Identifying persons with diabetes who could benefit from a palliative approach to care

Patient Risk Factor Profiles Associated With the Timing of Goals-of-Care Consultation Before Death: A Classification and Regression Tree Analysis

Background:

Early palliative care consultation (“PCC”) to discuss goals-of-care benefits seriously ill patients. Risk factor profiles associated with the timing of conversations in hospitals, where late conversations most likely occur, are needed.

Objective:

To identify risk factor patient profiles associated with PCC timing before death.

Methods:

Secondary analysis of an observational study was conducted at an urban, academic medical center. Patients aged 18 years and older admitted to the medical center, who had PCC, and died July 1, 2014 to October 31, 2016, were included. Patients admitted for childbirth or rehabilitationand patients whose date of death was unknown were excluded. Classification and Regression Tree modeling was employed using demographic and clinical variables.

Results:

Of 1141 patients, 54% had PCC “close to death” (0-14 days before death); 26% had PCC 15 to 60 days before death; 21% had PCC >60 days before death (median 13 days before death). Variables associated with receiving PCC close to death included being Hispanic or “Other” race/ethnicity intensive care patients with extreme illness severity (85%), with age <46 or >75 increasing this probability (98%). Intensive care patients with extreme illness severity were also likely to receive PCC close to death (64%) as were 50% of intensive care patients with less than extreme illness severity.

Conclusions:

A majority of patients received PCC close to death. A complex set of variable interactions were associated with PCC timing. A systematic process for engaging patients with PCC earlier in the care continuum, and in intensive care regardless of illness severity, is needed.

Diabetes-related symptoms, acute complications and management of diabetes mellitus of patients who are receiving palliative care: a protocol for a systematic review

INTRODUCTION

Worldwide, an estimated 40 million people are in need of palliative care each year, but only 14% receive it. The incidence of diabetes mellitus (DM) in patients receiving palliative care is higher than in the general population. This association is intended to grow as a result of the rising burden of DM worldwide, ageing populations and the improved overall survival time of several diseases over the last few decades. Recommendations for DM management in the context of palliative care are mainly based on expert opinion as there is a lack of suitable evidence base and randomised clinical trials in palliative care are scarce. The aim of our systematic review is to identify the best DM management practices in order to reduce important DM-related symptoms and acute complications in patients receiving palliative care.

METHODS AND ANALYSIS

The authors will study the DM treatment and management literature, surveying the different approaches employed to treat adult palliative patients. Core health bibliographic databases will be searched from January 1990 to May 2019. Data sources will include Ovid MEDLINE, Embase, PubMed, Web of Sciences, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, Cumulative Index to Nursing and Allied Health Literature and grey literature. Details regarding diet, oral and injectable glucose-lowering medicines, insulin regimens and blood glucose monitoring strategies will be evaluated. We defined the primary outcomes to compare between DM management approaches as the presence of symptoms (polyuria, polydipsia and polyphagia) and acute complications of DM (hypoglycaemia, hyperglycaemic hyperosmolar state and diabetic ketoacidosis), and secondary outcomes as hospital admissions and deaths due to DM-related complications, health-related quality of life and glycaemic control.

ETHICS AND DISSEMINATION

The systematic review methodology does not require ethics approval due to the nature of the study design. The results of the systematic review will be published in a peer-reviewed journal and will be publicly available.

PROSPERO REGISTRATION NUMBER

CRD42018115772.

Non-specialist palliative care: A principle-based concept analysis

BACKGROUND

Building palliative care capacity among all healthcare practitioners caring for patients with chronic illnesses, who do not work in specialist palliative care services (non-specialist palliative care), is fundamental in providing more responsive and sustainable palliative care. Varying terminology such as 'generalist', 'basic' and 'a palliative approach' are used to describe this care but do not necessarily mean the same thing. Internationally, there are also variations between levels of palliative care which means that non-specialist palliative care may be applied inconsistently in practice because of this. Thus, a systematic exploration of the concept of non-specialist palliative care is warranted.

AIM

To advance conceptual, theoretical and operational understandings of and clarity around the concept of non-specialist palliative care.

DESIGN

The principle-based method of concept analysis, from the perspective of four overarching principles, such as epistemological, pragmatic, logical and linguistic, were used to analyse non-specialist palliative care.

