[What is the profile of palliative care in Germany. Results of a representative survey]

Patients in palliative care-Development of a predictive model for anxiety using routine data

Introduction

Anxiety is one of the most common psychological symptoms in patients in a palliative care situation. This study aims to develop a predictive model for anxiety using data from the standard documentation routine.

Methods

Data sets of palliative care patients collected by the German quality management benchmarking system called Hospice and Palliative Care Evaluation (HOPE) from 2007 to 2011 were randomly divided into a training set containing two-thirds of the data and a test set with the remaining one-third. We dichotomized anxiety levels, proxy rated by medical staff using the validated HOPE Symptom and Problem Checklist, into two groups with no or mild anxiety versus moderate or severe anxiety. Using the training set, a multivariable logistic regression model was developed by backward stepwise selection. Predictive accuracy was evaluated by the area under the receiver operating characteristic curve (AUC) based on the test set.

Results

An analysis of 9924 data sets suggests a predictive model for anxiety in patients receiving palliative care which contains gender, age, ECOG, living situation, pain, nausea, dyspnea, loss of appetite, tiredness, need for assistance with activities of daily living, problems with organization of care, medication with sedatives/anxiolytics, antidepressants, antihypertensive drugs, laxatives, and antibiotics. It results in a fair predictive value (AUC = 0.72).

Conclusions

Routinely collected data providing individual-, disease- and therapy-related information contain valuable information that is useful for the prediction of anxiety risks in patients receiving palliative care. These findings could thus be advantageous for providing appropriate support for patients in palliative care settings and should receive special attention in future research.

Validation of the German Version of the Quality of Dying and Death Questionnaire for Health Professionals

Purpose:

To validate the Quality of Dying and Death (QoDD) instrument for health professionals (QoDD-D-MA) and to test its feasibility in 2 German palliative care units (PCUs).

Methods:

The QoDD was translated from English to German and then retranslated following European Organisation for Research and Treatment of Cancer (EORTC) guidelines. Data were collected in 2 German PCUs to calculate aspects of validity and reliability.

Results:

Mean total score was 83.05 (range 49-100; N = 232). The QoDD-D-MA showed satisfactory psychometric properties, Cronbach α = .830; interrater reliability r = .245 ( P < .01). The QoDD-D-MA was independent of patients’ demographic and clinical aspects. Some challenges occurred when applying the instrument.

Conclusions:

Feasibility could be improved by adapting the QoDD-D-MA to create a self-assessment version and finding a solution for items that result in many missing data. Future research should validate the QoDD-D-MA in other care settings.

Palliative care consultation service and palliative care unit: why do we need both?

BACKGROUND

Palliative care (PC) infrastructure has developed differently around the globe. Whereas some institutions consider the palliative care unit (PCU) a valuable component, others report that the sole provision of a state-of-the art palliative care consultation service (PCCS) suffices to adequately care for the severely ill and dying.

OBJECTIVE

To aid institutional planning, this study aimed at gathering patient data to distinguish assignments of a concomitantly run PCU and PCCS at a large hospital and academic medical center.

METHODS

Demographics, Eastern Cooperative Oncology Group performance status, symptom/problem burden, discharge modality, and team satisfaction with care for all 601 PCU and 851 PCCS patients treated in 2009 and 2010 were retrospectively analyzed.

RESULTS

Patients admitted to the PCU versus those consulted by the PCCS: (a) had a significantly worse performance status (odds ratio [OR], 1.48); (b) were significantly more likely to suffer from severe symptoms and psychosocial problems (OR, 2.05), in particular concerning physical suffering and complexity of care; and (c) were significantly much more likely to die during hospital stay (OR, 11.03). For patients who were dying or in other challenging clinical situations (suffering from various severe symptoms), self-rated team satisfaction was significantly higher for the PCU than the PCCS.

CONCLUSION

This study presents a direct comparison between patients in a PCU and a PCCS. Results strongly support the hypothesis that the coexistence of both institutions in one hospital contributes to the goal of ensuring optimal high-quality PC for patients in complex and challenging clinical situations.

[Accompanying evalution of funded projects in palliative medicine of the German Cancer Aid]

INTRODUCTION

The German Cancer Aid funded 12 regional projects which developed different models of palliative home care. The realization of the projects were concurrently monitored and evaluated.

