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Tavabie S, Ta Y, Stewart E, Tavabie O, Bowers S, White N, Seton-Jones C, Bass S, Taubert M, Berglund A, Ford-Dunn S, Cox S, Minton O. Seeking Excellence in End of Life Care UK (SEECare UK): a UK multi-centred service evaluation. BMJ Support Palliat Care 2023:spcare-2023-004177. [PMID: 37433625 DOI: 10.1136/spcare-2023-004177] [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: 01/19/2023] [Accepted: 05/17/2023] [Indexed: 07/13/2023]
Abstract
OBJECTIVE To evaluate the care of patients dying in hospital without support from specialists in palliative care (SPC), better understand their needs and factors influencing their care. METHODS Prospective UK-wide service evaluation including all dying adult inpatients unknown to SPC, excluding those in emergency departments/intensive care units. Holistic needs were assessed through a standardised proforma. RESULTS 88 hospitals, 284 patients. 93% had unmet holistic needs, including physical symptoms (75%) and psycho-socio-spiritual needs (86%). People were more likely to have unmet needs and require SPC intervention at a district general hospital (DGH) than a teaching hospital/cancer centre (unmet need 98.1% vs 91.2% p0.02; intervention 70.9% vs 50.8% p0.001) and when end-of-life care plans (EOLCP) were not used (unmet need 98.3% vs 90.3% p0.006; intervention 67.2% vs 53.3% p0.02). Multivariable analyses demonstrated the independent influence of teaching/cancer hospitals (adjusted OR (aOR)0.44 CI 0.26 to 0.73) and increased SPC medical staffing (aOR1.69 CI 1.04 to 2.79) on need for intervention, however, integrating the use of EOLCP reduced the impact of SPC medical staffing. CONCLUSION People dying in hospitals have significant and poorly identified unmet needs. Further evaluation is required to understand the relationships between patient, staff and service factors influencing this. The development, effective implementation and evaluation of structured individualised EOLCP should be a research funding priority.
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Affiliation(s)
- Simon Tavabie
- Transforming End of Life Care, University College London Hospitals NHS Foundation Trust, London, UK
| | - Yinting Ta
- Palliative Medicine, St Bartholomew's Hospital, London, UK
| | - Eleanor Stewart
- Palliative Medicine, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Oliver Tavabie
- Gastroenterology, Kingston Hospital NHS Foundation Trust, Kingston upon Thames, UK
| | - Sarah Bowers
- Palliative Medicine, NHS Tayside, Dundee, UK
- Medicine, University of St Andrews, St Andrews, UK
| | - Nicola White
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | | | - Stephen Bass
- Palliative Care Team, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Mark Taubert
- Velindre Cancer Centre, Velindre NHS Trust, Cardiff, UK
| | - Anja Berglund
- Palliative Medicine, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Suzanne Ford-Dunn
- Palliative Medicine, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
| | - Sarah Cox
- Palliative Medicine, Chelsea and Westminster Healthcare NHS Trust, London, UK
| | - Ollie Minton
- Palliative Medicine, University Hospitals Sussex NHS Foundation Trust, Worthing, UK
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Sallnow L, Smith R, Ahmedzai SH, Bhadelia A, Chamberlain C, Cong Y, Doble B, Dullie L, Durie R, Finkelstein EA, Guglani S, Hodson M, Husebø BS, Kellehear A, Kitzinger C, Knaul FM, Murray SA, Neuberger J, O'Mahony S, Rajagopal MR, Russell S, Sase E, Sleeman KE, Solomon S, Taylor R, Tutu van Furth M, Wyatt K. Report of the Lancet Commission on the Value of Death: bringing death back into life. Lancet 2022; 399:837-884. [PMID: 35114146 PMCID: PMC8803389 DOI: 10.1016/s0140-6736(21)02314-x] [Citation(s) in RCA: 170] [Impact Index Per Article: 85.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 02/07/2023]
Affiliation(s)
| | | | | | - Afsan Bhadelia
- Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Yali Cong
- Peking University Health Science Center, Beijing, China
| | | | | | | | | | | | | | | | | | | | | | | | - Julia Neuberger
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | - Sarah Russell
- Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Eriko Sase
- Georgetown University, Washington, DC, USA
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Mori M, Kawaguchi T, Imai K, Yokomichi N, Yamaguchi T, Suzuki K, Matsunuma R, Watanabe H, Maeda I, Matsumoto Y, Matsuda Y, Morita T. Visualizing How to Use Parenteral Opioids for Terminal Cancer Dyspnea: A Pilot, Multicenter, Prospective, Observational Study. J Pain Symptom Manage 2021; 62:936-948. [PMID: 33992759 DOI: 10.1016/j.jpainsymman.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/28/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT How physicians use opioids for dyspnea in imminently dying cancer patients (terminal dyspnea) varies markedly, which could hamper quality care. OBJECTIVES To examine the adherence to an algorithm-based treatment for terminal dyspnea, and explore its outcomes over 24 hours. METHODS This was a pre-planned subgroup analysis of a multicenter prospective observational study. Inclusion criteria were: advanced cancer patients admitted to palliative care units, ECOG performance status = 3-4, and a dyspnea intensity ≥2 on the Integrated Palliative care Outcome Scale (IPOS). We developed an algorithm to visualize how palliative care physicians would use parenteral opioids. Participating physicians (palliative care specialists) initiated parenteral opioids, choosing whether to use the algorithm based on their preference. We measured the adherence rate to the algorithm over 24 hours (predefined goal = 70%), and compared dyspnea IPOS scores and adverse events between patients with and without algorithm-based treatment. RESULTS Of 164 patients (median survival = 5 days), 71 (43%) received algorithm-based treatment, and 70 (99%; 95% confidence interval = 92%-100%) adhered to it over 24 hours. In a complete case analysis, mean dyspnea IPOS scores significantly decreased from 2.9 (standard error = 0.1) to 1.5 (0.1) in the algorithm group (n = 54; P < 0.001), and 2.9 (0.1) to 1.6 (0.1) in the non-algorithm group (n = 72; P < 0.001). There was no significant between-group difference in changes in dyspnea IPOS scores (P = 0.65). Adverse events were rare (n = 5). CONCLUSION The algorithm-based treatment was feasible, and might be as effective and safe as the usual care by palliative care specialists. Its implementation may help physicians provide quality care for terminal dyspnea.
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Affiliation(s)
- Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan.
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Medical Center, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-chuo Hospital, Osaka, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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Higginson IJ, Reilly CC, Maddocks M. Breathlessness. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Atallah A, Butin M, Moret S, Claris O, Massoud M, Gaucherand P, Doret-Dion M. Standardized healthcare pathway in intrauterine growth restriction and minimum evidence-based care. J Gynecol Obstet Hum Reprod 2020; 50:101998. [PMID: 33221557 DOI: 10.1016/j.jogoh.2020.101998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Fetal growth restricted fetuses are less likely to receive evidence-based care; a previous work demonstrated an improvement in neonatal prognosis when fetuses with intrauterine growth restriction (IUGR) received minimum evidence based-care. OBJECTIVE The objective of the study was to evaluate the impact of a standardized healthcare pathway on the implementation of the recommended clinical practice in the antenatal management of IUGR fetuses, in comparison to a traditional pathway. The quality of the implementation of practice has been defined whether or not minimum evidence-based care (MEC), defined according to the recommendations of the French college of gynecologists and obstetricians (CNGOF), has been implemented. STUDY DESIGN From a historical cohort of 31,052 children, born at the Femme Mère Enfant Hospital (Lyon, France) between January 1st, 2011 and December 31st, 2017, we selected the population of IUGR fetuses. We compared the rate of MEC between the IUGR fetuses followed-up in the traditional healthcare pathway versus the IUGR fetuses followed-up in a standardized healthcare pathway between 2015 and 2017. RESULTS A total of 245 IUGR were tracked between 2015 and 2017. Over this period, 120 fetuses were followed within the traditional pathway and 125 within the IUGR pathway. The standardized pathway resulted in a higher rate of MEC (86,4%) when compared to IUGR fetuses followed-up in the traditional pathway (27,5% (OR* 20 (95 % CI 10.0-39.7). Among early-onset IUGR: 31 % received MEC in the traditional pathway versus 83 % in the standardized pathway (p<0.001). Among late-onset IUGR: 22 % received MEC in the traditional pathway versus 92 % in the standardized pathway (p<0.001). The provided care in the standardized pathway resulted in an increase of complete antenatal corticosteroid therapy (92,8 %) when compared to the traditional pathway (50.0 %; p<0.001) and a reduction of the rate of caesarean sections before labor for non-reassuring fetal heart rate (15 %) when compared to the traditional pathway (41.3 % p=0.007). CONCLUSION The standardized pathway improves the implementation of the local recommendations in the management of early- and late-onset IUGR. This study is the first to suggest a standardized care pathway in prenatal medicine. A medico-economic study could estimate the health care savings that such a pathway would provide by allowing a medical management in accordance with the recommendations.
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Affiliation(s)
- Anthony Atallah
- Hospices Civils de Lyon, Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France; University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, HESPER EA 7425, F-69008 Lyon, F-42023, Saint-Etienne, France.
| | - Marine Butin
- Hospices Civils de Lyon, Department of Neonatalogy, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel 69500, Bron, France; International Center for Research in Infectiology, INSERM U1111, CNRS UMR5308, University of Lyon 1, Lyon, France.
| | - Stéphanie Moret
- Hospices Civils de Lyon, Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.
| | - Olivier Claris
- Hospices Civils de Lyon, Department of Neonatalogy, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel 69500, Bron, France; University of Lyon, EA, 4129, Lyon, France.
| | - Mona Massoud
- Hospices Civils de Lyon, Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France.
| | - Pascal Gaucherand
- Hospices Civils de Lyon, Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France; University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, HESPER EA 7425, F-69008 Lyon, F-42023, Saint-Etienne, France.
| | - Muriel Doret-Dion
- Hospices Civils de Lyon, Department of Obstetrics and Gynecology, Femme Mère Enfant Hospital, University Hospital Center, 59 Boulevard Pinel, 69500, Bron, France; University of Lyon, University Claude Bernard Lyon 1, University of Saint-Étienne, HESPER EA 7425, F-69008 Lyon, F-42023, Saint-Etienne, France.
