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Thomas C, Alici Y, Breitbart W, Bruera E, Blackler L, Sulmasy DP. Drugs, delirium, and ethics at the end of life. J Am Geriatr Soc 2024. [PMID: 38240387 DOI: 10.1111/jgs.18766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/27/2024]
Abstract
For older persons with delirium at the end of life, treatment involves complex trade-offs and highly value-sensitive decisions. The principles of beneficence, nonmaleficence, respect for autonomy, and justice establish important parameters but lack the structure necessary to guide clinicians in the optimal management of these patients. We propose a set of ethical rules to guide therapeutics-the canons of therapy-as a toolset to help clinicians deliberate about the competing concerns involved in the management of older patients with delirium at the end of life. These canons are standards of judgment that reflect how many experienced clinicians already intuitively practice, but which are helpful to articulate and apply as basic building blocks for a relatively neglected but emerging ethics of therapy. The canons of therapy most pertinent to the care of patients with delirium at the end of life are as follows: (1) restoration, which counsels that the goal of all treatment is to restore the patient, as much as possible, to homeostatic equilibrium; (2) means-end proportionality, which holds that every treatment should be well-fitted to the intended goal or end; (3) discretion, which counsels that an awareness of the limits of medical knowledge and practice should guide all treatment decisions; and (4) parsimony, which maintains that only as much therapeutic force as is necessary should be used to achieve the therapeutic goal. Carefully weighed and applied, these canons of therapy may provide the ethical structure needed to help clinicians optimally navigate complex cases.
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Affiliation(s)
- Columba Thomas
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
| | - Yesne Alici
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
- Weill Cornell Medical College, New York, New York, USA
| | - William Breitbart
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation, and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Liz Blackler
- Ethics Committee, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Daniel P Sulmasy
- Kennedy Institute of Ethics, Georgetown University, Washington, DC, USA
- Departments of Medicine and Philosophy and the Pellegrino Center for Clinical Bioethics, Georgetown University, Washington, DC, USA
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Featherstone I, Siddiqi N, Jones L, Coppo E, Sheldon T, Hosie A, Wolkowski A, Bush SH, Taylor J, Teodorczuk A, Johnson MJ. 'It's tough. It is hard': A qualitative interview study of staff and volunteers caring for hospice in-patients with delirium. Palliat Med 2023:2692163231170655. [PMID: 37129262 DOI: 10.1177/02692163231170655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
BACKGROUND Delirium is a distressing condition often experienced by hospice in-patients. Increased understanding of current multidisciplinary care of delirium is needed to develop interventions in this setting. AIM(S) To explore hospice staff and volunteers' practice, its influences and what may need to change to improve hospice delirium care. DESIGN Qualitative interview study using behaviour change theory from a critical realist stance. SETTING/PARTICIPANTS Thirty-seven staff, including different professional groups and roles, and volunteers were purposively sampled from two in-patient hospices. RESULTS We found that participants' practice focus was on managing hyperactive symptoms of delirium, through medication use and non-pharmacological strategies. Delirium prevention, early recognition and hypoactive delirium received less attention. Our theoretically-informed analysis identified this focus was influenced by staff and volunteers' emotional responses to the distress associated with hyperactive symptoms of delirium as well as understanding of delirium prevention, recognition and care, which varied between staff groups. Non-pharmacological delirium management was supported by adequate staffing levels, supportive team working and a culture of person-centred and family-centred care, although behaviours that disrupted the calm hospice environment challenged this. CONCLUSIONS Our findings can inform hospice-tailored behaviour change interventions that develop a shared team understanding and engage staff's emotional responses to improve delirium care. Reflective learning opportunities are needed that increase understanding of the potential to reduce patient distress through prevention and early recognition of delirium, as well as person-centred management. Organisational support for adequate, flexible staffing levels and supportive team working is required to support person-centred delirium care.
