Palliative care needs, symptoms, and treatment intensity along the disease trajectory in medical oncology outpatients: a retrospective chart review

Early palliative care versus standard care in haematologic cancer patients at their last active treatment: study protocol of a feasibility trial

Background

Patients with advanced haematological malignancies suffer from a very high symptom burden and psychological, spiritual, social and physical symptoms comparable with patients with metastatic non-haematological malignancy. Referral to palliative care services for these patients remains limited or often confined to the last days of life. We developed a palliative care intervention (PCI) integrated with standard haematological care. The aim of the study was focussed on exploring the feasibility of the intervention by patients, professionals and caregivers and on assessing its preliminary efficacy.

Methods/design.

This is a mixed-methods phase 2 trial.

The Specialist Palliative Care Team (SPCT) will follow each patient on a monthly basis in the outpatient clinic or will provide consultations during any hospital admission. SPCT and haematologists will discuss active patient issues to assure a team approach to the patient’s care.

This quantitative study is a monocentric parallel-group superiority trial with balanced randomisation comparing the experimental PCI plus haematological standard care versus haematological standard care alone.

The primary endpoint will calculate on adherence to the planned PCI, measured as the percentage of patients randomised to the experimental arm who attend all the planned palliative care visits in the 24 weeks after randomisation.

The qualitative study follows the methodological indications of concurrent nested design and was aimed at exploring the acceptability of the PCI from the point of view of patients, caregivers and physicians.

Discussion

In this trial, we will test the feasibility of an integrated palliative care approach starting when the haematologist decides to propose the last active treatment to the patient, according to his/her clinical judgement. We decided to test this criterion because it is able to intercept a wide range of patients’needs. The feasibility of this approach requires that we enrol at least 60 patients and that more than 50% of them be followed by the palliative care team for at least 24 weeks.

The trial will include integrated qualitative data analysis; to give essential information on feasibility and acceptability.

Trial registration

ClinicalTrials.gov: NCT03743480 (November 16, 2018).

A pilot study on patient-related costs and factors associated with the cost of specialist palliative care in the hospital: first steps towards a patient classification system in Germany

Background

Specialist palliative care in the hospital addresses a heterogeneous patient population with complex care needs. In Germany, palliative care patients are classified based on their primary diagnosis to determine reimbursement despite findings that other factors describe patient needs better. To facilitate adequate resource allocation in this setting, in Australia and in the UK important steps have been undertaken towards identifying drivers of palliative care resource use and classifying patients accordingly. We aimed to pioneer patient classification based on determinants of resource use relevant to specialist palliative care in Germany first, by calculating the patient-level cost of specialist palliative care from the hospital’s perspective, based on the recorded resource use and, subsequently, by analysing influencing factors.

Methods

Cross-sectional study of consecutive patients who had an episode of specialist palliative care in Munich University Hospital between 20 June and 4 August, 2016. To accurately reflect personnel intensity of specialist palliative care, aside from administrative data, we recorded actual use of all involved health professionals’ labour time at patient level. Factors influencing episode costs were assessed using generalized linear regression and LASSO variable selection.

Results

The study included 144 patients. Mean costs of specialist palliative care per palliative care unit episode were 6542€ (median: 5789€, SE: 715€) and 823€ (median: 702€, SE: 31€) per consultation episode. Based on multivariate models that considered both variables recorded at beginning and at the end of episode, we identified factors explaining episode cost including phase of illness, Karnofsky performance score, and type of discharge.

Conclusions

This study is an important step towards patient classification in specialist palliative care in Germany as it provides a feasible patient-level costing method and identifies possible starting points for classification. Application to a larger sample will allow for meaningful classification of palliative patients.

Role of Early Palliative Care Interventions in Hematological Malignancies and Bone Marrow Transplant Patients: Barriers and Potential Solutions

INTRODUCTION

Despite advances in palliative care management of physical, psychological, and emotional symptoms along the spectrum of chronic conditions, early palliative care interventions are not used frequently and comprehensively in bone marrow transplant units.

METHODS

The literature review of PubMed articles in English published until December 2017.

