiary hospital palliative care outreach service, residential InReach geriatric service and a community palliative care service effectively delivered comprehensive and timely specialist care to residents infected with COVID‐19. Daily videoconferencing rounds were efficient, minimised infection risk and facilitated family members attending virtually during patient assessments and care planning discussions. This model was both reactive and proactive and importantly scalable should further infective outbreaks occur in Australasian residential aged care facilities.

Increased number of deaths within 24 h of admission during a period of social restriction related to the COVID-19 pandemic: A retrospective service evaluation in a metropolitan palliative care unit

Background: COVID-19 has led to implementation of wide-ranging social restriction measures with consequent impact on health care utilisation in many domains. There is little published data on the experience of palliative care services catering to a population with low case numbers of COVID-19. Aim: This study aimed to consider the impact of COVID-19 on utilisation of inpatient palliative care in the context of low community transmission, and low numbers of cases in hospital. Design: A retrospective service evaluation examining differences in number of admissions, diagnoses, number of deaths and time from admission to death, across three discrete 8-week time periods spanning the early COVID-19 pandemic. Setting/participants: All admissions (n = 194) to a metropolitan tertiary hospital inpatient palliative care unit in Melbourne during the study period. Results: An initial 16.9% fall in admissions was followed by a return to baseline admission numbers, with a 46.7% increase in number of deaths compared to baseline. The number of deaths within 24 h rose from 10.8% to 37.3% (p < 0.01). The number of patients with non-malignant diagnoses increased from 32.4% to 52%, and those with non-malignant diagnoses were more likely to die rapidly (p < 0.01). There were no patients with COVID-19 infection. Conclusion: Increased numbers of deaths within 24 h of admission occurred on the palliative care unit despite low COVID-19 case numbers in the wider community, and in the setting of widespread social restriction measures. More research is needed examining the health-related consequences of such restrictions for individuals not infected with COVID-19.

Prevalence and Factors Associated With Will-to-Live in Patients With Advanced Disease: Results From a Portuguese Retrospective Study

ContextWill-to-live (WtL) is a complex and multifactorial dimension of end-of-life experience. Health care decisions on assisted suicide and euthanasia are rarely based on WtL evidence-based discussions. ObjectivesTo inform the debate, we aimed to evaluate the prevalence of WtL and its associations within a tertiary home-based palliative care unit. MethodsRetrospective analysis of all WtL entries registered in our anonymized clinical registry, from October 2018 to September 2020. ResultsOne-hundred and twelve patients were included: 53% were male, average age was 66 years old; 88% had malignancies, with a mean performance status of 55%. Mean for WtL of was 3.26 (SD = 3.87) with a prevalence of 60.7% strong, 8.9% moderate and 30.4% weak WtL. Weaker WtL was observed among patients who were not well adapted to their disease (P = .001), felt a burden to others (P< .001), were depressed (P = .001), anxious (P< .001) and endorsed a desire for death (P< .001). Weaker WtL was associated with pain (P = .002) and lower well-being (P = .001). Results from the logistic regression model found that the adaptation to disease emerged as a significant predictor of WtL (P = .025), and burden to others remained marginally significant (P = .087). ConclusionThe factors associated with lower WtL scores are consistent with previous studies, indicating that these patients experience a myriad of physical, psychological and existential symptoms requiring an interdisciplinary palliative care approach. These factors pertaining to WtL should be made known, as Portugal considers how to navigate death-hastening legislation.

Opioid Use Disorders among Patients on Long-Term Morphine for Management of Chronic Cancer Pain: A Pilot Study from a Tertiary Palliative Care Facility.

Objectives:Long-term opioid use can be associated with misuse and addiction. In the backdrop of increasing burden of cancer patients in India, it is important to assess the rate of opioid use disorders among those with chronic cancer pain. The objectives were to measure the rate of opioid use disorder in chronic cancer pain patients being managed with morphine and to assess its association with demographic and clinical characteristics.Materials and Methods:A cross-sectional study was conducted on chronic cancer pain patients who were prescribed morphine for ≥12 months, dosage of ≥60 mg/day. They were assessed using MINI version 7.0.0, WHO-ASSIST Hindi questionnaire, Addiction Behavior Checklist, and DSM-5 for opioid use disorder.Results:Forty patients who were treated with morphine for a total of 1479 months participated. The average morphine consumption was 159.50 ± 327.90 mg/day. Six (15%) showed possible inappropriate opioid analgesic use and none of the patients had opioid use disorder.Conclusion:This study reports the absence of opioid use disorder due to vigilant use of morphine in chronic cancer patients.