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Affiliation(s)
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Lesley Jones
- Hull York Medical School, University of Hull, Hull, UK
| | - Eleonora Coppo
- Cardinal Massaia Hospital of Asti, Asti, Piemonte, Italy
| | - Trevor Sheldon
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent's Health Network, Sydney, NSW, Australia
- IMPAACT, Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | | | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada
- Bruyere Research Institute, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Johanna Taylor
- Department of Health Sciences, University of York, York, UK
| | - Andrew Teodorczuk
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- The Prince Charles Hospital, Metro North Mental Health, Brisbane, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Southport, QLD, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Stevens E, Scott EME. Delirium Among Patients With Cancer in the Intensive Care Unit: Prognostic Sign or Opportunity for Intervention. JCO Oncol Pract 2023:OP2300061. [PMID: 37075269 DOI: 10.1200/op.23.00061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023] Open
Affiliation(s)
- Erin Stevens
- Division of Palliative Medicine, The Ohio State University, Columbus, OH
- Department of Internal Medicine, The Ohio State University, Columbus, OH
- The James Comprehensive Cancer Center, The Ohio State University, Columbus, OH
| | - Erin M E Scott
- Division of Palliative Medicine, The Ohio State University, Columbus, OH
- Department of Internal Medicine, The Ohio State University, Columbus, OH
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Green A, Hosie A, Phillips JL, Kochovska S, Noble B, Brassil M, Cumming A, Lawlor PG, Bush SH, Davis JM, Edwards L, Hunt J, Wilcock J, Phillipson C, Wesley Ely E, Parr C, Lovell M, Agar M. Stakeholder perspectives of a pilot multicomponent delirium prevention intervention for adult patients with advanced cancer in palliative care units: A behaviour change theory-based qualitative study. Palliat Med 2022; 36:1273-1284. [PMID: 36062724 DOI: 10.1177/02692163221113163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Theory-based and qualitative evaluations in pilot trials of complex clinical interventions help to understand quantitative results, as well as inform the feasibility and design of subsequent effectiveness and implementation trials. AIM To explore patient, family, clinician and volunteer ('stakeholder') perspectives of the feasibility and acceptability of a multicomponent non-pharmacological delirium prevention intervention for adult patients with advanced cancer in four Australian palliative care units that participated in a phase II trial, the 'PRESERVE pilot study'. DESIGN A trial-embedded qualitative study via semi-structured interviews and directed content analysis using Michie's Behaviour Change Wheel and the Theoretical Domains Framework. SETTING/PARTICIPANTS Thirty-nine people involved in the trial: nurses (n = 17), physicians (n = 6), patients (n = 6), family caregivers (n = 4), physiotherapists (n = 3), a social worker, a pastoral care worker and a volunteer. RESULTS Participants' perspectives aligned with the 'capability', 'opportunity' and 'motivation' domains of the applied frameworks. Of seven themes, three were around the alignment of the delirium prevention intervention with palliative care (intervention was considered routine care; intervention aligned with the compassionate and collaborative culture of palliative care; and differing views of palliative care priorities influenced perspectives of the intervention) and four were about study processes more directly related to adherence to the intervention (shared knowledge increased engagement with the intervention; impact of the intervention checklist on attention, delivery and documentation of the delirium prevention strategies; clinical roles and responsibilities; and addressing environmental barriers to delirium prevention). CONCLUSION This theory-informed qualitative study identified multiple influences on the delivery and documentation of a pilot multicomponent non-pharmacological delirium prevention intervention in four palliative care units. Findings inform future definitive studies of delirium prevention in palliative care.Australian New Zealand Clinical Trials Registry, ACTRN12617001070325; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373168.
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Affiliation(s)
- Anna Green
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Annmarie Hosie
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,School of Nursing & Midwifery, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, Darlinghurst, NSW, Australia
| | - Jane L Phillips
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,Faculty of Health, School of Nursing, Queensland University of Technology, Kelvin Grove, Brisbane, QLD, Australia
| | - Slavica Kochovska
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Beverly Noble
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meg Brassil
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Health Care, Sydney, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Jan Maree Davis
- Department of Palliative Care, Calvary Health Care Kogarah, Kogarah, NSW, Australia
| | - Layla Edwards
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Jane Hunt
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Julie Wilcock
- Ingham Institute, Liverpool Hospital, Liverpool, NSW, Australia
| | - Carl Phillipson
- Central Adelaide Palliative Care Service, The Queen Elizabeth Hospital, Woodville South, SA, Australia
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, TN, USA
| | - Cynthia Parr
- HammondCare, Greenwich Hospital, Greenwich, NSW, Australia
| | - Melanie Lovell
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,HammondCare, Greenwich Hospital, Greenwich, NSW, Australia.,Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Meera Agar
- Faculty of Health, IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia.,Ingham Institute, Liverpool Hospital, Liverpool, NSW, Australia.,South West Sydney Clinical School, University of New South Wales, Kensington, NSW, Australia
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Clinical Nursing Paths Benefit Patient Outcomes Undergoing Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:4655293. [PMID: 35769161 PMCID: PMC9236777 DOI: 10.1155/2022/4655293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 05/27/2022] [Accepted: 06/01/2022] [Indexed: 11/23/2022]
Abstract
Objective The purpose of the study is to investigate patient outcomes of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) under clinical nursing paths (CNP) and whether the application of CNP can be a protective factor against the recurrence of HCC. Methods The study comprised of 48 patients who received TACE for HCC under the CNP (assigned into the CNP group) and 41 who received TACE for HCC under the routine care (assigned into the control group). Their treatment safety, pain, and psychology were compared. The nursing satisfaction and quality of life were investigated when patients were discharged from the hospital. A 6-month follow-up was performed to analyze the related factors affecting disease recurrence. Results In the CNP group, the incidence rate of total adverse reactions, VAS scores, SAS and SDA scores were lower, but conversely, the satisfaction and SF-36 scores were higher than those in the control group (P < 0.05). Logistic regression analysis revealed that advanced TNM stage, larger tumor diameter, greater Child-Pugh classification, and the presence of peripheral blood vessel invasion were independent risk factors of HCC recurrence (P < 0.05). Conclusion The study demonstrated that CNP intervention can improve the safety and quality of life of patients undergoing TACE for HCC and reduce their negative emotions and pain feelings, which is worthy of clinical application.
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Featherstone I, Sheldon T, Johnson M, Woodhouse R, Boland JW, Hosie A, Lawlor P, Russell G, Bush S, Siddiqi N. Risk factors for delirium in adult patients receiving specialist palliative care: A systematic review and meta-analysis. Palliat Med 2022; 36:254-267. [PMID: 34930056 DOI: 10.1177/02692163211065278] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions. AIM To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care. DESIGN Systematic review and meta-analysis (PROSPERO CRD42019157168). DATA SOURCES CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed. RESULTS Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty. POTENTIALLY MODIFIABLE RISK FACTORS Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence). NON-MODIFIABLE RISK FACTORS Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium. CONCLUSIONS Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care.