RESULTS

Patients with hematologic malignancies and bone marrow transplant interventions are a heterogeneous group. The majority experience symptoms associated with induction or condition regimens. Curative intent of treatment is the norm. Pain, mucositis, nausea and vomiting, diarrhea, psychological, spiritual, and emotional concerns may not be properly and comprehensively tackled by primary oncology and bone marrow transplant teams. Quality of life may be decreased due to the presence of these symptoms. Obstacles to early palliative care interventions include overestimation of survival, focus on curative intent with underestimation of palliative care needs, lack of a comprehensive understanding of hematologic malignancies and bone marrow transplant process on the side of palliative care providers, and logistical restrictions. Potential interventions include education of oncologists, palliative care providers, patients, integration of models of care pre- and posttreatment and bone marrow transplantation, development of guidelines, institutional commitment and leadership in creating new initiatives, clinical research activities to measure outcomes, and community-based participatory research.

CONCLUSIONS

Early palliative care interventions are beneficial for patients with hematologic malignancies and bone marrow transplant processes. Better understanding of barriers to its implementation and development of creative initiatives is of paramount importance. New research endeavors should focus on providers' attitudes toward patients and communities.

[Palliative therapy concepts in intensive care medicine]

Involvement of palliative care is so far not common practice for critically ill patients on surgical intensive care units (ICUs) in Germany. The objectives of palliative care concepts are improvement of patient quality of life by relief of disease-related symptoms using an interdisciplinary approach and support of patients and their relatives considering their current physical, psychological, social and spiritual needs. The need for palliative care can be identified via defined screening criteria. Integration of palliative care can either be realized using a consultative model which focusses on involvement of palliative care consultants or an integrative model which embeds palliative care principles into the routine daily practice by the ICU team. Early integration of palliative care in terms of advance care planning (ACP) can lead to an increase in goals of care discussions and quality of life as well as a decrease of mortality and length of stay on the ICU. Moreover, stress reactions of relatives and ICU staff can be reduced and higher satisfaction with therapy can be achieved. The core of goal of care discussions is professional and well-structured communication between patients, relatives and staff. Consideration of palliative care principles by model-based integration into ICU practice can improve complex intensive care courses of disease in a productive but dignified way without neglecting curative attempts.

Palliative care at the end-of-life in glioma patients

The end-of-life (EOL) phase of patients with a glioma starts when symptom prevalence increases and antitumor treatment is no longer effective. During the EOL phase, care is primarily aimed at reducing symptom burden while maintaining quality of life as long as possible without inappropriate prolongation of life. Palliative care during the EOL phase also involves complex medical decisions for the prevention and relief of suffering. We discuss the prevalence and treatment of the most common EOL symptoms, decision making in the EOL phase, the organization of EOL care, and the role of the patient's caregiver. Treating disease-specific symptoms, such as impaired consciousness, seizures, focal neurologic deficits and cognitive disturbances, is a major concern during the EOL phase, as these symptoms may interfere with EOL decision making. Advance care planning is aimed at reaching consensus about possible EOL decisions between all participants, respecting the values of patients and their informal caregivers. In order to prevent the possibility that the patient becomes incompetent to make informed decisions, we recommend initiating EOL conversations at a relatively early stage in the disease course.

CARE Track for Advanced Cancer: Impact and Timing of an Outpatient Palliative Care Clinic

BACKGROUND

Studies suggest that outpatient palliative care can reduce hospitalization and increase hospice utilization for patients with cancer, however there are insufficient resources to provide palliative care to all patients from time of diagnosis. It is also unclear whether inpatient consultation alone provides similar benefits. A better understanding of the timing, setting, and impact of palliative care for patients with cancer is needed.

OBJECTIVES

The purpose of this study was to measure timing of referral to outpatient palliative care and impact on end-of-life (EOL) care.

DESIGN

The Comprehensive Assessment with Rapid Evaluation and Treatment (CARE Track) program is a phased intervention integrating outpatient palliative care into cancer care. In Year 1 patients were referred at the discretion of their oncologist.

SETTING

Academic medical center.

MEASUREMENTS

We compared EOL hospitalization, hospice utilization, and costs of care for CARE Track patients compared to those never seen by palliative care or seen only in hospital.