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Bertocchi E, Artioli G, Rabitti E, Bedini G, Di Leo S, Asensio Sierra NM, Braglia L, Costantini M. Quality of cancer end-of-life care: discordance between bereaved relatives and professional proxies. BMJ Support Palliat Care 2020; 12:bmjspcare-2019-002108. [PMID: 32690478 DOI: 10.1136/bmjspcare-2019-002108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 04/07/2020] [Accepted: 06/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Quality of care for patients dying in hospital remains suboptimal. A major problem is the identification of valid sources of information about the views and experiences of dying patients and their relatives. AIM This study aimed to estimate the agreement on quality of end-of-life care from the perspectives of bereaved relatives, physicians and nurses interviewed after the patients' death. DESIGN In this prospective study, we interviewed, after the patient death, the bereaved relatives, the attending physicians and the reference nurses, using the Toolkit After-death Family Interview and the View Of Informal Carers-Evaluation of Services (VOICES). Agreement was assessed using Lin's concordance correlation coefficient, Cohen's kappa, overall concordance correlation coefficient and Fleiss' kappa. SETTING/PARTICIPANTS We enrolled a consecutive series of 40 adult patients who died of cancer between January and December 2016 who had spent at least 48 hours in the medical oncology ward of the Santa Maria Hospital of Reggio Emilia, Italy. RESULTS We interviewed all physicians and nurses, and 26 (65.0%) out of 40 relatives. We found a poor agreement on overall quality of care among the three proxies (+0.21; -0.04 to 0.44), between relatives and nurses (+0.05; -0.39 to +0.47), and between relatives and physicians (+0.25; -0.13 to +0.57). A similar poor agreement was observed for all the other Toolkit and VOICES scales. CONCLUSIONS The agreement was rather poor, confirming previous results in different settings. Information from professional proxies should not be used for assessing the quality of care or for estimating missing information from bereaved relatives.
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Affiliation(s)
- Elisabetta Bertocchi
- Palliative Care Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Giovanna Artioli
- Palliative Care Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Elisa Rabitti
- Psycho-Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Gabriele Bedini
- Casa Madonna dell'Uliveto Hospice, Albinea, Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Silvia Di Leo
- Psycho-Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Nuria Maria Asensio Sierra
- Medicina Oncologica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Luca Braglia
- Research and Statistics Infrastructure, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Massimo Costantini
- Scientific Directorate, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
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Seckler E, Regauer V, Rotter T, Bauer P, Müller M. Barriers to and facilitators of the implementation of multi-disciplinary care pathways in primary care: a systematic review. BMC FAMILY PRACTICE 2020; 21:113. [PMID: 32560697 PMCID: PMC7305630 DOI: 10.1186/s12875-020-01179-w] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/28/2020] [Indexed: 12/11/2022]
Abstract
Background Care pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered. The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC). Methods A systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed. Results Fourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied. The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multi-disciplinary communication and individual tailored interventions were identified as facilitators. Conclusions In the implementation of CPWs in PC, a multitude of barriers and facilitators must be considered, and most of them can be modified through the careful design of intervention and implementation strategies. Furthermore, process evaluations must become a standard component of implementing CPWs to enable other projects to build upon previous experience. Trial registration PROSPERO 2018 CRD42018087689.
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Affiliation(s)
- Eva Seckler
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Hochschulstraße 1, 83024, Rosenheim, Germany. .,Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Marchioninistraße 17, 81377, Munich, Germany.
| | - Verena Regauer
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Hochschulstraße 1, 83024, Rosenheim, Germany.,Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Marchioninistraße 17, 81377, Munich, Germany
| | - Thomas Rotter
- Healthcare Quality Programs, Queen's University, 84 Barrie Street, Kingston, Ontario, K7L 3N6, Canada
| | - Petra Bauer
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Hochschulstraße 1, 83024, Rosenheim, Germany.,Faculty for Applied Health and Social Sciences, Rosenheim Technical University of Applied Sciences, Hochschulstraße 1, 83024, Rosenheim, Germany
| | - Martin Müller
- Centre for Research, Development and Technology Transfer, Rosenheim Technical University of Applied Sciences, Hochschulstraße 1, 83024, Rosenheim, Germany.,Faculty for Applied Health and Social Sciences, Rosenheim Technical University of Applied Sciences, Hochschulstraße 1, 83024, Rosenheim, Germany
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Abstract
Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.
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Affiliation(s)
- David Hui
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- University of Texas MD Anderson Cancer Center, Houston, TX
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9
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Abstract
The authors conducted an integrative review to determine evidence-based and most efficient strategies for improving the palliative care of patients at the end-of-life stage. Thirteen articles that met the overall inclusion criteria were evaluated. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart approach was used for the screening process. The Critical Appraisal Skill Program and the Mixed-Methods Appraisal Tool were also used for the critical appraisal of the data. Full reports of relevant articles were retrieved, and data were extracted by 2 reviewers independently. The quality of studies was appraised in reference to Consolidated Criteria for Reporting Qualitative Research guidelines. Key aspects included communication and coordination among the team members-patient-centered approach. The major theme was the application of a holistic approach to palliative care consisting of providing comfort to the dying patient. It was identified that relationships, which were identified as spiritual needs, are also crucial to the improvement of palliative care. Improving nursing education in this area, undertaking appropriate curriculum development, and providing coordination among training programs will help knowledgeable health care providers deliver compassionate, affordable, sustainable, and high-quality care to a growing population of aging patients facing the end of their lives.
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Sharpe KK, Noble C, Hiremagular B, Grealish L. Implementing an integrated pathway to care for the dying: is your organisation ready? Int J Palliat Nurs 2019; 24:70-78. [PMID: 29469642 DOI: 10.12968/ijpn.2018.24.2.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Integrated pathways for care of the dying aim to promote the delivery of high-quality palliative care, regardless of access to specialist services. AIM To produce a heuristic technique to assist with planning and evaluating the integration of the care of the dying pathway into everyday work. METHODS Electronic databases were searched to identify research papers focused on the implementation of integrated pathways for care of the dying in acute hospital settings. RESULTS A total of 13 articles were reviewed using the four elements of normalisation process theory-coherence, cognitive participation, collective action and reflexive monitoring. These results informed the development of a heuristic for organisational readiness. CONCLUSION The organisational readiness heuristic provides an evidence-based checklist for organisational leaders who are planning to introduce new, or evaluate current, integrated pathways for care of the dying. The next step is to trial the heuristic for feasibility in practice.
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Affiliation(s)
- Kendall K Sharpe
- Medical Education Registrar, Gold Coast Health, Queensland, Australia
| | - Christy Noble
- Principal Medical Education Officer; Principal Research Fellow (Allied Health), Gold Coast Health, Queensland, Australia
| | - Balaji Hiremagular
- Senior Staff Specialist, Nephrology, Gold Coast Health, Queensland, Australia
| | - Laurie Grealish
- Associate Professor, Subacute and Aged Nursing, Gold Coast Health, Queensland; Menzies Health Institute, Griffith University, Queensland, Australia
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Managing uncertain recovery for patients nearing the end of life in hospital: a mixed-methods feasibility cluster randomised controlled trial of the AMBER care bundle. Trials 2019; 20:506. [PMID: 31419994 PMCID: PMC6697995 DOI: 10.1186/s13063-019-3612-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/23/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The AMBER (Assessment, Management, Best Practice, Engagement, Recovery Uncertain) care bundle is a complex intervention used in UK hospitals to support patients with uncertain recovery. However, it has yet to be evaluated in a randomised controlled trial (RCT) to identify potential benefits or harms. The aim of this trial was to investigate the feasibility of a cluster RCT of the AMBER care bundle. METHODS This is a prospective mixed-methods feasibility cluster RCT. Quantitative data collected from patients (or proxies if patients lack capacity) were used (i) to examine recruitment, retention and follow-up rates; (ii) to test data collection tools for the trial and determine their optimum timing; (iii) to test methods to identify the use of financial resources; and (iv) to explore the acceptability of study procedures for health professionals and patients. Descriptive statistical analyses and thematic analysis used the framework approach. RESULTS In total, 894 patients were screened, of whom 220 were eligible and 19 of those eligible (8.6%) declined to participate. Recruitment to the control arm was challenging. Of the 728 patients screened for that arm, 647 (88.9%) were excluded. Overall, 65 patients were recruited (81.3% of the recruitment target of 80). Overall, many were elderly (≥80 years, 46.2%, n = 30, mean = 77.8 years, standard deviation [SD] = 12.3 years). Over half (53.8%) had a non-cancer diagnosis, with a mean of 2.3 co-morbidities; 24.6% patients (n = 16) died during their hospital stay and 35.4% (n = 23) within 100 days of discharge. In both trial arms, baseline IPOS subscale scores identified moderate patient anxiety (control: mean 13.3, SD 4.8; intervention: mean 13.3, SD 5.1), and howRwe identified a good care experience (control: mean 13.1, SD 2.5; intervention: mean 11.5, SD 2.1). Collecting quantitative service use and quality of life data was feasible. No patient participants regarded study involvement negatively. Focus groups with health professionals identified concerns regarding (i) the subjectivity of the intervention's eligibility criteria, (ii) the need to prognosticate to identify potential patients and (iii) consent procedures and the length of the questionnaire. CONCLUSIONS A full trial of the AMBER care bundle is technically feasible but impractical due to fundamental issues in operationalising the intervention's eligibility criteria, which prevents optimal recruitment. Since this complex intervention continues to be used in clinical care and advocated in policy, alternative research approaches must be considered and tested. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number (ISRCTN) Register, ISRCTN36040085 .