MATERIAL AND METHODS

The funded projects were asked to document all patients who were cared for beginning in January 2009 using HOPE (Hospice and palliative survey), MIDOS (Minimal documentation system for palliative patients) and the Barthel index. Documentation was mandatory at the beginning and the end of care as well as when patients changed settings, for example when patients were transferred from a palliative care unit to a palliative home care service. Additionally the projects were visited by an independent observer.

RESULTS

Overall the 12 projects documented 2,663 patients. Analysis revealed differences between the projects mainly concerning target groups and interventions.

DISCUSSION

The results of this evaluation can support the discussion about the development of palliative home care in Germany with particular focus on possible interrelations between structures, target groups and possible outcomes of care.

Patterns of care and course of symptoms in palliative radiotherapy: a multicenter pilot study analysis

BACKGROUND AND PURPOSE

To evaluate patterns of care as well as effectiveness and side effects of palliative treatment in four German radiation oncology departments.

PATIENTS AND METHODS

All referrals in four German radiation oncology departments (two university hospitals, one academic hospital, one private practice) were prospective documented for 1 month in 2008 (2 months at one of the university hospitals). In palliatively irradiated patients, treatment aims and indications as well as treated sites and fractionation schedules were recorded. In addition, symptoms and side effects were analyzed with standardized questionnaires before and at the end of radiotherapy.

RESULTS

During the observation period, 603 patients underwent radiation therapy in the four centers and 153 (24%, study population) were treated with palliative intent. Within the study, patients were most frequently treated for bone (34%) or brain (27%) metastases. 62 patients reported severe or very severe pain, 12 patients reported severe or very severe dyspnea, 27 patients reported neurological deficits or signs of cranial pressure, and 43 patients reported a poor or very poor sense of well-being. The most frequent goals were symptom relief (53%) or prevention of symptoms (46%). Life prolongation was intended in 37% of cases. A wide range of fractionation schedules was applied with total doses ranging from 3-61.2 Gy. Of the patients, 73% received a slightly hypofractionated treatment schedule with doses of > 2.0 Gy to ≤ 3.0 Gy per fraction and 12% received moderate to highly hypofractionated therapy with doses of > 3.0 Gy to 8.0 Gy. Radiation therapy led to a significant improvement of well-being (35% of patients) and reduction of symptoms, especially with regard to pain (66%), dyspnea (61%), and neurological deficits (60%). Therapy was very well tolerated with only 4.5% grade I or II acute toxicities being observed. Unscheduled termination was observed in 19 patients (12%).

CONCLUSIONS

Palliative radiation therapy is effective in reducing symptoms, increases subjective well-being, and has minimal side effects. More studies are necessary for subgroup analyses and for clarifying the different goals in palliative radiotherapy.

Integrating Palliative Medicine into Comprehensive Breast Cancer Therapy - a Pilot Project

BACKGROUND: To comply with the World Health Organization (WHO) recommendations, our institution's administrative directives were adopted to advocate the provision of palliative care (PC) early in the disease trajectory of breast cancer (BC). To assess the outcome of this recommendation, this study evaluated the effects of this approach. METHODS: A retrospective systematic chart analysis of a 2-year period was performed. The first PC consultation of patients was analyzed according to (a) physical condition, (b) symptom burden of the patients, and (c) reasons for PC consultation. RESULTS: Many patients were already in a reduced physical state and experienced burdening symptoms when first counselled by PC. After a 1-year experience with PC consultations, the number of burdening symptoms identified at first PC consultation decreased and senologists increasingly requested PC support also for non-somatic issues. CONCLUSIONS: A development towards a better understanding of PC competencies after a 1-year initiation period could be demonstrated, but BC patients continued to be in late stages of the disease at the time of first PC contact. Disease-specific guidelines may facilitate and optimize the integration of PC into breast cancer therapy.

[Validation of the new version of the minimal documentation system (MIDOS) for patients in palliative care : the German version of the edmonton symptom assessment scale (ESAS)]

BACKGROUND

repeated self-assessment of symptoms and problems of patients is required for quality assurance in palliative care. In Germany, the Minimal Documentation System (MIDOS) has been designed specifically for palliative care patients. To adapt MIDOS as a German version of the Edmonton Symptom Assessment Scale (ESAS) a revised version of MIDOS(2) has now been validated. Two original items on average and highest pain intensity (11-step NRS) were replaced by one item on pain intensity on a 4-step VRS and the assessment of vomitus, lack of appetite and depressive mood were added to the assessment of nausea, dyspnoea, constipation, weakness, tiredness, anxiety, others and well-being which were already part of the original version.