RESULTS

Patients were referred a median of 72.5 days prior to death. CARE Track patients had few hospitalizations at end of life, were less likely to die in hospital, had increased hospice utilization, and decreased costs of care; these results were significant even after controlling for differences between groups. Inpatient consultation alone did not impact these variables. However, only approximately half of patients with incurable cancers were referred to this program.

CONCLUSION

Referral outpatient palliative care within 3 months of death improved EOL care and reduced costs, benefits not seen with inpatient care only. However, many patients were never referred, and methods of systematically identifying appropriate patients are needed.

Measuring intensity of end of life care: a systematic review

Background

Many studies have measured the intensity of end of life care. However, no summary of the measures used in the field is currently available.

Objectives

To summarise features, characteristics of use and reported validity of measures used for evaluating intensity of end of life care.

Methods

This was a systematic review according to PRISMA guidelines. We performed a comprehensive literature search in Ovid Medline, Embase, The Cochrane Library of Systematic Reviews and reference lists published between 1990-2014. Two reviewers independently screened titles, abstracts, full texts and extracted data. Studies were eligible if they used a measure of end of life care intensity, defined as all quantifiable measures describing the type and intensity of medical care administered during the last year of life.

Results

A total of 58 of 1590 potentially eligible studies met our inclusion criteria and were included. The most commonly reported measures were hospitalizations (n = 44), intensive care unit admissions (n = 39) and chemotherapy use (n = 27). Studies measured intensity of care in different timeframes ranging from 48 hours to 12 months. The majority of studies were conducted in cancer patients (n = 31). Only 4 studies included information on validation of the measures used. None evaluated construct validity, while 3 studies considered criterion and 1 study reported both content and criterion validity.

Conclusions

This review provides a synthesis to aid in choosing intensity of end of life care measures based on their previous use but simultaneously highlights the crucial need for more validation studies and consensus in the field.

Is There a Need for Early Palliative Care in Patients With Life-Limiting Illnesses? Interview Study With Patients About Experienced Care Needs From Diagnosis Onward

The early integration of specialist palliative care has been shown to benefit the quality of life of patients with advanced cancer. In order to explore whether other seriously ill people and people at even earlier phases would also benefit from early palliative care, we conducted 18 qualitative interviews with people having cancer, chronic obstructive lung disease, heart failure, or dementia at different phases of the illness trajectory about how they experienced care needs related to their disease from diagnosis onward. Respondents experienced needs within the different domains of palliative care at different stages of the illness and different illness types or duration of the illness. This study contributes to the understanding of primary care needs of patients for whom palliative care (not necessarily specialized palliative care) could be beneficial.

Comparison of the Treatments of Patients With Cancer in Their Last 6 Months Between ICU and Cancer Center

PURPOSE

To investigate the treatments of patients with cancer in their last 6 months of life in intensive care unit (ICU) and Cancer Center.

METHOD

A prospective study was conducted on patients with cancer who died between January 2010 and July 2013 in the ICU and the Cancer Center (55 and 161 cases, respectively) of Tongji Hospital, Wuhan, China. The differences were compared by Chi-square test or Fisher test.

RESULTS

The differences in the treatments of patients with cancer between 2 groups were statistically significant. The proportion of patients with cancer who accepted blood transfusion (except albumin) was significantly higher in the ICU than in the Cancer Center.

CONCLUSION

Patients with cancer in the ICU were more likely to receive active treatments and less palliative and hospice care at the end of life than patients in the Cancer Center.

Physician-patient end-of-life care discussions: correlates and associations with end-of-life care preferences of cancer patients-a cross-sectional survey study

BACKGROUND

Honoring patients' treatment preferences is a key component of high-quality end-of-life care. Connecting clinical practices to patients' preferences requires effective communication. However, few cancer patients reported discussing end-of-life-care preferences with their physicians.

AIM

To identify correlates of physician-patient end-of-life-care discussions and to investigate associations of physician-patient end-of-life-care discussions with patient end-of-life-care preferences.

DESIGN

A cross-sectional survey from April 2011 through November 2012.