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Starks MA, Sanders GD, Coeytaux RR, Riley IL, Jackson LR, Brooks AM, Thomas KL, Choudhury KR, Califf RM, Hernandez AF. Assessing heterogeneity of treatment effect analyses in health-related cluster randomized trials: A systematic review. PLoS One 2019; 14:e0219894. [PMID: 31404063 PMCID: PMC6690528 DOI: 10.1371/journal.pone.0219894] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 07/04/2019] [Indexed: 01/28/2023] Open
Abstract
Background Cluster-randomized trials (CRTs) are being increasingly used to test a range of interventions, including medical interventions commonly used in clinical practice. Policies created by the NIH and the Food and Drug Administration (FDA) require the reporting of demographics and the examination of demographic heterogeneity of treatment effect (HTE) for individually randomized trials. Little is known about how frequent demographics are reported and HTE analyses are conducted in CRTs. Objectives We sought to understand the prevalence of HTE analyses and the statistical methods used to conduct them in CRTs focused on treating cardiovascular disease, cancer, and chronic lower respiratory diseases. Additionally, we also report on the proportion of CRTs that reported on baseline demographics of its populations and conducted demographic HTE analyses. Data sources We searched PubMed and Embase for CRTs published between 1/1/2010 and 3/29/2016 that focused on treating the top 3 Center for Disease Control causes of death (cardiovascular disease, chronic lower respiratory disease, and cancer). Evidence Screening And Review: Of 1,682 unique titles, 117 abstracts were screened. After excluding 53 articles, we included 64 CRT publications and abstracted information on study characteristics and demographic information, statistical analysis, HTE analysis, and study quality. Results Age and sex were reported in greater than 95.3% of CRTs, while race and ethnicity were reported in only 20.3% of CRTs. HTE analyses were conducted in 28.1% (n = 18) of included CRTs and 77.8% (n = 12) were prespecified analyses. Four CRTs conducted a demographic subgroup analysis. Only 6/18 CRTs used interaction testing to determine whether HTE existed. Conclusions Baseline demographic reporting was high for age and sex in CRTs, but was uncommon for race and ethnicity. HTE analyses were uncommon and was rare for demographic subgroups, which limits the ability to examine the extent of benefits or risks for treatments tested with CRT designs.
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Affiliation(s)
- Monique Anderson Starks
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
- * E-mail:
| | - Gillian D. Sanders
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Remy Rene Coeytaux
- Department of Family and Community Medicine, Wake Forest School of Medicine; Winston-Salem, NC, United States of America
| | - Isaretta L. Riley
- Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Larry R. Jackson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Amanda McBroom Brooks
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
| | - Kevin L. Thomas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Kingshuk Roy Choudhury
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, United States of America
| | - Robert M. Califf
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, United States of America
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, United States of America
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Moon F, Fraser L, McDermott F. Sitting with silence: hospital social work interventions for dying patients and their Families. SOCIAL WORK IN HEALTH CARE 2019; 58:444-458. [PMID: 30887906 DOI: 10.1080/00981389.2019.1586027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 02/06/2019] [Accepted: 02/15/2019] [Indexed: 06/09/2023]
Abstract
The recent controversy around the hospital end of life care has highlighted the vulnerability of dying patients and their families. However, little is known about how social workers provide support and intervention around the end of life in the hospital. Eight hospital social workers provided qualitative descriptions of their clinical practice for adult patients and their families. Highlighting a theoretical orientation towards a person-in-environment approach, social workers develop unique interventions to contribute to multidisciplinary care. Findings emphasize the need to prepare social work students and clinicians for the reality of working with end of life issues.
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Affiliation(s)
- Felicity Moon
- a Social Work Department , Monash Medical Centre Clayton , Clayton , Australia
| | - Lucinda Fraser
- a Social Work Department , Monash Medical Centre Clayton , Clayton , Australia
| | - Fiona McDermott
- b Monash Medical Centre Clayton , Monash Health & Monash University , Clayton , Australia
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Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol 2018; 19:e588-e653. [DOI: 10.1016/s1470-2045(18)30415-7] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/16/2018] [Accepted: 05/22/2018] [Indexed: 02/06/2023]
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15
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Brinkman-Stoppelenburg A, Witkamp FE, van Zuylen L, van der Rijt CCD, van der Heide A. Palliative care team consultation and quality of death and dying in a university hospital: A secondary analysis of a prospective study. PLoS One 2018; 13:e0201191. [PMID: 30138316 PMCID: PMC6107115 DOI: 10.1371/journal.pone.0201191] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 07/10/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Involvement of palliative care experts improves the quality of life and satisfaction with care of patients who are in the last stage of life. However, little is known about the relation between palliative care expert involvement and quality of dying (QOD) in the hospital. We studied the association between palliative care team (PCT) consultation and QOD in the hospital as experienced by relatives. METHODS We conducted a secondary analysis of data from a prospective study among relatives of patients who died from cancer in a university hospital and compared characteristics and QOD of patients for whom the PCT was or was not consulted. RESULTS 175 out of 343 (51%) relatives responded to the questionnaire. In multivariable linear regression PCT was associated with a 1.0 point better QOD (95% CI 0.07-1.96). In most of the subdomains of QOD, we found a non-significant trend towards a more favorable outcome for patients for whom the PCT was consulted. Patients for whom the PCT was consulted had more often discussed their preferences for medical treatment, had more often been aware of their imminent death and had more often been at peace with their imminent death. Further, patients for whom the PCT was consulted and their relatives had more often been able to say goodbye. Relatives had also more often been present at the moment of death when a PCT had been consulted. CONCLUSION For patients dying in the hospital, palliative care consultation is associated with a favorable QOD.
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Affiliation(s)
| | - Frederika E. Witkamp
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
- Faculty of Nursing and Center of Expertise in Care Innovations, Rotterdam University of Applied Sciences, Rotterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | | | - Agnes van der Heide
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, the Netherlands
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Kanno Y, Sato K, Shimizu M, Funamizu Y, Andoh H, Kishino M, Senaga T, Takahashi T, Miyashita M. Validity and Reliability of the Dying Care Process and Outcome Scales Before and After Death From the Bereaved Family Members' Perspective. Am J Hosp Palliat Care 2018; 36:130-137. [PMID: 29945455 DOI: 10.1177/1049909118785178] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE: There are no instruments evaluating the processes and outcomes of dying care right before and after death. Therefore, we developed and examined the validity and reliability of 2 scales for evaluating dying care processes and outcomes before and after death. METHODS: A cross-sectional, anonymous questionnaire was administered to bereaved family members of patients with cancer who had died in 5 facilities. We evaluated the Dying Care Process Scale for Bereaved Family Members (DPS-B) and the Dying Care Outcome Scale for Bereaved Family Members (DOS-B) with 345 bereaved family members. RESULTS: A factor analysis revealed that DPS-B and DOS-B each consisted of 4 subscales. For the DPS-B, they were "symptom management," "respect for the patient's dignity before and after death," "explanation to the family," and "family care." For the DOS-B, they were "peaceful dying process for the patient," "being respected as a person before and after death," "good relationship between the patient and family," and "peaceful dying process for the family." Both DPS-B and DOS-B had sufficient convergent and discriminative validity, sufficient internal consistency (DPS-B: α = 0.91 and subscales' αs = 0.78-0.91; DOS-B: α = 0.91 and subscales' αs = 0.78-0.94), and sufficient test-retest reliability (DPS-B: intraclass correlation coefficient [ICC] of total score = 0.79 and subscales = 0.55-0.79; DOS-B: ICC of total score = 0.88 and subscales = 0.70-0.88). SIGNIFICANCE OF RESULTS: Both DPS-B and DOS-B are valid and reliable scales for evaluating the dying care processes and outcomes before and after death from the bereaved family members' perspectives.
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Affiliation(s)
- Yusuke Kanno
- 1 Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Miyagi, Japan.,2 Division of Psycho-Oncology, Exploratory Oncology Research & Clinical Trial Center, National Cancer Center, Chiba, Japan
| | - Kazuki Sato
- 1 Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Miyagi, Japan.,3 Department of Nursing, Nagoya University Graduate School of Medicine, Aichi, Japan
| | - Megumi Shimizu
- 1 Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Miyagi, Japan.,4 Clinical Research, Innovation, and Education Center, Tohoku University Hospital, Miyagi, Japan
| | - Yuko Funamizu
- 5 Department of Palliative Care Team, Nakadori General Hospital, Akita, Japan
| | - Hideaki Andoh
- 6 Department of Clinical Nursing, Akita University Graduate School of Health Science, Akita, Japan
| | - Megumi Kishino
- 7 Department of Palliative Care Unit, Shimura Hospital, Hiroshima, Japan.,8 Department of Nursing/Palliative Care Team, Kobe University Hospital, Hyogo, Japan
| | - Tomomi Senaga
- 9 Department of Palliative Care Unit, Adventist Medical Center, Okinawa, Japan
| | - Tetsu Takahashi
- 10 Department of Surgery, Koga General Hospital, Miyazaki, Japan.,11 Yusho-Kai Home Medical Care Clinic, Kita-Senju, Japan
| | - Mitsunori Miyashita
- 1 Division of Palliative Nursing, Health Sciences, Tohoku University Graduate School of Medicine, Miyagi, Japan
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Seymour J, Clark D. The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England. Wellcome Open Res 2018; 3:15. [PMID: 29881785 PMCID: PMC5963294 DOI: 10.12688/wellcomeopenres.13940.2] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2018] [Indexed: 02/02/2023] Open
Abstract
Background: The Liverpool Care Pathway for the Dying Patient ('LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care. It was discontinued in 2014 following mounting criticism and a national review. Understanding the problems encountered in the roll out of the LCP has crucial importance for future policy making in end of life care. We provide an in-depth account of LCP development and implementation with explanatory theoretical perspectives. We address three critical questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice? 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. We also draw on the 'boundary object' concept and on wider analyses of the use of ICPs. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.