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Affiliation(s)
| | - Trevor Sheldon
- Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University, London, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, England, UK
| | | | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, England, UK
| | - Annmarie Hosie
- School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
| | - Peter Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada
| | - Gregor Russell
- Bradford District Care NHS Foundation Trust, Saltaire, England, UK
| | - Shirley Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyere Research Institute, Ottawa, ON, Canada
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK
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Agar MR, Siddiqi N, Hosie A, Boland JW, Johnson MJ, Featherstone I, Lawlor PG, Bush SH, Page V, Amgarth-Duff I, Garcia M, Disalvo D, Rose L. Outcomes and measures of delirium interventional studies in palliative care to inform a core outcome set: A systematic review. Palliat Med 2021; 35:1761-1775. [PMID: 34448431 DOI: 10.1177/02692163211040186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement. AIM To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions. DESIGN Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. DATA SOURCES We searched six electronic databases (1980-November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions. RESULTS From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life. CONCLUSION The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research.
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Affiliation(s)
- Meera R Agar
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,South West Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Ingham Institute of Applied Medical Research, Sydney, NSW, Australia
| | - Najma Siddiqi
- Hull York Medical School, Department of Health Sciences, University of York, York, UK.,Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Annmarie Hosie
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia.,St Vincent's Health Network Sydney, East Sydney, NSW, Australia
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Imogen Featherstone
- Hull York Medical School, Department of Health Sciences, University of York, York, UK
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Valerie Page
- Watford General Hospital, Watford, Hertfordshire, UK
| | - Ingrid Amgarth-Duff
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Maja Garcia
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Domenica Disalvo
- IMPACCT Centre (Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation), Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
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Gillespie J, Przybylak-Brouillard A, Watt CL. The Palliative Care Information Needs of Patients with Amyotrophic Lateral Sclerosis and their Informal Caregivers: A Scoping Review. J Pain Symptom Manage 2021; 62:848-862. [PMID: 33757892 DOI: 10.1016/j.jpainsymman.2021.03.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Amyotrophic Lateral Sclerosis (ALS) is a fatal neurodegenerative disease, associated with impaired quality of life for patients and caregivers. As treatment is largely supportive, early involvement of palliative care (PC) is recommended as standard of care. Despite this, literature surrounding PC information needs is limited. OBJECTIVES To explore the PC information needs of patients with ALS and their caregivers and identify gaps in the literature. METHODS A scoping review using MEDLINE, EMBASE, CINAHL and PsycINFO databases (2000-2019) was conducted. Articles examining PC information needs as stated by ALS patients and/or current/bereaved caregivers were included. Studies examining other diagnoses and those focused on healthcare workers were excluded. Thematic synthesis was used to summarize and identify prevalent domains and themes in the literature. RESULTS 581 articles underwent primary screening, with thirty-two ultimately included (26 original articles, six reviews). Fourteen examined information needs of both patients and caregivers, 13 caregivers only, 5 patients only. The most common PC information needs were as follows: for patients, disease course/prognosis (n = 10), general disease information (n = 9), decision-making (n = 7) and symptoms (n = 6); for caregivers, services and resources (n = 15), disease course/prognosis (n = 14), general disease information (n = 13) and skills (n = 10). There was substantial variability in information needs, both between patients and caregivers and among members of the same group. CONCLUSION ALS patients and caregivers have unique and varying PC information needs. Future research should better characterize these needs to improve patient and caregiver quality of life. The delivery of information must be tailored to individual patient or caregiver preferences.
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Affiliation(s)
- Jacqueline Gillespie
- Division of Palliative Care, Trillium Health Partners, Mississauga, Ontario, Canada
| | | | - Christine L Watt
- Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada; Bruyere Research Institute, Ottawa, Ontario, Canada.
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Webber C, Watt CL, Bush SH, Lawlor PG, Talarico R, Tanuseputro P. Hospitalization Outcomes of Delirium in Patients Admitted to Acute Care Hospitals in Their Last Year of Life: A Population-Based Retrospective Cohort Study. J Pain Symptom Manage 2021; 61:1118-1126.e5. [PMID: 33157179 DOI: 10.1016/j.jpainsymman.2020.10.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/26/2020] [Accepted: 10/27/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Delirium is a highly distressing neurocognitive disorder for patients at the end of life. OBJECTIVES To compare hospitalization outcomes between patients with and without delirium admitted to acute care hospitals in the last year of life. METHODS Using linked administrative data from ICES (previously known as the Institute for Clinical Evaluative Sciences), this population-based retrospective cohort study included adults who died in Ontario between January 1, 2014 and December 31, 2016 and were admitted to an acute care hospital in their last year of life. Delirium was identified via diagnosis codes on the hospitalization discharge record. Outcomes included lengths of stay, discharge location, and in-hospital mortality. We used multivariable generalized estimating equations to compare outcomes between patients with and without delirium. RESULTS Of 208,715 decedents, 9.3% experienced delirium in at least one hospitalization in the last year of life. The mean hospitalization lengths of stay was 13.8 days in patients with delirium (SD = 21.1) or 1.80 times longer (95% CI = 1.75-1.84) compared with those without delirium. Among patients discharged alive, patients with delirium were 1.32 times (95% CI = 1.27-1.38) more likely to be discharged to another institution rather than discharged home. There was no difference in in-hospital mortality between patients with and without delirium (relative risk = 1.01; 95% CI = 0.98-1.05). CONCLUSION In the last year of life, hospitalized patients with recorded delirium experience poorer outcomes, including longer lengths of stay and increased risk of postdischarge institution use, compared with those without delirium. These outcomes illustrate added burden for patients, their families, and the health care system, thus highlighting the need for delirium prevention and early detection in addition to informed transitional care decisions.