DATA SOURCES

The databases of CINAHL, PubMed, PsycINFO, The Cochrane Library and Embase were searched. Additional searches of grey literature databases, key text books, national palliative care policies and websites of chronic illness and palliative care organisations were also undertaken.

CONCLUSION

Essential attributes of non-specialist palliative care were identified but were generally poorly measured and understood in practice. This concept is strongly associated with quality of life, holism and patient-centred care, and there was blurring of roles and boundaries particularly with specialist palliative care. Non-specialist palliative care is conceptually immature, presenting a challenge for healthcare practitioners on how this clinical care may be planned, delivered and measured.

Managing people with diabetes during the cancer palliation in the era of simultaneous care

Managing people with diabetes and cancer during palliation constitutes a daunting challenge. Cancer, diabetes and treatment toxicity could be seen as a "Bermuda Triangle" for physician and health care professionals in general. Based on literature review, the present paper stresses the distinctive aspects that diabetes and cancer together involve and bring out. Considering the simultaneous care approach as the basement of our perspective, we explore the areas of palliative intervention for which the specific features of persons with diabetes and cancer emerge: pain manifestation and treatment, response to opioids, psychosocial and communication aspects, infection-related susceptibility and complications. The overall impact of suffering that these two diseases in association involve requires new awareness and a cultural attitude towards new network based approaches in order to strengthen the person-centered health care in this field.

Estimating the need for palliative care at the population level: A cross-national study in 12 countries

BACKGROUND

To implement the appropriate services and develop adequate interventions, detailed estimates of the needs for palliative care in the population are needed.

AIM

To estimate the proportion of decedents potentially in need of palliative care across 12 European and non-European countries.

DESIGN

This is a cross-sectional study using death certificate data.

SETTING/PARTICIPANTS

All adults (⩾18 years) who died in 2008 in Belgium, Czech Republic, France, Hungary, Italy, Spain (Andalusia, 2010), Sweden, Canada, the United States (2007), Korea, Mexico, and New Zealand ( N = 4,908,114). Underlying causes of death were used to apply three estimation methods developed by Rosenwax et al., the French National Observatory on End-of-Life Care, and Murtagh et al., respectively.

RESULTS

The proportion of individuals who died from diseases that indicate palliative care needs at the end of life ranged from 38% to 74%. We found important cross-country variation: the population potentially in need of palliative care was lower in Mexico (24%-58%) than in the United States (41%-76%) and varied from 31%-83% in Hungary to 42%-79% in Spain. Irrespective of the estimation methods, female sex and higher age were independently associated with the likelihood of being in need of palliative care near the end of life. Home and nursing home were the two places of deaths with the highest prevalence of palliative care needs.

CONCLUSION

These estimations of the size of the population potentially in need of palliative care provide robust indications of the challenge countries are facing if they want to seriously address palliative care needs at the population level.

Increasing our understanding of dying of breast cancer: Comorbidities and care

Background: Screening and treatment for breast cancer have improved. However, attention to palliative support and non-cancer co-morbidities has been limited. This study identified types of care for and co-morbidities of persons dying of breast cancer compared to persons dying from all cancers and from non-cancer causes. Methods: Linked administrative data from population-based registries were used to examine 121,458 deaths in Nova Scotia from 1995 to 2009. Results: Breast cancer decedents' mean age was similar to that of all cancer decedents (72.0 versus 72.1 years), but their age spread was greater (20-59 years: 23.1% versus 16.7%; 90+ years: 11.2% versus 6.5%). Among women dying of breast cancer, 15.6% were enrolled in the diabetes registry and 15.1% in the cardiovascular registry, indicating that they had these non-cancer conditions prior to their death. Compared to all cancer decedents, breast cancer decedents were twice as likely to have dementia as a cause of death, and were less likely to die in hospital but more likely to die in a nursing home. Breast cancer decedents had place of death rates more similar to non-cancer than cancer decedents. Conclusions: Rates of dementia and diabetes among the breast cancer decedents were particularly note-worthy in this novel study given that these comorbidities have not received much attention in the breast cancer research literature. Further collaboration with non-cancer disease programs is advised. The extent of adequate comprehensive palliative support for the 20% of the breast cancer decedents who are nursing home residents requires investigation.