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Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Barber House, Clarkehouse Road, Sheffield, S10 2LA, UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Rutherford/ McCowan Building, Dumfries, DG1 4ZL , UK
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Davies AN, Waghorn M, Webber K, Johnsen S, Mendis J, Boyle J. A cluster randomised feasibility trial of clinically assisted hydration in cancer patients in the last days of life. Palliat Med 2018; 32:733-743. [PMID: 29343167 DOI: 10.1177/0269216317741572] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The provision of clinically assisted hydration at the end-of-life is one of the most contentious issues in medicine. AIM The aim of this feasibility study was to answer the question 'can a definitive (adequately powered) study be done?' DESIGN The study was a cluster randomised trial, with sites randomised on a one-to-one basis to intervention 'A' (regular mouth care and usual other care) or intervention 'B' (clinically assisted hydration, mouth care and usual other care). Participants were assessed every 4 h, and data collected on clinical problems, therapeutic interventions and overall survival. SETTING/PARTICIPANTS The study was conducted at 12 sites/'clusters' with specialist palliative care teams (4 cancer centres and 8 hospices), and participants were cancer patients in the last week of life who were unable to maintain sufficient oral fluid intake. RESULTS The study achieved its pre-determined criteria for success. Two hundred patients were recruited to the study, and 199 participants completed the study, over a 1-year period. A total of 38.5% participants discontinued clinically assisted hydration due to adverse effects: none of these adverse events were rated as 'severe' or worse in intensity. The primary reasons for discontinuation were site problems ( n = 2), localised oedema ( n = 13), generalised oedema ( n = 5), respiratory secretions ( n = 6) and nausea and vomiting ( n = 1). CONCLUSION The results of this feasibility study suggest that a definitive study can be done, but that minor changes are needed to the protocol to standardise the administration of clinically assisted hydration (which may reduce the incidence of certain adverse effects).
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Affiliation(s)
- Andrew N Davies
- 1 Royal Surrey County Hospital, Guildford, UK.,2 University of Surrey, Guildford, UK
| | | | - Katherine Webber
- 1 Royal Surrey County Hospital, Guildford, UK.,2 University of Surrey, Guildford, UK
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Do End-of-Life Care Pathways Improve Outcomes in Caring for the Dying? CLIN NURSE SPEC 2018; 32:19-20. [PMID: 29200036 DOI: 10.1097/nur.0000000000000343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system. AIM To propose optimal payment arrangements for palliative care. APPROACH Review of relevant literature on funding mechanisms in health care generally and palliative care in particular. RESULTS Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting. CONCLUSIONS If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.
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Affiliation(s)
- Stephen Duckett
- Health Program, Grattan Institute, 8 Malvina Place, Carlton, VIC, 3053, Australia.
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21
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Seymour J, Clark D. The Liverpool Care Pathway for the Dying Patient: a critical analysis of its rise, demise and legacy in England. Wellcome Open Res 2018; 3:15. [PMID: 29881785 PMCID: PMC5963294 DOI: 10.12688/wellcomeopenres.13940.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2018] [Indexed: 01/29/2023] Open
Abstract
Background: The Liverpool Care Pathway for the Dying Patient ('the LCP') was an integrated care pathway (ICP) recommended by successive governments in England and Wales to improve end-of-life care, using insights from hospice and palliative care. It was discontinued in 2014 following mounting criticism and a national review. The ensuing debate among clinicians polarised between 'blaming' of the LCP and regret at its removal. Employing the concept of 'boundary objects', we aimed to address three questions: 1) why and how did the LCP come to prominence as a vehicle of policy and practice 2) what factors contributed to its demise? 3) what immediate implications and lessons resulted from its withdrawal? Methods: We use primary and secondary sources in the public domain to assemble a critical and historical review. Results: The rapidity of transfer and translation of the LCP reflected uncritical enthusiasm for ICPs in the early 2000s. The subsequent LCP 'scandal' demonstrated the power of social media in creating knowledge, as well as conflicting perceptions about end-of-life interventions. While the LCP had some weaknesses in its formulation and implementation, it became the bearer of responsibility for all aspects of NHS end-of-life care. This was beyond its original remit. It exposed fault lines in the NHS, provided a platform for debates about the 'evidence' required to underpin innovations in palliative care and became a conduit of discord about 'good' or 'bad' practice in care of the dying. It also fostered a previously unseen critique of assumptions within palliative care. Conclusions: In contrast to most observers of the LCP story who refer to the dangers of scaling up clinical interventions without an evidence base, we call for greater assessment of the wider risks and more careful consideration of the unintended consequences that might result from the roll out of new end-of-life interventions.
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Affiliation(s)
- Jane Seymour
- School of Nursing and Midwifery, University of Sheffield, Barber House, Clarkehouse Road, Sheffield, S10 2LA, UK
| | - David Clark
- School of Interdisciplinary Studies, University of Glasgow, Rutherford/ McCowan Building, Dumfries, DG1 4ZL , UK
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Ang K, Hepgul N, Gao W, Higginson IJ. Strategies used in improving and assessing the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions: A systematic review. Palliat Med 2018; 32:500-516. [PMID: 28691583 DOI: 10.1177/0269216317717369] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Implementation fidelity is critical in evaluating effectiveness of interventions. AIM Identifying and summarising strategies to improve and assess the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions. DESIGN Systematic review. DATA SOURCES Published and completed randomised controlled trials from 2000 to current evaluating effectiveness of specialised palliative care services on patient-centred outcomes in adult patients were examined. MEDLINE was searched from 2008 to 29 September 2015 and supplemented by randomised controlled trials identified in a 2008 systematic review. RESULTS Altogether, 20 randomised controlled trials involving 8426 patients were reviewed using 40 subcomponents of five elements of implementation fidelity (resulting in 20 × 40 = 800 items). Over 88 strategies were identified, classified under the following elements: 'treatment design', 'training providers', 'delivery of treatment', 'receipt of treatment' and 'enactment of treatment skills'. No single overarching strategy was discovered. Strategies under 'treatment design' aimed to ensure equivalent treatment dose between and within intervention and control groups, and delivery of necessary ingredients. Ongoing 'training (of) providers' included supervision and ensuring skill acquisition. Use of treatment manuals and implementation checklists aimed to aid 'delivery of treatment'. Research teams aimed to improve 'receipt of treatment' by transmitting clear information and verifying understanding, while improving 'enactment of treatment skills' by reviewing and reinforcing prior content. Only 26% of the items received sufficient reporting; 34% were either not used or reported on. CONCLUSION Implementation fidelity in palliative care is under-recognised. A table to collate these strategies to improve implementation fidelity in palliative care research and clinical practice is proposed.
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Affiliation(s)
- Kexin Ang
- 1 Department of Neurology, National Neuroscience Institute, Singapore.,2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Nilay Hepgul
- 2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Wei Gao
- 2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Irene J Higginson
- 2 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Chen S, Awan S, Rajji T, Abdool P, George TP, Collins A, Kidd SA. Integrated Care Pathways for Schizophrenia: A Scoping Review. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 43:760-767. [PMID: 26512011 DOI: 10.1007/s10488-015-0696-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This paper summarizes the existing evidence for integrated care pathways (ICPs) for the treatment of schizophrenia. Scoping review methods following PRISMA guidelines were employed due to the variable nature of the evidence in this area. The review identified 13 papers. Of these papers, 7 focused on describing ICP content and process-related data and 6 examined clinical outcomes. Of the 6 studies providing outcome data, 2 reported improved outcomes associated with ICPs. Conceptually, ICPs hold great promise for improving the quality of schizophrenia care. However, in contrast with other specialty healthcare domains, the schizophrenia ICP evidence base is very limited and has not fulsomely begun to address ICPs for effectiveness.
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Affiliation(s)
- Sheng Chen
- Complex Mental Illness Program, Toronto Centre for Addiction and Mental Health, 1001 Queen St. W., Unit 2-1, #161, Toronto, ON, M6J 1H1, Canada
| | - Saima Awan
- ICP Program, Toronto Centre for Addiction and Mental Health, Toronto, Canada
| | - Tarek Rajji
- Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - Petal Abdool
- Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - Tony P George
- Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - April Collins
- Complex Mental Illness Program, Toronto Centre for Addiction and Mental Health, 1001 Queen St. W., Unit 2-1, #161, Toronto, ON, M6J 1H1, Canada
| | - Sean A Kidd
- Complex Mental Illness Program, Toronto Centre for Addiction and Mental Health, 1001 Queen St. W., Unit 2-1, #161, Toronto, ON, M6J 1H1, Canada. .,Department of Psychiatry, Toronto Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada.
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Abstract
Introduction There has been a growing emphasis on the use of integrated care plans to deliver cancer care. However little is known about how integrated care plans for cancer patients are developed including featured core activities, facilitators for uptake and indicators for assessing impact. Methods Given limited consensus around what constitutes an integrated care plan for cancer patients, a scoping review was conducted to explore the components of integrated care plans and contextual factors that influence design and uptake. Results Five types of integrated care plans based on the stage of cancer care: surgical, systemic, survivorship, palliative and comprehensive (involving a transition between stages) are described in current literature. Breast, esophageal and colorectal cancers were common disease sites. Multi-disciplinary teams, patient needs assessment and transitional planning emerged as key features. Provider buy-in and training alongside informational technology support served as important facilitators for plan uptake. Provider-level measurement was considerably less robust compared to patient and system-level indicators. Conclusions Similarities in design features, components and facilitators across the various types of integrated care plans indicates opportunities to leverage shared features and enable a management lens that spans the trajectory of a patient's journey rather than a phase-specific silo approach to care.