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Affiliation(s)
- Colleen Webber
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada.
| | - Christine L Watt
- Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Peter G Lawlor
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Peter Tanuseputro
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Bruyère Research Institute, Ottawa, Ontario, Canada; ICES, Ottawa, Ontario, Canada; Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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10
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Arnold E, Finucane AM, Spiller JA, Tieges Z, MacLullich AM. Validation of the 4AT tool for delirium assessment in specialist palliative care settings: protocol of a prospective diagnostic test accuracy study [version 1; peer review: 2 approved]. AMRC OPEN RESEARCH 2021; 3:16. [PMID: 35966135 PMCID: PMC7613285 DOI: 10.12688/amrcopenres.12973.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Delirium is a serious and distressing neuropsychiatric condition, which is prevalent across all palliative care settings. Hypoactive delirium is particularly common, but difficult to recognize, partly due to overlapping symptoms with depression and dementia. Delirium screening tools can lead to earlier identification and hence better management of patients. The 4AT (4 'A's Test) is a brief tool for delirium detection, designed for use in clinical practice. It has been validated in 17 studies in over 3,700 patients. The test is currently used in specialist palliative care units, but has not been validated in this setting. The aim of the study is to determine the diagnostic accuracy of the 4AT for delirium detection against a reference standard, in hospice inpatients. METHODS 240 participants will be recruited from the inpatient units of two hospices in Scotland. If a patient lacks capacity to consent, agreement will be sought from a legal proxy. Each participant will complete the 4AT and a reference standard assessment based on the diagnostic delirium criteria in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). This will be supplemented by tests of cognition and attention, including reverse days of the week, counting down from 20 to 1, Vigilance 'A', the Observational Scale for Level of Arousal, the modified Richmond Agitation Sedation Scale and the Delirium Rating Scale-Revised-98. The assessments will be conducted in a randomized order by two independent clinicians, who will be blinded to the results until both are complete. Primary outcomes will be the sensitivity and specificity of the 4AT in detecting delirium. DISCUSSION The findings will inform clinical practice regarding delirium assessment in palliative care settings. TRIAL REGISTRATION ISRCTN ISRCTN97417474 (21/02/2020).
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Affiliation(s)
- Elizabeth Arnold
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Anne M. Finucane
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Juliet A. Spiller
- Marie Curie Hospice Edinburgh, 45 Frogston Road West, Edinburgh, Scotland, EH10 7DR, UK
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
| | - Alasdair M.J. MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, Scotland, EH16 4SA, UK
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11
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Watt CL, Scott M, Webber C, Sikora L, Bush SH, Kabir M, Boland JW, Woodhouse R, Sands MB, Lawlor PG. Delirium screening tools validated in the context of palliative care: A systematic review. Palliat Med 2021; 35:683-696. [PMID: 33588640 DOI: 10.1177/0269216321994730] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Delirium is a distressing neuropsychiatric disorder affecting patients in palliative care. Although many delirium screening tools exist, their utility, and validation within palliative care settings has not undergone systematic review. AIM To systematically review studies that validate delirium screening tools conducted in palliative care settings. DESIGN Systematic review with narrative synthesis (PROSPERO ID: CRD42019125481). A risk of bias assessment via Quality Assessment Tool for Diagnostic Accuracy Studies-2 was performed. DATA SOURCES Five electronic databases were systematically searched (January 1, 1982-May 3, 2020). Quantitative studies validating a screening tool in adult palliative care patient populations were included. Studies involving alcohol withdrawal, critical or perioperative care were excluded. RESULTS Dual-reviewer screening of 3749 unique titles and abstracts identified 95 studies for full-text review and of these, 17 studies of 14 screening tools were included (n = 3496 patients). Data analyses revealed substantial heterogeneity in patient demographics and variability in screening and diagnostic practices that limited generalizability between study populations and care settings. A risk of bias assessment revealed methodological and reporting deficits, with only 3/17 studies at low risk of bias. CONCLUSIONS The processes of selecting a delirium screening tool and determining optimal screening practices in palliative care are complex. One tool is unlikely to fit the needs of the entire palliative care population across all palliative care settings. Further research should be directed at evaluating and/or adapting screening tools and practices to fit the needs of specific palliative care settings and populations.