METHOD

all patients admitted to the palliative care unit were asked to participate voluntarily in this study. MIDOS(2), the German versions of the ESAS and the quality of life questionnaire EORTC QLQ-C15-Pal were completed on the same day during their inpatient stay. MIDOS(2) was repeated on the next day.

RESULTS

from August 2009 to March 2010, 60 patients (55% men, 45% women; mean age = 64.3, range = 23.6-92.4 years) treated in the palliative care unit completed the study. Self-assessment with MIDOS(2) was reported to burden the patients only slightly (mean burden = 1.1, range: 0 = no to 10 = maximum burden on a NRS), application of MIDOS(2) took between 1 and 7 min (mean duration = 2.4 min) and 61.7% of the patients preferred MIDOS(2) (with VRS) to ESAS (30%) (with NRS) for routine daily documentation. External criterion validity by inter-item correlations of MIDOS(2) with ESAS varied between r = .533 (anxiety) and .881 (nausea) and between r = .348 (depressive mood) and .717 (constipation) for the corresponding items of the EORTC QLQ-C15-Pal. Test-retest reliability between the sum scores of symptoms and problems reported in MIDOS(2) on the first day and on the second day was .688, and r = .573 for well-being.

CONCLUSION

MIDOS(2) can be recommended for routine daily documentation in palliative care because of low burden, little expenditure of time and high participation of patients. Statistical evaluation indicated good external validity and reliability.

Subjective Definitions of Problems and Symptoms in Palliative Care

Background

Data from the core data set of the Hospice and Palliative Care Evaluation (HOPE) from 1999 to 2001 demonstrated considerable variance in the incidence of patients’ symptoms and problems between participating services. This paper aims to investigate these differences more closely.

Methods

During the evaluation period of HOPE in 2002 a telephone survey with a representative of each participating unit was performed. Telephone interviews assessed the professionals’ definitions of selected symptoms and estimates of problem and symptom incidences. Content analysis was used to evaluate qualitative answers.

Results

Staff members rated pain, weakness, nausea/emesis as the most frequent physical symptoms; anxiety, depression and amentia as most frequent psychological symptoms; wound treatment, mobilisation and weakness as nursing problems and organisation of care settings, loneliness, demands of relatives the most common social needs. Staff members used a wide range of definitions for cachexia, weakness and depression.

Discussion

Standard definitions of symptoms and problems were lacking in the articulation of subjective staff members’ perspectives. Meaningful evaluation of multicentre surveys would require training in symptom assessment and classification in order to produce a common basis for documentation. Even though definitions differed widely, underlying concepts seemed to be compatible.

Differential palliative care issues in patients with primary and secondary brain tumours

INTRODUCTION

Cancer may affect the central nervous system either by primary or secondary brain tumours (PBT/SBT). Specific needs of these patients and special requirements of services caring for them have not been adequately addressed so far.

METHODS

Since 1999, an annual, 3-month census is being conducted in different palliative care settings throughout Germany. Pooled data from the years 2002-2005 were analysed to test for differences between patients with PBT, SBT and other palliative care patients (OP). Symptom frequencies, ECOG status and nursing needs were tested for differences (chi(2)). Free text entries for reasons for admission were recorded, categorised and analysed descriptively.

RESULTS

A total of 5,684 patients were documented (PBT n = 153, 2.7%; SBT n = 661, 11.9%; OP n = 4,872, 85.4%). For patients with PBT, poor functional status and high need for nursing support was reported more frequently than for patients with SBT and OP. For patients with PBT/SBT physical symptoms (pain, nausea, vomiting, constipation and loss of appetite) were documented less frequently and in lower intensity than for OP. However, nursing, psychological, and social problems/symptoms were documented significantly more often and showed higher intensity, particularly the patients'' need for support with the activities of daily living, disorientation/confusion of the patients and overburdening of the family. For 67% of all patients, a reason for admission was documented in free text. Main reasons were symptom control (OP>SBT>PBT), social issues (PBT>SBT>OP), functional deficits (PBT>SBT>OP) and cognitive impairment (PBT/SBT>OP). Distinct neurological deficits and problems were documented more often as secondary ICD-diagnoses than as a leading reason for admission.

CONCLUSION

The specific palliative care problems and the rationales leading to health care utilisation point to the need for an appropriate interdisciplinary and multi-professional provision of care for patients with brain malignancies, with a particular view on the needs of the families and an early integration of social and psychological support.