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Allanson ER, Tunçalp Ö, Vogel JP, Khan DN, Oladapo OT, Long Q, Gülmezoglu AM. Implementation of effective practices in health facilities: a systematic review of cluster randomised trials. BMJ Glob Health 2017; 2:e000266. [PMID: 29081997 PMCID: PMC5656132 DOI: 10.1136/bmjgh-2016-000266] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 05/16/2017] [Accepted: 06/05/2017] [Indexed: 11/08/2022] Open
Abstract
Background The capacity for health systems to support the translation of research in to clinical practice may be limited. The cluster randomised controlled trial (cluster RCT) design is often employed in evaluating the effectiveness of implementation of evidence-based practices. We aimed to systematically review available evidence to identify and evaluate the components in the implementation process at the facility level using cluster RCT designs. Methods All cluster RCTs where the healthcare facility was the unit of randomisation, published or written from 1990 to 2014, were assessed. Included studies were analysed for the components of implementation interventions employed in each. Through iterative mapping and analysis, we synthesised a master list of components used and summarised the effects of different combinations of interventions on practices. Results Forty-six studies met the inclusion criteria and covered the specialty groups of obstetrics and gynaecology (n=9), paediatrics and neonatology (n=4), intensive care (n=4), internal medicine (n=20), and anaesthetics and surgery (n=3). Six studies included interventions that were delivered across specialties. Nine components of multifaceted implementation interventions were identified: leadership, barrier identification, tailoring to the context, patient involvement, communication, education, supportive supervision, provision of resources, and audit and feedback. The four main components that were most commonly used were education (n=42, 91%), audit and feedback (n=26, 57%), provision of resources (n=23, 50%) and leadership (n=21, 46%). Conclusions Future implementation research should focus on better reporting of multifaceted approaches, incorporating sets of components that facilitate the translation of research into practice, and should employ rigorous monitoring and evaluation.
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Affiliation(s)
- Emma R Allanson
- School of Women's and Infants' Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, Crawley, Australia.,Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Özge Tunçalp
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Joshua P Vogel
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Dina N Khan
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Olufemi T Oladapo
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Qian Long
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
| | - Ahmet Metin Gülmezoglu
- Department of Reproductive Health and Research, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, Geneva, Switzerland
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Beernaert K, Smets T, Cohen J, Verhofstede R, Costantini M, Eecloo K, Van Den Noortgate N, Deliens L. Improving comfort around dying in elderly people: a cluster randomised controlled trial. Lancet 2017; 390:125-134. [PMID: 28526493 DOI: 10.1016/s0140-6736(17)31265-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 02/23/2017] [Accepted: 03/10/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Over 50% of elderly people die in acute hospital settings, where the quality of end-of-life care is often suboptimum. We aimed to assess the effectiveness of the Care Programme for the Last Days of Life (CAREFuL) at improving comfort and quality of care in the dying phase in elderly people. METHODS We did a cluster randomised controlled trial in acute geriatric wards in ten hospitals in Flemish Region, Belgium, between Oct 1, 2012, and March 31, 2015. Hospitals were randomly assigned to implementation of CAREFuL (CAREFuL group) or to standard care (control group) using a random number generator. Patients and families were masked to interventaion allocation; hospital staff were unmasked. CAREFuL comprised a care guide for the last days of life, training, supportive documentation, and an implementation guide. Primary outcomes were comfort around dying, measured with the End-of-Life in Dementia-Comfort Assessment in Dying (CAD-EOLD), and symptom management, measured with the End-of-Life in Dementia-Symptom Management (SM-EOLD), by nurses and family carers. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01890239. FINDINGS 451 (11%) of 4241 beds in ten hospitals were included in the analyses. Five hospitals were randomly assigned to standard health care practice and five to the CAREFuL programme; 118 patients in the control group and 164 in the CAREFuL group were eligible for assessment. Assessments were done for 132 (80%) of 164 patients in the CAREFuL group and 109 (92%) of 118 in the control group by nurses, and 48 (29%) in the CAREFuL group and 23 (19%) in the control group by family carers. Implementation of CAREFuL compared with control significantly improved nurse-assessed comfort (CAD-EOLD baseline-adjusted mean difference 4·30, 95% CI 2·07-6·53; p<0·0001). No significant differences were noted for the CAD-EOLD assessed by family carers (baseline-adjusted mean difference -0·62, 95% CI -6·07 to 4·82; p=0·82) or the SM-EOLD assessed by nurses (-0·41, -1·86 to 1·05; p=0·58) or by family carers (-0·59, -3·75 to 2·57; p=0·71). INTERPRETATION Although a continuous monitoring of the programme is warranted, these results suggest that implementation of CAREFuL might improve care during the last days of life for patients in acute geriatric hospital wards. FUNDING The Flemish Government Agency for Innovation by Science and Technology and the Belgian Cancer Society "Kom Op Tegen Kanker".
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Affiliation(s)
- Kim Beernaert
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium; End-of-Life Care Research Group, Ghent University, Ghent, Belgium.
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium; End-of-Life Care Research Group, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium; End-of-Life Care Research Group, Ghent University, Ghent, Belgium
| | - Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium; End-of-Life Care Research Group, Ghent University, Ghent, Belgium
| | - Massimo Costantini
- Palliative Care Unit, Arcispedale Santa Maria Nuova-IRCCS, Reggio Emilia, Italy
| | - Kim Eecloo
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium; End-of-Life Care Research Group, Ghent University, Ghent, Belgium
| | - Nele Van Den Noortgate
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium; End-of-Life Care Research Group, Ghent University, Ghent, Belgium; Department of Geriatric Medicine, Ghent University Hospital, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel, Brussels, Belgium; End-of-Life Care Research Group, Ghent University, Ghent, Belgium; Department of Medical Oncology, Ghent University, Ghent, Belgium
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Andersson S, Lindqvist O, Fürst CJ, Brännström M. Care professional's experiences about using Liverpool Care Pathway in end-of-life care in residential care homes. Scand J Caring Sci 2017; 32:299-308. [DOI: 10.1111/scs.12462] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Accepted: 03/05/2017] [Indexed: 12/13/2022]
Affiliation(s)
| | - Olav Lindqvist
- Department of Nursing; Umeå University; Umeå Sweden
- Department of Learning, Informatics, Management and Ethics/MMC; Karolinska Institutet; Stockholm Sweden
| | - Carl-Johan Fürst
- The Institute for Palliative Care; Lund University and Region Skåne; Lund Sweden
| | - Margareta Brännström
- Department of Nursing; Umeå University; Skellefteå Sweden
- The Arctic Research Centre; Umeå University; Umeå Sweden
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Waller A, Dodd N, Tattersall MHN, Nair B, Sanson-Fisher R. Improving hospital-based end of life care processes and outcomes: a systematic review of research output, quality and effectiveness. BMC Palliat Care 2017; 16:34. [PMID: 28526095 PMCID: PMC5438503 DOI: 10.1186/s12904-017-0204-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 04/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As in other areas of health delivery, there is a need to ensure that end-of-life care is guided by patient centred research. A systematic review was undertaken to examine the quantity and quality of data-based research aimed at improving the (a) processes and (b) outcomes associated with delivering end-of-life care in hospital settings. METHODS Medline, EMBASE and Cochrane databases were searched between 1995 and 2015 for data-based papers. Eligible papers were classified as descriptive, measurement or intervention studies. Intervention studies were categorised according to whether the primary aim was to improve: (a) end of life processes (i.e. end-of-life documentation and discussions, referrals); or (b) end-of-life outcomes (i.e. perceived quality of life, health status, health care use, costs). Intervention studies were assessed against the Effective Practice and Organisation of Care methodological criteria for research design, and their effectiveness examined. RESULTS A total of 416 papers met eligibility criteria. The number increased by 13% each year (p < 0.001). Most studies were descriptive (n = 351, 85%), with fewer measurement (n = 17) and intervention studies (n = 48; 10%). Only 18 intervention studies (4%) met EPOC design criteria. Most reported benefits for end-of-life processes including end-of-life discussions and documentation (9/11). Impact on end-of-life outcomes was mixed, with some benefit for psychosocial distress, satisfaction and concordance in care (3/7). CONCLUSION More methodologically robust studies are needed to evaluate the impact of interventions on end-of-life processes, including whether changes in processes translate to improved end-of-life outcomes. Interventions which target both the patient and substitute decision maker in an effort to achieve these changes would be beneficial.