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Affiliation(s)
- Christine L Watt
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada
| | - Mary Scott
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Colleen Webber
- Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lindsey Sikora
- University of Ottawa, Health Sciences Library, Ottawa, ON, Canada
| | - Shirley H Bush
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Rebecca Woodhouse
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Megan B Sands
- University of New South Wales Prince of Wales Clinical School, Randwick, NSW, Australia
| | - Peter G Lawlor
- Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON, Canada.,Bruyère Research Institute, Ottawa, ON, Canada.,The Ottawa Hospital Research Institute, Ottawa, ON, Canada
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12
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Guo D, Lin T, Deng C, Zheng Y, Gao L, Yue J. Risk Factors for Delirium in the Palliative Care Population: A Systematic Review and Meta-Analysis. Front Psychiatry 2021; 12:772387. [PMID: 34744847 PMCID: PMC8566675 DOI: 10.3389/fpsyt.2021.772387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 09/23/2021] [Indexed: 02/05/2023] Open
Abstract
Objective: Delirium is common and highly distressing for the palliative care population. Until now, no study has systematically reviewed the risk factors of delirium in the palliative care population. Therefore, we performed a systematic review and meta-analysis to evaluate delirium risk factors among individuals receiving palliative care. Methods: We systematically searched PubMed, Medline, Embase, and Cochrane database to identify relevant observational studies from database inception to June 2021. The methodological quality of the eligible studies was assessed by the Newcastle Ottawa Scale. We estimated the pooled adjusted odds ratio (aOR) for individual risk factors using the inverse variance method. Results: Nine studies were included in the review (five prospective cohort studies, three retrospective case-control studies and one retrospective cross-section study). In pooled analyses, older age (aOR: 1.02, 95% CI: 1.01-1.04, I 2 = 37%), male sex (aOR:1.80, 95% CI: 1.37-2.36, I 2 = 7%), hypoxia (aOR: 0.87, 95% CI: 0.77-0.99, I 2 = 0%), dehydration (aOR: 3.22, 95%CI: 1.75-5.94, I 2 = 18%), cachexia (aOR:3.40, 95% CI: 1.69-6.85, I 2 = 0%), opioid use (aOR: 2.49, 95%CI: 1.39-4.44, I 2 = 0%), anticholinergic burden (aOR: 1.18, 95% CI: 1.07-1.30, I 2 = 9%) and Eastern Cooperative Oncology Group Performance Status (aOR: 2.54, 95% CI: 1.56-4.14, I 2 = 21%) were statistically significantly associated with delirium. Conclusion: The risk factors identified in our review can help to highlight the palliative care population at high risk of delirium. Appropriate strategies should be implemented to prevent delirium and improve the quality of palliative care services.
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Affiliation(s)
- Duan Guo
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China.,Department of Palliative Medicine, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Taiping Lin
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Chuanyao Deng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Yuxia Zheng
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Langli Gao
- West China School of Nursing, Sichuan University, Chengdu, China.,Department of Geriatrics, West China Hospital, Sichuan University, Chengdu, China
| | - Jirong Yue
- Department of Geriatrics and National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, China
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13
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Lawlor PG, McNamara-Kilian MT, MacDonald AR, Momoli F, Tierney S, Lacaze-Masmonteil N, Dasgupta M, Agar M, Pereira JL, Currow DC, Bush SH. Melatonin to prevent delirium in patients with advanced cancer: a double blind, parallel, randomized, controlled, feasibility trial. Palliat Care 2020; 19:163. [PMID: 33087111 PMCID: PMC7579814 DOI: 10.1186/s12904-020-00669-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/07/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Delirium is highly problematic in palliative care (PC). Preliminary data indicate a potential role for melatonin to prevent delirium, but no randomized controlled trials (RCTs) are reported in PC. METHODS Patients aged ≥18 years, with advanced cancer, admitted to an inpatient Palliative Care Unit (PCU), having a Palliative Performance Scale rating ≥ 30%, and for whom consent was obtained, were included in the study. Patients with delirium on admission were excluded. The main study objectives were to assess the feasibility issues of conducting a double-blind RCT of exogenous melatonin to prevent delirium in PC: recruitment, retention, procedural acceptability, appropriateness of outcome measures, and preliminary efficacy and safety data. Study participants were randomized in a double-blind, parallel designed study to receive daily melatonin 3 mg or placebo orally at 21:00 over 28 days or less if incident delirium, death, discharge or withdrawal occurred earlier. Delirium was diagnosed using the Confusion Assessment Method. Efficacy endpoints in the melatonin and placebo groups were compared using time-to-event analysis: days from study entry to onset of incident delirium. RESULTS Over 16 months, 60/616 (9.7%; 95% CI: 7.5-12.4%) screened subjects were enrolled. The respective melatonin (n = 30) vs placebo (n = 30) outcomes were: incident delirium in 11/30 (36.7%; 95%CI: 19.9-56.1%) vs 10/30 (33%; 95% CI: 17.3-52.8%); early discharge (6 vs 5); withdrawal (6 vs 3); death (0 vs 1); and 7 (23%) vs 11 (37%) reached the 28-day end point. The 25th percentile time-to-event were 9 and 18 days (log rank, χ2 = 0.62, p = 0.43) in melatonin and placebo groups, respectively. No serious trial medication-related adverse effects occurred and the core study procedures were acceptable. Compared to those who remained delirium-free during their study participation, those who developed delirium (n = 21) had poorer functional (p = 0.036) and cognitive performance (p = 0.013), and in particular, poorer attentional capacity (p = 0.003) at study entry. CONCLUSIONS A larger double-blind RCT is feasible, but both subject accrual and withdrawal rates signal a need for multisite collaboration. The apparent trend for shorter time to incident delirium in the melatonin group bodes for careful monitoring in a larger trial. TRIAL REGISTRATION Registered on July 21st 2014 with ClinicalTrials.gov : NCT02200172 .