Continuous subcutaneous infusion for pain control in dying patients: experiences from a tertiary palliative care center

BackgroundContinuous subcutaneous infusion (CSCI) via ambulatory infusion pump (AIP) is a valuable method of pain control in palliative care. When using CSCI, low-dose methadone as add-on to other opioids might be an option in complex pain situations. This study aimed to investigate the effects, and adverse effects, of CSCI for pain control in dying patients, with particular interest in methadone use.MethodsThis was an observational cohort study. Imminently dying patients with pain, admitted to specialized palliative inpatient wards and introduced on CSCI, were monitored daily by staff for symptoms (Integrated Palliative Care Outcome Scale - IPOS), sedation (Richmond Agitation and Sedation Scale – RASS), performance status (Eastern Cooperative Oncology Group - ECOG) and delirium (Confusion Assessment Method - CAM).ResultsNinety-three patients with a median survival of 4 days were included. Of the 47 patients who survived ≥3 days, the proportion of patients with severe/overwhelming pain decreased from 45 to 19% (p < 0.001) after starting CSCI, with only a moderate increase in morphine equivalent daily dose of opioids (MEDD). Alertness was marginally decreased (1 point on the 10-point RASS scale, p = 0.001), whereas performance status and prevalence of delirium, regardless of age, remained unchanged.Both patients with methadone as add-on (MET, n = 13) and patients with only other opioids (NMET, n = 34), improved in pain control (p < 0.05 and 0.001, respectively), despite that MET patients had higher pain scores at baseline (p < 0.05) and were on a higher MEDD (240 mg vs.133 mg). No serious adverse effects demanding treatment stop were reported.ConclusionsCSCI via AIP is an effective way to reduce pain in dying patients without increased adverse effects. Add-on methadone may be beneficial in patients with severe complex pain.

Access to palliative care services for limited English proficient patients with advanced NSCLC.

99 Background: More than a quarter of people living in British Columbia, Canada speak languages other than English in their homes. Immigrants often encounter communication challenges with their health care providers (HCPs), have poor health literacy, and have a limited understanding on navigating the health care system. NSCLC patients with limited English proficiency (LEP) may receive less palliative care services despite high symptom burden and significant needs due to these factors. The study goals were to observe the difference in access to community palliative home care (CPHC) and rate of completing a Do Not Resuscitate (DNR) form between NSCLC patients who are English proficient (EP) and LEP. Methods: All patients with advanced NSCLC referred to BC Cancer–Vancouver Centre in 2016 and received medical care were included (N=176). Patients seen with a medical interpreter were considered to be LEP. Demographics and clinical information were collected retrospectively. UVA using X2 test and Fisher’s exact test were used to compare EP and LEP patients. Mann-Whitney test was used to compare the median time from CPHC referral and signed DNR to death between EP and LEP patients. Results: Language of communication: English 65%, Cantonese 22%, Mandarin 6%, Korean 1%, Tagalog 1%, and other 5%. Baseline characteristics: median age 69 EP vs 76 LEP, female 44% EP vs 65% LEP, non-squamous 68% EP vs 72% LEP and squamous 14% EP vs 6% LEP. There was no difference in the rate of CPHC referral (87% EP vs 80% LEP, p=0.342) and signed DNR form (92% EP vs 89% LEP, p=0.549). The median time from CPHC referral to death was 10 weeks EP vs 15 weeks LEP (p=0.039). The median time from signed DNR to death was 5 weeks EP vs 6 weeks LEP (p=0.806). There was no statistically significant difference in location of death between the two groups: acute care 20% EP vs 24% LEP, home 27% EP vs 13% LEP, hospice 36% EP vs 39% LEP, and tertiary palliative care unit 17% EP vs 24% LEP (p=0.251). Conclusions: EP and LEP patients with NSCLC had similar rates of CPHC service referrals and end of life planning. This suggests assistance of medical interpreters at the time of oncology visits help message delivery between LEP patients and HCPs. LEP patients had earlier referrals to CPHC prior to death which may reflect an enhanced awareness and effort by HCPs to have earlier conversations with patients who may have language and cultural barriers with discussing goals of care. Good communication improves patients and their family’s understanding of the goals and scope of palliative care services and allow HCPs to better understand the patients’ wishes.

The desire for death in Portuguese home-care palliative patients: Retrospective analysis of the prevalence and associated factors.