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Affiliation(s)
- Amy Waller
- Priority Research Centre in Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia. .,Hunter Medical Research Institute, Newcastle, NSW, 2305, Australia.
| | - Natalie Dodd
- Priority Research Centre in Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Newcastle, NSW, 2305, Australia
| | - Martin H N Tattersall
- University of Sydney, Chris O'Brien Lifehouse, Level 6 North, Missenden Road, Camperdown, 2050, Australia
| | - Balakrishnan Nair
- Faculty of Health and Medicine, University of Newcastle, Callaghan, NSW, 2308, Australia.,Hunter New England Local Health District, Newcastle, 2305, Australia
| | - Rob Sanson-Fisher
- Priority Research Centre in Health Behaviour, University of Newcastle, Callaghan, NSW, 2308, Australia.,Hunter Medical Research Institute, Newcastle, NSW, 2305, Australia
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Kluger BM, Fox S, Timmons S, Katz M, Galifianakis NB, Subramanian I, Carter JH, Johnson MJ, Richfield EW, Bekelman D, Kutner JS, Miyasaki J. Palliative care and Parkinson's disease: Meeting summary and recommendations for clinical research. Parkinsonism Relat Disord 2017; 37:19-26. [DOI: 10.1016/j.parkreldis.2017.01.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 12/01/2016] [Accepted: 01/10/2017] [Indexed: 12/25/2022]
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Salins N, Johnson J, Macaden S. Feasibility and Acceptability of Implementing the Integrated Care Plan for the Dying in the Indian Setting: Survey of Perspectives of Indian Palliative Care Providers. Indian J Palliat Care 2017; 23:3-12. [PMID: 28216856 PMCID: PMC5294434 DOI: 10.4103/0973-1075.197952] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Capacity to provide end-of-life care in India is scored as 0.6/100, and very few people in India have access to palliative and end-of-life care. Lack of end-of-life care provision in India has led to a significant number of people receiving inappropriate medical treatment at the end of life, with no access to pain and symptom control and high treatment costs. The International Collaborative for the Best Care for the Dying Person is an initiative that offers the opportunity to apply international evidence on the key factors required to provide best care for the dying in the Indian context. The aim of this study is to ascertain the perceptions of Indian palliative care providers regarding the feasibility and acceptability of implementing the international program in the Indian setting. METHODS Thirty participants from 16 palliative care centers who had participated in the foundation course of the International Collaborative for Best Care for the Dying Person were purposively chosen for the study. All participants were asked to complete the survey questionnaire that had both open- and close-ended questions. RESULTS Twenty-three participants completed this survey. The majority of items in the international program were considered relevant, representative of end-of-life care and acceptable in Indian setting. However, participants felt that the concept of the multidisciplinary team (MDT) being responsible for recognizing death may not be possible in the existing Indian setting and a senior doctor may not always be available to document a MDT decision. Some participants felt that in the Indian setting, it was not always possible to communicate about the dying process and make patient aware of the same. A small number of participants felt that using leaflets for communicating end-of-life care process may not be always possible due to logistic reasons and cost. Six participants felt that giving the dying person the opportunity to discuss their wishes, feelings, faith, beliefs, and values may not be possible, representative, and not applicable in Indian setting. The majority of participants felt that using equipment such as a syringe driver for continuous infusion is relevant (n = 16) and representative (n = 13) of end-of-life care, however most thought that it could be challenging to apply in an Indian setting (n = 17), including concerns about lack of familiarity and knowledge and applicability in home care settings. Six participants had reservations regarding the limitation of life-sustaining treatment and felt that discussion and review of cardiopulmonary resuscitation should happen prior to patients entering their end-of-life phase. While most participants thought relevance, representation, and applicability of assessing skin integrity as important, a few participants felt this assessment challenging, especially in home setting, and recommended Braden scale to be used instead of Waterlow for assessing skin integrity. Most participants agreed on the importance of assisted hydration and nutrition; however, again a minority highlighted challenges in this area. Five participants felt that they would sometimes continue hydration under duress from a patient's family. Participants agreed unanimously on the relevance and representation of recording of physical symptoms by MDT-initial and ongoing-with a few participants indicating that frequent observations recommended in the care plan may not be feasible in home care setting. The majority also agreed on the relevance, representation (n = 21), and applicability (n = 18) of providing written information about after-death care, with a small number indicating challenges in the Indian setting, for example, very few unit currently having this information available (n = 2). Notifying general practitioners, primary care physicians, and other appropriate services on patients' death may not be easily applicable in the Indian setting. CONCLUSIONS The survey of palliative care providers about the feasibility and acceptability of integrated care plan at end of life has shown that the international program is relevant, representative of end-of-life care, and acceptable in Indian setting. As would be expected, a number of items need careful consideration and appropriate modification to ensure relevance, representation, and applicability to Indian sociocultural context. The results also suggest that palliative care providers need additional training for the implementation of some of the items in the development of an India-specific document and supporting quality improvement program.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Jeremy Johnson
- Emeritus Palliative Care Consultant and Director of Education and Research, Karunashraya, Bengaluru, Karnataka, India
| | - Stanley Macaden
- Honorary Palliative Care Consultant and Ex Director, Bangalore Baptist Hospital, Bengaluru, Karnataka, India; National Coordinator, Palliative Care Programme of The Christian Medical Association of India, New Delhi, India
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Vanhaecht K, Lodewijckx C, Sermeus W, Decramer M, Deneckere S, Leigheb F, Boto P, Kul S, Seys D, Panella M. Impact of a care pathway for COPD on adherence to guidelines and hospital readmission: a cluster randomized trial. Int J Chron Obstruct Pulmon Dis 2016; 11:2897-2908. [PMID: 27920516 PMCID: PMC5126002 DOI: 10.2147/copd.s119849] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Current in-hospital management of exacerbations of COPD is suboptimal, and patient outcomes are poor. The primary aim of this study was to evaluate whether implementation of a care pathway (CP) for COPD improves the 6 months readmission rate. Secondary outcomes were the 30 days readmission rate, mortality, length of stay and adherence to guidelines. PATIENTS AND METHODS An international cluster randomized controlled trial was performed in Belgium, Italy and Portugal. General hospitals were randomly assigned to an intervention group where a CP was implemented or a control group where usual care was provided. The targeted population included patients with COPD exacerbation. RESULTS Twenty-two hospitals were included, whereof 11 hospitals (n=174 patients) were randomized to the intervention group and 11 hospitals (n=168 patients) to the control group. The CP had no impact on the 6 months readmission rate. However, the 30 days readmission rate was significantly lower in the intervention group (9.7%; 15/155) compared to the control group (15.3%; 22/144) (odds ratio =0.427; 95% confidence interval 0.222-0.822; P=0.040). Performance on process indicators was significantly higher in the intervention group for 2 of 24 main indicators (8.3%). CONCLUSION The implementation of this in-hospital CP for COPD exacerbation has no impact on the 6 months readmission rate, but it significantly reduces the 30 days readmission rate.
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Affiliation(s)
- Kris Vanhaecht
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven; Department of Quality Management, University Hospitals Leuven
| | - Cathy Lodewijckx
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven
| | - Walter Sermeus
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven
| | - Marc Decramer
- Department of Clinical and Experimental Medicine, KU Leuven - University of Leuven; University Hospitals Leuven, Leuven
| | - Svin Deneckere
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven; Medical Department, Delta Hospitals Roeselare, Roeselare, Belgium
| | - Fabrizio Leigheb
- Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
| | - Paulo Boto
- Department of Health Services Policy and Management, Centro de Investigação em Saúde Pública, Escola Nacional de Saúde Pública, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Seval Kul
- Department of Biostatistics, School of Medicine, University of Gaziantep, Gaziantep, Turkey
| | - Deborah Seys
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven
| | - Massimiliano Panella
- Department of Public Health and Primary Care, Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven; Department of Translational Medicine, University of Eastern Piedmont, Vercelli, Italy
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Siouta N, Van Beek K, van der Eerden ME, Preston N, Hasselaar JG, Hughes S, Garralda E, Centeno C, Csikos A, Groot M, Radbruch L, Payne S, Menten J. Integrated palliative care in Europe: a qualitative systematic literature review of empirically-tested models in cancer and chronic disease. BMC Palliat Care 2016; 15:56. [PMID: 27391378 PMCID: PMC4939056 DOI: 10.1186/s12904-016-0130-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 06/30/2016] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Integrated Palliative Care (PC) strategies are often implemented following models, namely standardized designs that provide frameworks for the organization of care for people with a progressive life-threatening illness and/or for their (in)formal caregivers. The aim of this qualitative systematic review is to identify empirically-evaluated models of PC in cancer and chronic disease in Europe. Further, develop a generic framework that will consist of the basis for the design of future models for integrated PC in Europe. METHODS Cochrane, PubMed, EMBASE, CINAHL, AMED, BNI, Web of Science, NHS Evidence. Five journals and references from included studies were hand-searched. Two reviewers screened the search results. Studies with adult patients with advanced cancer/chronic disease from 1995 to 2013 in Europe, in English, French, German, Dutch, Hungarian or Spanish were included. A narrative synthesis was used. RESULTS 14 studies were included, 7 models for chronic disease, 4 for integrated care in oncology, 2 for both cancer and chronic disease and 2 for end-of-life pathways. The results show a strong agreement on the benefits of the involvement of a PC multidisciplinary team: better symptom control, less caregiver burden, improvement in continuity and coordination of care, fewer admissions, cost effectiveness and patients dying in their preferred place. CONCLUSION Based on our findings, a generic framework for integrated PC in cancer and chronic disease is proposed. This framework fosters integration of PC in the disease trajectory concurrently with treatment and identifies the importance of employing a PC-trained multidisciplinary team with a threefold focus: treatment, consulting and training.