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Affiliation(s)
- Peter G. Lawlor
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | | | - Franco Momoli
- grid.28046.380000 0001 2182 2255School of Epidemiology and Public Health, University of Ottawa, London, Canada
| | - Sallyanne Tierney
- grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
| | | | - Monidipa Dasgupta
- grid.39381.300000 0004 1936 8884Department of Geriatric Medicine, Department of Medicine, University of Western Ontario, London, Canada
| | - Meera Agar
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Jose L. Pereira
- grid.25073.330000 0004 1936 8227Division of Palliative Care, Department of Family Medicine, McMaster University, Hamilton, Canada
| | - David C. Currow
- Centre of Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Hamilton, Canada
| | - Shirley H. Bush
- grid.28046.380000 0001 2182 2255Division of Palliative Care, Department of Medicine, University of Ottawa, 43 Bruyère Street, Ottawa, ON K1N 5C8 Canada ,grid.418792.10000 0000 9064 3333Bruyère Research Institute, Ottawa, Canada ,grid.412687.e0000 0000 9606 5108Ottawa Hospital Research Institute, Ottawa, Canada ,grid.418792.10000 0000 9064 3333Bruyère Continuing Care, Ottawa, Canada
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14
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Lee KY, Tan ECK, Hanrahan JR, Chircop C, Michael F, Ong JA. Effect of Antipsychotics and Non-Pharmacotherapy for the Management of Delirium in People Receiving Palliative Care. J Pain Palliat Care Pharmacother 2020; 34:225-236. [DOI: 10.1080/15360288.2020.1784353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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15
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Munday J, Higgins N, Mathew S, Dalgleish L, Batterbury AS, Burgess L, Campbell J, Delaney LJ, Griffin BR, Hughes JA, Ingleman J, Keogh S, Coyer F. Nurse-Led Randomized Controlled Trials in the Perioperative Setting: A Scoping Review. J Multidiscip Healthc 2020; 13:647-660. [PMID: 32821111 PMCID: PMC7419608 DOI: 10.2147/jmdh.s255785] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/28/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Nurses provide care at each phase of the complex, perioperative pathway and are well placed to identify areas of care requiring investigation in randomized controlled trials. Yet, currently, the scope of nurse-led randomized controlled trials conducted within the perioperative setting are unknown. This scoping review aims to identify areas of perioperative care in which nurse-led randomized controlled trials have been conducted, to identify issues impacting upon the quality of these trials and identify gaps for future investigation. METHODS This scoping review was conducted in reference to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. Searches were conducted in PubMed, Embase, Cumulative Index for Nursing and Allied Health Literature and the Cochrane Central Register of Controlled Trials, with a date range of 2014-19. Sources of unpublished literature included Open Grey, and ProQuest Dissertation and Theses, Clinical Trials.gov and the Australian and New Zealand Clinical Trials Registry. After title and abstract checking, full-text retrieval and data extraction, studies were appraised using the Joanna Briggs Institute Critical Appraisal Checklists for randomized controlled trials. Data were synthesized according to the main objectives. Key information was tabulated. RESULTS From the 86 included studies, key areas where nurses have led randomized controlled trials include patient or caregiver anxiety; postoperative pain relief; surgical site infection prevention: patient and caregiver knowledge; perioperative hypothermia prevention; postoperative nausea and vomiting; in addition to other diverse outcomes. Issues impacting upon quality (including poorly reported randomization), and gaps for future investigation (including a focus on vulnerable populations), are evident. CONCLUSION Nurse-led randomized controlled trials in the perioperative setting have focused on key areas of perioperative care. Yet, opportunities exist for nurses to lead experimental research in other perioperative priority areas and within different populations that have been neglected, such as in the population of older adults undergoing surgery.