Desire for death (DfD) is a complex and multifactorial dimension of end-of-life experience. We aimed to evaluate the prevalence of DfD and its associations, arising within the setting of a tertiary home-based palliative care (PC) unit. Retrospective analysis of all DfD entries registered in our anonymized database from October 2018 to April 2020. Of the 163 patients anonymously registered in our database, 122 met entry criteria; 52% were male, the average age was 69 years old; 85% had malignancies, with a mean performance status (PPS) of 56%. The prevalence of DfD was 20%. No statistical differences were observed between patients with and without DfD regarding sex, age, marital status, religion, social support, prior PC or psychological follow-up, type of diagnosis, presence of advanced directives/living will, time since diagnosis and PC team's follow-up time. Statistically significant associations were found between higher PPS scores and DfD (OR = 0.96; 95% confidence interval (CI) [0.93-0.99]); Edmonton Symptom Assessment Scale scores for drowsiness (OR = 4.05; 95% CI [1.42-11.57]), shortness of breath (OR = 3.35; 95% CI [1.09-10.31]), well-being (OR = 7.64; 95% CI [1.63-35.81]). DfD was associated with being depressed (OR = 19.24; 95% CI [3.09-+inf]); feeling anxious (OR = 11.11; 95% CI [2.51-49.29]); HADS anxiety subscale ≥11 (OR = 25.0; 95% CI [2.10-298.29]); will-to-live (OR = 39.53; 95% CI [4.85-321.96]). Patients feeling a burden were more likely to desire death (OR = 14.67; 95% CI [1.85-116.17]), as well as those who were not adapted to the disease (OR = 4.08; 95% CI [1.30-12.84]). In multivariate regression analyses predicting DfD, three independent factors emerged: higher PPS scores were associated with no DfD (aOR = 0.95; 95% CI [0.91-0.99]), while the sense of being a burden (aOR = 12.82; 95% CI [1.31-125.16]) and worse well-being (aOR = 7.72; 95% CI [1.26-47.38]) predicted DfD. Prevalence of DfD was 20% and consistent with previous Portuguese evidence on DfD in PC inpatients. Both physical and psychosocial factors contribute to a stronger DfD.

Pediatric Palliative Care and the PICU: Where We Have Been and Where We Are Going

This review provides pediatric intensivists and other pediatric clinicians a review of pediatric palliative care, focusing on its integration into the pediatric intensive care unit (PICU) and outlining vital skills for the intensivist. Pediatric palliative care is a relatively young but growing field and is becoming increasingly available at many children’s hospitals. However, there has been a shortage of palliative care physicians historically (Lupu, J Pain Symptom Manag. 40(6):899–911, 2010). Palliative care teams are multidisciplinary and focus on assisting the PICU with pain and symptom management, communication with families, goals of care discussions, complicated grief, and bereavement. Palliative care team involvement may prolong life, improve quality of life by addressing physical and psychological suffering, decrease lengths of hospital and intensive care stay, and improve hospital wide resource utilization. Many PICU patients may benefit from palliative care services. All providers, including pediatric intensivists, should be able to perform primary, or basic, palliative care, including evaluating symptoms and communicating about goals of care and end of life (Hughes and Smith, Annu Rev Public Health. 35:459–475, 2014). More advanced secondary and tertiary palliative care relies on specialists to help navigate more nuanced communications and symptom management (Hughes and Smith, Annu Rev Public Health. 35:459–475, 2014). Palliative care has been shown to have great benefits for patients across the spectrum of diagnoses and prognoses. All providers, including intensivists, should have formalized training in primary palliative care. Mastering and incorporating primary palliative care skills into the clinical practice of non-palliative care providers will facilitate its delivery to patients.

Art Therapy in a Palliative Care Unit: Symptom Relief and Perceived Helpfulness in Patients and Their Relatives

ContextCreative arts therapies aim to expand conventional palliative care interventions by making clinical care more holistic. ObjectivesThe objective of the present study was to evaluate the benefits of an art therapy intervention in a tertiary hospital palliative care unit, directly in adult cancer inpatients and indirectly in their relatives. MethodsWe evaluated the intensity of pain, anxiety, depression, and well-being using the Edmonton Symptom Assessment Scale before and after the first, third, and fifth art therapy sessions. After the third and fifth sessions, perceived helpfulness was assessed via a questionnaire developed by the palliative care team, combining open-ended questions and a checklist. We categorized the narrative data into three predetermined types: generally helpful (some positive experience), helpfulness related to a dyadic relationship (patient-art therapist), and helpfulness related to a triadic relationship (patient-image-art therapist). ResultsWe observed a significant reduction in anxiety, depression, and pain as well as a significant increase in well-being at each of the time points evaluated. Ninety-eight percent of the patients considered the art therapy helpful, which could be categorized as generally helpful in 54.8%, related to a triadic relationship in 32.9%, and to a dyadic relationship in 12.3%. Relatives gave similar opinions regarding the effects on patients and, in addition, reported an indirect helpful effect for themselves. The most frequently selected experiences from the checklist were feeling calm, being entertained, and expressing and communicating emotions. ConclusionThis art therapy intervention was beneficial in reducing symptom intensity. Almost all the participants directly or indirectly involved in the creative art process considered it helpful. They reported a wide variety of sensory, emotional, cognitive, and spiritual experiences.