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Affiliation(s)
- Naouma Siouta
- Department of Radiation-Oncology and Palliative Medicine, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium.
| | - K Van Beek
- Department of Radiation-Oncology and Palliative Medicine, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
| | - M E van der Eerden
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - N Preston
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - J G Hasselaar
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - S Hughes
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - E Garralda
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona, Navarra, Spain
| | - C Centeno
- Department of Palliative Medicine, University of Navarra Hospital, Pamplona, Navarra, Spain
| | - A Csikos
- Faculty of Medicine, Institute of Family Medicine, University of Pécs Medical School, Pécs, Hungary
| | - M Groot
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - L Radbruch
- Department of Palliative Medicine, University Hospital Bonn, Bonn, Germany
| | - S Payne
- International Observatory on End of Life Care, Division of Health Research, Lancaster University, Lancaster, UK
| | - J Menten
- Department of Radiation-Oncology and Palliative Medicine, University Hospital Gasthuisberg, Herestraat 49, 3000, Leuven, Belgium
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Nipp RD, Yao NA, Lowenstein LM, Buckner JC, Parker IR, Gajra A, Morrison VA, Dale W, Ballman KV. Pragmatic study designs for older adults with cancer: Report from the U13 conference. J Geriatr Oncol 2016; 7:234-41. [PMID: 27197914 DOI: 10.1016/j.jgo.2016.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 12/30/2015] [Accepted: 02/10/2016] [Indexed: 11/18/2022]
Abstract
Cancer is a disease occurring disproportionately in older adults. However, the evidence base regarding how best to care for these patients remains limited due to their underrepresentation in cancer clinical trials. Pragmatic clinical trials represent a promising approach for enhancing the evidence base in geriatric oncology by allowing investigators to enroll older, frailer patients onto cancer clinical trials. These trials are more accessible, less resource intensive, and place minimal additional burden on participating patients. Additionally, these trials can be designed to measure endpoints directly relevant to older adults, such as quality of life, functional independence and treatment tolerability which are often not addressed in standard clinical trials. Therefore, pragmatic clinical trials allow researchers to include patients for whom the treatment will ultimately be applied and to utilize meaningful endpoints. Examples of pragmatic studies include both large, simple trials and cluster randomized trials. These study designs allow investigators to conduct clinical trials within the context of everyday practice. Further, researchers can devise these studies to place minimal burden on the patient, the treating clinicians and the participating institutions. In order to be successful, pragmatic trials must efficiently utilize the electronic medical record for data capture while also maximizing patient recruitment, enrollment and retention. Additionally, by strategically utilizing pragmatic clinical trials to test therapies and interventions that have previously shown efficacy in younger, fitter patients, these trials represent a potential mechanism to improve the evidence base in geriatric oncology and enhance care for older adults with cancer.
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Affiliation(s)
- Ryan D Nipp
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Department of Medicine, Division of Hematology & Oncology, Boston, MA, USA.
| | - Nengliang Aaron Yao
- University of Virginia Cancer Center, Department of Public Health Sciences, Charlottesville, VA, USA
| | - Lisa M Lowenstein
- University of Texas MD Anderson Cancer Center, Department of Health Services Research, Division of OVP, Cancer Prevention and Population Sciences, Houston, TX, USA
| | - Jan C Buckner
- Mayo Clinic, Department of Oncology, Division of Medical Oncology, Rochester, MN, USA
| | - Ira R Parker
- Thomas Jefferson University, Philadelphia, PA; La Jolla, CA, USA
| | - Ajeet Gajra
- SUNY Upstate University, Department of Medicine, Syracuse, NY, USA; VA Medical Center, Syracuse, NY, USA
| | - Vicki A Morrison
- University of Minnesota, Veterans Affairs Medical Center, Minneapolis, MN, USA
| | - William Dale
- University of Chicago, Section of Geriatrics & Palliative Medicine, Chicago, IL, USA
| | - Karla V Ballman
- Weill Cornell Medical College, Division of Biostatistics and Epidemiology, New York, NY 10065, USA
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Andersson S, Lindqvist O, Fürst CJ, Brännström M. End-of-life care in residential care homes: a retrospective study of the perspectives of family members using the VOICES questionnaire. Scand J Caring Sci 2016; 31:72-84. [DOI: 10.1111/scs.12317] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/16/2015] [Indexed: 12/14/2022]
Affiliation(s)
| | - Olav Lindqvist
- Department of Nursing; Umeå University; Umeå Sweden
- Department of Learning, Informatics, Management and Ethics/MMC; Karolinska Institutet; Stockholm Sweden
| | - Carl-Johan Fürst
- The Institute for Palliative Care; Lund University and Region; Skåne Lund Sweden
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Verhofstede R, Smets T, Cohen J, Costantini M, Van Den Noortgate N, Deliens L. Implementing the care programme for the last days of life in an acute geriatric hospital ward: a phase 2 mixed method study. BMC Palliat Care 2016; 15:27. [PMID: 26944263 PMCID: PMC4779213 DOI: 10.1186/s12904-016-0102-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 02/26/2016] [Indexed: 11/10/2022] Open
Abstract
Background To improve the quality of end-of-life care in geriatric hospital wards we developed the Care Programme for the Last Days of Life. It consists of 1) the Care Guide for the Last Days of Life, 2) supportive documentation and 3) an implementation guide. The aim of this study is (1) to determine the feasibility of implementing the Care Programme for the Last Days of Life in the acute geriatric hospital setting and (2) to explore the health care professionals’ perceptions of the effects of the Care Programme on end-of-life care. Methods A phase 2 mixed methods study according with the MRC framework was performed in the acute geriatric ward of Ghent University Hospital between 1 April and 30 September 2013. During the implementation process a mixed methods approach was used including observation, interviews and the use of a quantitative process evaluation tool. This tool measured the success of implementation using several indicators, such as whether a steering group was formed, whether and how much of the health care staff was informed and trained and how many patients were cared for according to the Care Guide for the Last Days of Life. Results The process evaluation tool showed that implementing the Care Programme for the Last Days of Life in the geriatric ward was successful and thus feasible; a steering group was formed consisting of two facilitators, health care staff of the geriatric ward were trained in using the Care Guide for the Last Days of Life which was subsequently introduced onto the ward and approximately 57 % of all dying patients were cared for according to the Care Guide for the Last Days of Life. With regard to health care professionals’ perceptions, nurses and physicians experienced the Care Guide for the Last Days of Life as improving the overall documentation of care, improving communication among health care staff and between health care staff and patient/family and improving the quality of end-of-life care. Barriers to implementing the Care Programme for the Last Days of Life successfully are, among others, difficulties with the content of the documents used within the Care Programme for the Last Days of Life and the low participation rate of physicians in the training sessions and audits. Conclusions Results of this mixed methods study suggest that implementing the Care Programme for the Last Days of Life is feasible and that it has favorable effects on end-of-life care as reported by health care professionals. Based on the identified barriers during the implementation process, we were able to make recommendations for future implementation and further refine the Care Programme for the Last Days of Life before implementing it in a phase 3 cluster randomized controlled trial for the evaluation of its effectiveness.
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Affiliation(s)
- Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.,Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Abstract
BACKGROUND This is an updated version of a Cochrane review published in Issue 11, 2013 in the Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time, and that it is provided by the most appropriate health professional. Since the last update, there have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the United Kingdom (UK). Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways via a systematic review. OBJECTIVES To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community).In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying, or those related to the care, such as families, carers and health professionals, or a combination of these. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane Library; 2015, Issue 6), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles, trial registries and reference lists of relevant articles. We conducted the original search in September 2009, and the second updated search in July 2015. SELECTION CRITERIA All randomised controlled trials (RCTs), quasi-randomised trials or high quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the results of the searches against the predetermined criteria for inclusion, assessed risk of bias, and extracted data. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We screened 3028 titles, and included one Italian cluster RCT with 16 general medicine wards (inpatient units in hospitals) and 232 carers of cancer patients in this updated review. We judged the study to be at a high risk of bias overall, mainly due to a lack of blinding and rates of attrition. Only 34% of the participants (range 14% to 75% on individual wards) were cared for in accordance with the care pathway as planned. However, these issues were to be expected due to the nature of the intervention and condition. The study population was all cancer patients in their last days of life. Participants were allocated to care using the Liverpool Care Pathway (LCP-I, Italian version of a continuous quality improvement programme of end-of-life care) or to standard care. The primary outcomes of this review were physical symptom severity, psychological symptom severity, quality of life, and any adverse effects. Physical symptom severity was assessed as overall control of pain, breathlessness, and nausea and vomiting. There was very low quality evidence of a difference in overall control of breathlessness that favoured the Liverpool Care Pathway group compared to usual care: the study reported an odds ratio (OR) of 2.0 with 95% confidence intervals (CIs) 1.1 to 3.8. Very low quality evidence of no difference was found for pain (OR 1.3, 95% CI 0.7 to 2.6, P = 0.461) and nausea and vomiting (OR 1.5, 95% CI 0.7 to 3.2, P = 0.252). None of the other primary outcomes were assessed by the study. Limited data on advance care planning were collected by the study authors, making results for this secondary outcome unreliable. None of our other secondary outcomes were assessed by the study. AUTHORS' CONCLUSIONS There is limited available evidence concerning the clinical, physical, psychological or emotional effectiveness of end-of-life care pathways.
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Affiliation(s)
- Raymond J Chan
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneQueenslandAustralia
| | - Joan Webster
- Royal Brisbane and Women's HospitalNursing and Midwifery Research CentreButterfield StreetHerstonQueenslandAustralia4029
| | - Alison Bowers
- West Moreton Hospital and Health ServiceCentre for Research and InnovationChelmsford AvenueIpswichQueenslandAustralia4305
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Higginson IJ, Rumble C, Shipman C, Koffman J, Sleeman KE, Morgan M, Hopkins P, Noble J, Bernal W, Leonard S, Dampier O, Prentice W, Burman R, Costantini M. The value of uncertainty in critical illness? An ethnographic study of patterns and conflicts in care and decision-making trajectories. BMC Anesthesiol 2016; 16:11. [PMID: 26860461 PMCID: PMC4746769 DOI: 10.1186/s12871-016-0177-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Accepted: 02/01/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND With increasingly intensive treatments and population ageing, more people face complex treatment and care decisions. We explored patterns of the decision-making processes during critical care, and sources of conflict and resolution. METHODS Ethnographic study in two Intensive Care Units (ICUs) in an inner city hospital comprising: non-participant observation of general care and decisions, followed by case studies where treatment limitation decisions, comfort care and/or end of life discussions were occurring. These involved: semi-structured interviews with consenting families, where possible, patients; direct observations of care; and review of medical records. RESULTS Initial non-participant observation included daytime, evenings, nights and weekends. The cases were 16 patients with varied diagnoses, aged 19-87 years; 19 family members were interviewed, aged 30-73 years. Cases were observed for <1 to 156 days (median 22), depending on length of ICU admission. Decisions were made serially over the whole trajectory, usually several days or weeks. We identified four trajectories with distinct patterns: curative care from admission; oscillating curative and comfort care; shift to comfort care; comfort care from admission. Some families considered decision-making a negative concept and preferred uncertainty. Conflict occurred most commonly in the trajectories with oscillating curative and comfort care. Conflict also occurred inside clinical teams. Families were most often involved in decision-making regarding care outcomes and seemed to find it easier when patients switched definitively from curative to comfort care. We found eight categories of decision-making; three related to the care outcomes (aim, place, response to needs) and five to the care processes (resuscitation, decision support, medications/fluids, monitoring/interventions, other specialty involvement). CONCLUSIONS Decision-making in critical illness involves a web of discussions regarding the potential outcomes and processes of care, across the whole disease trajectory. When measures oscillate between curative and comfort there is greatest conflict. This suggests a need to support early communication, especially around values and preferred care outcomes, from which other decisions follow, including DNAR. Offering further support, possibly with expert palliative care, communication, and discussion of 'trial of treatment' may be beneficial at this time, rather than waiting until the 'end of life'.