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Affiliation(s)
- Judy Munday
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Department of Health and Nursing Science, University of Agder, Grimstad, 4879, Norway
- Mater Research Institute-UQ, South Brisbane, QLD4101, Australia
| | - Niall Higgins
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD4029, Australia
| | - Saira Mathew
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Lizanne Dalgleish
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD4029, Australia
| | - Anthony S Batterbury
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD4029, Australia
| | - Luke Burgess
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Mater Research Institute-UQ, South Brisbane, QLD4101, Australia
| | - Jill Campbell
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD4029, Australia
| | - Lori J Delaney
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Colleges of Health and Medicine, Australian National University, Acton, ACT2601, Australia
| | - Bronwyn R Griffin
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - James A Hughes
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD4029, Australia
| | - Jessica Ingleman
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Samantha Keogh
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD4029, Australia
- Alliance for Vascular Access Teaching and Research, Griffith University, Brisbane, QLD, 4111, Australia
| | - Fiona Coyer
- Centre for Healthcare Transformation, Faculty of Health, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- School of Nursing, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Royal Brisbane and Women’s Hospital, Herston, QLD4029, Australia
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16
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Hosie A, Phillips J, Lam L, Kochovska S, Noble B, Brassil M, Kurrle S, Cumming A, Caplan GA, Chye R, Ely EW, Lawlor PG, Bush SH, Davis JM, Lovell M, Parr C, Williams S, Hauser K, McArdle S, Jacquier K, Phillipson C, Kuwahata L, Kerfoot J, Brown L, Fazekas B, Cheah SL, Edwards L, Green A, Hunt J, Attwood R, Assen T, Garcia M, Wilcock J, Agar M. A Multicomponent Nonpharmacological Intervention to Prevent Delirium for Hospitalized People with Advanced Cancer: A Phase II Cluster Randomized Waitlist Controlled Trial (The PRESERVE Pilot Study). J Palliat Med 2020; 23:1314-1322. [PMID: 32343634 DOI: 10.1089/jpm.2019.0632] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background: Delirium is a common debilitating complication of advanced cancer. Objective: To determine if a multicomponent nonpharmacological delirium prevention intervention was feasible for adult patients with advanced cancer, before a phase III (efficacy) trial. Design: Phase II (feasibility) cluster randomized controlled trial. All sites implemented delirium screening and diagnostic assessment. Strategies within sleep, vision and hearing, hydration, orientation, mobility, and family domains were delivered to enrolled patients at intervention site admission days 1-7. Control sites then implemented the intervention ("waitlist sites"). Setting: Four Australian palliative care units. Measurements: The primary outcome was adherence, with an a priori endpoint of at least 60% patients achieving full adherence. Secondary outcomes were interdisciplinary care delivery, delirium measures, and adverse events, analyzed descriptively and inferentially. Results: Sixty-five enrolled patients (25 control, 20 intervention, and 20 waitlist) had 98% delirium screens and 75% diagnostic assessments completed. Nurses (67%), physicians (16%), allied health (8.4%), family (7%), patients (1%), and volunteers (0.5%) delivered the intervention. There was full adherence for 5% patients at intervention sites, partial for 25%. Both full and partial adherence were higher at waitlist sites: 25% and 45%, respectively. One-third of control site patients (32%) became delirious within seven days of admission compared to one-fifth (20%) at both intervention and waitlist sites (p = 0.5). Mean (standard deviation) Delirium Rating Scale-Revised-1998 scores were 16.8 + 12.0 control sites versus 18.4 + 8.2 (p = 0.6) intervention and 18.7 + 7.8 (p = 0.5) waitlist sites. The intervention caused no adverse events. Conclusion: The intervention requires modification for optimal adherence in a phase III trial.
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Affiliation(s)
- Annmarie Hosie
- School of Nursing Sydney, The University of Notre Dame Australia, Darlinghurst, New South Wales, Australia.,St. Vincent's Health Network Sydney, Darlinghurst, New South Wales, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jane Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Lawrence Lam
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Beverly Noble
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Meg Brassil
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Susan Kurrle
- Northern Clinical School, Hornsby Ku-ring-gai Health Service, University of Sydney, Hornsby, New South Wales, Australia
| | - Anne Cumming
- Australian Commission on Safety and Quality in Health Care, Sydney, New South Wales, Australia
| | - Gideon A Caplan
- Prince of Wales Hospital, Geriatric Medicine, Randwick, New South Wales, Australia.,UNSW Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Richard Chye
- St. Vincent's Health Network Sydney, Darlinghurst, New South Wales, Australia.,UNSW Medicine, University of New South Wales, Randwick, New South Wales, Australia
| | - Eugene Wesley Ely
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Vanderbilt University, Nashville, Tennessee, USA.,Tennessee Valley Veteran's Affairs Geriatric Research Education Clinical Center (GRECC), Nashville, Tennessee, USA
| | - Peter G Lawlor
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Shirley H Bush
- Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Department of Medicine, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Palliative Care, Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Jan Maree Davis
- Department of Palliative Care, Calvary Health Care Kogarah, Kogarah, New South Wales, Australia
| | - Melanie Lovell
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia.,Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Cynthia Parr
- HammondCare, Greenwich Hospital, Greenwich, New South Wales, Australia
| | - Sally Williams
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Katherine Hauser
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Susan McArdle
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Karen Jacquier
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | - Carl Phillipson
- The Queen Elizabeth Hospital, Woodville, South Australia, Australia
| | | | | | - Linda Brown
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Belinda Fazekas
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Seong Leang Cheah
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Layla Edwards
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Anna Green
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Jane Hunt
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Robyn Attwood
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Teresa Assen
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Maja Garcia
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Julie Wilcock
- Ingham Institute, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Meera Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,Ingham Institute, Liverpool Hospital, Liverpool, New South Wales, Australia
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17
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Predisposing and precipitating risk factors for delirium in palliative care patients. Palliat Support Care 2019; 18:437-446. [DOI: 10.1017/s1478951519000919] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
AbstractObjectiveDelirium is a common complication in palliative care patients, especially in the terminal phase of the illness. To date, evidence regarding risk factors and prognostic outcomes of delirium in this vulnerable population remains sparse.MethodIn this prospective observational cohort study at a tertiary care center, 410 palliative care patients were included. Simple and multiple logistic regression models were used to identify associations between predisposing and precipitating factors and delirium in palliative care patients.ResultsThe prevalence of delirium in this palliative care cohort was 55.9% and reached 93% in the terminally ill. Delirium was associated with prolonged hospitalization (p < 0.001), increased care requirements (p < 0.001) and health care costs (p < 0.001), requirement for institutionalization (OR 0.11; CI 0.069–0.171; p < 0.001), and increased mortality (OR 18.29; CI 8.918–37.530; p < 0.001). Predisposing factors for delirium were male gender (OR 2.19; CI 1.251–3.841; p < 0.01), frailty (OR 15.28; CI 5.885–39.665; p < 0.001), hearing (OR 3.52; CI 1.721–7.210; p < 0.001), visual impairment (OR 3.15; CI 1.765–5.607; p < 0.001), and neoplastic brain disease (OR 3.63; CI 1.033–12.771; p < 0.05). Precipitating factors for delirium were acute renal failure (OR 6.79; CI 1.062–43.405; p < 0.05) and pressure sores (OR 3.66; CI 1.102–12.149; p < 0.05).Significance of resultsOur study identified several predisposing and precipitating risk factors for delirium in palliative care patients, some of which can be targeted early and modified to reduce symptom burden.