SETTING/PARTICIPANTS

A convenience sample of 2467 cancer patients (89.3% participation rate) whose disease was diagnosed as terminal and unresponsive to current curative cancer treatment was recruited from 23 teaching hospitals throughout Taiwan.

RESULTS

Only 7.8% of respondents reported discussing end-of-life-care preferences with their physicians. Physicians were more likely to discuss end-of-life-care preferences with cancer patients who accurately understood their prognosis but less likely to do so if patients were married or received care in a hospital with an inpatient hospice unit. Furthermore, physician-patient end-of-life-care discussions were significantly, positively associated with the likelihood of preferring comfort-oriented care and hospice care, but negatively associated with preferences for receiving cardiopulmonary resuscitation when life is in danger and aggressive life-sustaining treatments at end of life, including intensive care unit admission, cardiac massage, intubation, and mechanical ventilation support.

CONCLUSION

Physician-patient end-of-life-care discussions are correlated with accurate prognostic awareness, marital status, and institutional characteristics and negatively associated with terminally ill cancer patients' preferences for aggressive end-of-life care. Interventions should be developed to facilitate timely end-of-life-care discussions between at-risk patients and their physicians, thus honoring patients' end-of-life-care preferences and possibly avoiding futile life-sustaining treatments.

Development and validation of a medical chart review checklist for symptom management performance of oncologists in the routine care of patients with advanced cancer

CONTEXT

Oncologists perform a range of pharmacological and nonpharmacological interventions to manage the symptoms of outpatients with advanced cancer.

OBJECTIVES

The aim of this study was to develop and test a symptom management performance checklist (SyMPeC) to review medical charts.

METHODS

First, the content of the checklist was determined by consensus of an interprofessional team. The SyMPeC was tested using the data set of the SAKK 96/06 E-MOSAIC (Electronical Monitoring of Symptoms and Syndromes Associated with Cancer) trial, which included six consecutive visits from 247 patients. In a test data set (half of the data) of medical charts, two people extracted and quantified the definitions of the parameters (content validity). To assess the inter-rater reliability, three independent researchers used the SyMPeC on a random sample (10% of the test data set), and Fleiss's kappa was calculated. To test external validity, the interventions retrieved by the SyMPeC chart review were compared with nurse-led assessment of patient-perceived oncologists' palliative interventions.

RESULTS

Five categories of symptoms were included: pain, fatigue, anorexia/nausea, dyspnea, and depression/anxiety. Interventions were categorized as symptom specific or symptom unspecific. In the test data set of 123 patients, 402 unspecific and 299 symptom-specific pharmacological interventions were detected. Nonpharmacological interventions (n = 242) were mostly symptom unspecific. Fleiss's kappa for symptom and intervention detections was K = 0.7 and K = 0.86, respectively. In 1003 of 1167 visits (86%), there was a match between SyMPeC and nurse-led assessment. Seventy-nine percent (195 of 247) of patients had no or one mismatch.

CONCLUSION

Chart review by SyMPeC seems reliable to detect symptom management interventions by oncologists in outpatient clinics. Nonpharmacological interventions were less symptom specific. A template for documentation is needed for standardization.

Concurrent Specialized Palliative Care Upon Initiation of First-Line Chemotherapy for Cancer Progression: Is It Early Enough?

PURPOSE

To evaluate the effectiveness of specialized palliative care (PC) administered at the time of administration of first-line chemotherapy for cancer progression.

METHODS

Patients who received regular specialist PC concomitantly with first-line chemotherapy after being diagnosed with progressive disease assigned to PC group. Patients transferred to palliative care unit (PCU) after discontinuation of chemotherapy were assigned to standard care (SC) group. We evaluated quality of palliative care using Support Team Assessment Schedule, quality of life (QOL) using Good Death Inventory, and short-term mortality in PCU.

RESULTS

A total of 28 and 63 patients patients were assigned to PC and SC groups, respectively. Physical symptoms, anxiety, communication scores, and QOL scores were significantly higher in the PC group (P < .001). Short-term mortality (<14 days) was significantly higher in the SC group (P = .0005).

CONCLUSION

This approach may facilitate high quality of PC.