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18
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Hosie A, Siddiqi N, Featherstone I, Johnson M, Lawlor PG, Bush SH, Amgarth-Duff I, Edwards L, Cheah SL, Phillips J, Agar M. Inclusion, characteristics and outcomes of people requiring palliative care in studies of non-pharmacological interventions for delirium: A systematic review. Palliat Med 2019; 33:878-899. [PMID: 31250725 DOI: 10.1177/0269216319853487] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Delirium is common, distressing, serious and under-researched in specialist palliative care settings. OBJECTIVES To examine whether people requiring palliative care were included in non-pharmacological delirium intervention studies in inpatient settings, how they were characterised and what their outcomes were. DESIGN Systematic review (PROSPERO 2017 CRD42017062178). DATA SOURCES Systematic search in March 2017 for non-pharmacological delirium intervention studies in adult inpatients. Database search terms were 'delirium', 'hospitalisation', 'inpatient', 'palliative care', 'hospice', 'critical care' and 'geriatrics'. Scottish Intercollegiate Guidelines Network methodological checklists guided risk of bias assessment. RESULTS The 29 included studies were conducted between 1994 and 2015 in diverse settings in 15 countries (9136 participants, mean age = 76.5 years (SD = 8.1), 56% women). Most studies tested multicomponent interventions (n = 26) to prevent delirium (n = 19). Three-quarters of the 29 included studies (n = 22) excluded various groups of people requiring palliative care; however, inclusion criteria, participant diagnoses, illness severity and mortality indicated their presence in almost all studies (n = 26). Of these, 21 studies did not characterise participants requiring palliative care or report their specific outcomes (72%), four reported outcomes for older people with frailty, dementia, cancer and comorbidities, and one was explicitly focused on people receiving palliative care. Study heterogeneity and limitations precluded definitive determination of intervention effectiveness and only allowed interpretations of feasibility for people requiring palliative care. Acceptability outcomes (intervention adverse events and patients' subjective experience) were rarely reported overall. CONCLUSION Non-pharmacological delirium interventions have frequently excluded and under-characterised people requiring palliative care and infrequently reported their outcomes.
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Affiliation(s)
- Annmarie Hosie
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | | | | | - Peter G Lawlor
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Shirley H Bush
- 4 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,5 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,6 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | | | - Layla Edwards
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Jane Phillips
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | - Meera Agar
- 1 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
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Watt CL, Momoli F, Ansari MT, Sikora L, Bush SH, Hosie A, Kabir M, Rosenberg E, Kanji S, Lawlor PG. The incidence and prevalence of delirium across palliative care settings: A systematic review. Palliat Med 2019; 33:865-877. [PMID: 31184538 PMCID: PMC6691600 DOI: 10.1177/0269216319854944] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed. AIM Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings. DESIGN This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment. DATA SOURCES Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included. RESULTS Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer (n = 34) and mixed diagnoses (n = 8) were represented. Delirium point prevalence estimates were 4%-12% in the community, 9%-57% across hospital palliative care consultative services, and 6%-74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings (n = 8) was 42%-88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29-0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used. CONCLUSION Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.
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Affiliation(s)
- Christine L Watt
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada
| | - Franco Momoli
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,4 Children's Hospital of Eastern Ontario Research Institute, Ottawa, ON, Canada.,5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Mohammed T Ansari
- 5 School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Lindsey Sikora
- 6 Health Sciences Library, University of Ottawa, Ottawa, ON, Canada
| | - Shirley H Bush
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
| | - Annmarie Hosie
- 8 IMPACCT, University of Technology Sydney, Ultimo, NSW, Australia
| | | | - Erin Rosenberg
- 9 Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,10 Department of Critical Care, The Ottawa Hospital, Ottawa, ON, Canada
| | - Salmaan Kanji
- 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,11 Department of Pharmacy, The Ottawa Hospital, Ottawa, ON, Canada.,12 Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Peter G Lawlor
- 1 Division of Palliative Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.,2 Division of Palliative Care, Bruyère Continuing Care, Élisabeth Bruyère Hospital, Ottawa, ON, Canada.,3 Ottawa Hospital Research Institute, Ottawa, ON, Canada.,7 Bruyère Research Institute, Ottawa, ON, Canada
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