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Affiliation(s)
- I J Higginson
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK.
| | - C Rumble
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK
| | - C Shipman
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK
| | - J Koffman
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK
| | - K E Sleeman
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK
| | - M Morgan
- King's College London, Department of Primary Care and Public Health Sciences, Capital House, London Bridge, London, UK
| | - P Hopkins
- King's College Hospital, King's Critical Care, Denmark Hill, London, UK
| | - J Noble
- King's College Hospital, King's Critical Care, Denmark Hill, London, UK
| | - W Bernal
- King's College Hospital, King's Critical Care, Denmark Hill, London, UK
| | - S Leonard
- King's College Hospital, King's Critical Care, Denmark Hill, London, UK
| | - O Dampier
- King's College Hospital, King's Critical Care, Denmark Hill, London, UK
| | - W Prentice
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK
| | - R Burman
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, Bessemer Road, Denmark Hill, London, SE5 9PJ, UK
| | - M Costantini
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
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Witkamp FE, van Zuylen L, van der Rijt CCD, van der Heide A. Effect of palliative care nurse champions on the quality of dying in the hospital according to bereaved relatives: A controlled before-and-after study. Palliat Med 2016; 30:180-8. [PMID: 25991728 DOI: 10.1177/0269216315588008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND To improve the quality of end-of-life care, hospitals increasingly appoint palliative care nurse champions. AIM We investigated the effect of nurse champions on the quality of life during the last 3 days of life and the quality of dying as experienced by bereaved relatives. DESIGN A controlled before-and-after study (June 2009-July 2012). Halfway, in each of seven intervention wards, two nurse champions were appointed; 11 wards served as control wards. The quality of life during the last 3 days of life, quality of dying and multiple dimensions of quality of dying were compared before and after the introduction of nurse champions. SETTING In a university hospital, each death at non-intensive care units was followed up by an invitation to relatives (10-13 weeks later) to answer a questionnaire. RESULTS For the two periods, data were collected on 86 and 84 patients in intervention wards and on 108 and 118 patients in control wards (overall response: 52%). In the intervention wards, no differences were found in the quality of life during the last 3 days of life and the quality of dying scores: in both periods, median score for the quality of life during the last 3 days of life was 3.0 and for the quality of dying 7.0. No differences were found in multiple quality of dying dimensions. In control wards, the median quality of dying score was 7.0 pre-intervention and 6.0 post-intervention (p = 0.04). Other scores were comparable with those in intervention wards. CONCLUSION Performing a complex intervention study in palliative care proved to be feasible. This study showed no differences in the experiences of bereaved relatives after introduction of nurse champions. The complexity of palliative care in the hospital might require more intensive and longer training of nurse champions.
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Affiliation(s)
- Frederika Erica Witkamp
- Department of Public Health, Erasmus MC: University Medical Center Rotterdam, Rotterdam, The Netherlands Department of Medical Oncology, Erasmus MC: University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Lia van Zuylen
- Department of Medical Oncology, Erasmus MC: University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Carin C D van der Rijt
- Department of Medical Oncology, Erasmus MC: University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Agnes van der Heide
- Department of Public Health, Erasmus MC: University Medical Center Rotterdam, Rotterdam, The Netherlands
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Ka-Ming Ho J. Resuscitation versus end-of-life care: Exploring the obstacles and supportive behaviors to providing end-of-life care as perceived by emergency nurses after implementing the end-of-life care pathway. Appl Nurs Res 2016; 29:e7-13. [DOI: 10.1016/j.apnr.2015.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 05/14/2015] [Accepted: 05/20/2015] [Indexed: 10/23/2022]
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Brännström M, Fürst CJ, Tishelman C, Petzold M, Lindqvist O. Effectiveness of the Liverpool care pathway for the dying in residential care homes: An exploratory, controlled before-and-after study. Palliat Med 2016; 30:54-63. [PMID: 25986540 DOI: 10.1177/0269216315588007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Clinical pathways aim to ensure that individuals receive appropriate evidence-based care and interventions, with the Liverpool Care Pathway for the Dying Patient focusing on end of life. However, controlled studies of the Liverpool Care Pathway for the Dying Patient, particularly outside of cancer settings, are lacking. AIM To compare the effects of the Liverpool Care Pathway for the Dying Patient and usual care on patients' symptom distress and well-being during the last days of life, in residential care homes. DESIGN Exploratory, controlled before-and-after study. During a 15-month baseline, usual care was carried out in two areas. During the following 15-months, usual care continued in the control area, while residential care home staff implemented Liverpool Care Pathway for the Dying Patient use in the intervention area. The intervention was evaluated by family members completing retrospective symptom assessments after the patient's death, using the Edmonton Symptom Assessment System and Views of Informal Carers - Evaluation of Services. SETTINGS/PARTICIPANTS Patients who died at all 19 residential care homes in one municipality in Sweden. RESULTS Shortness of breath (estimate = -2.46; 95% confidence interval = -4.43 to -0.49) and nausea (estimate = -1.83; 95% confidence interval = -3.12 to -0.54) were significantly reduced in Edmonton Symptom Assessment System in patients in the intervention compared to the control area. A statistically significant improvement in shortness of breath was also found on the Views of Informal Carers - Evaluation of Services item (estimate = -0.47; 95% confidence interval = -0.85 to -0.08). CONCLUSION When implemented with adequate staff training and support, the Liverpool Care Pathway for the Dying Patient may be a useful tool for providing end-of-life care of elderly people at the end of life in non-cancer settings.
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Affiliation(s)
| | - Carl Johan Fürst
- The Institute for Palliative Care, Lund University and Region Skåne, Lund, Sweden
| | - Carol Tishelman
- Medical Management Centre (MMC), Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden
| | - Max Petzold
- Akademistatistik - Centre for Applied Biostatistics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olav Lindqvist
- Medical Management Centre (MMC), Department of Learning, Informatics, Management and Ethics, Karolinska Institutet, Stockholm, Sweden Department of Nursing, Umeå University, Umeå, Sweden
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Schulz C, Schlieper D, Altreuther C, Schallenburger M, Fetz K, Schmitz A. The characteristics of patients who discontinue their dying process - an observational study at a single university hospital centre. BMC Palliat Care 2015; 14:72. [PMID: 26643576 PMCID: PMC4672507 DOI: 10.1186/s12904-015-0070-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 11/30/2015] [Indexed: 11/30/2022] Open
Abstract
Background End-of-life integrated care plans are used as structuring tools for the care of the dying. A widely adopted example is the Liverpool Care Pathway for the Dying Patient (LCP). Recently, several concerns were raised about LCP care, such as a worry that diagnosis of dying might be leading to a self-fulfilling trajectory, including hastening of death. However, data on rates of discontinuation of LCP care are lacking. In an observational study, we therefore investigated the incidence, features and trajectory of patients who were discontinued from the LCP. We hypothesised that (1) it is common to discontinue patients from the LCP, (2) quality of life does not decrease for discontinued LCP patients, and (3) discontinued patients live longer than patients who remain within LCP care. Methods All adult patients who were diagnosed as dying in a German university hospital specialized palliative care unit were included in 2013 and 2014. Actuarial estimation of survival prognostication tools and a number of quality of life indicators were used for data collection. Survival time was analysed using Kaplan-Meier estimates. Group differences in quality of life were tested using multivariate analysis of variance. Results 159 patients were included in a digital version of the LCP. 15 patients (9.4 %) were discontinued later. Quality of life did not decrease for discontinued patients during LCP care (p = 0.16). LCP discontinued patients lived significantly longer than the remaining LCP subgroup (difference of means 296 hours, 95 % confidence interval 105.5 to 451.5 hours; difference of survival function estimates p < 0.0001). Conclusions When patients are diagnosed as dying, death is not the inevitable outcome of an end-of-life integrated care plan such as the LCP. Instead, it is common to discontinue the LCP care. Regular careful interprofessional assessments are important for identifying those patients who need to be discontinued from their end-of-life care plan. In this study, we found no evidence for harm by the LCP. We conclude that a correctly applied integrated care plan can be useful to provide good and safe care for the dying. Trial registration Internal Clinical Trial Register of the Medical Faculty, Heinrich Heine University Düsseldorf, No. 2015053680 (22 May 2015).
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Affiliation(s)
- Christian Schulz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Daniel Schlieper
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Christiane Altreuther
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Manuela Schallenburger
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Katharina Fetz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany. .,Department of Health, Witten/Herdecke University, Alfred-Herrhausen-Straße 50, 58448, Witten, Germany.
| | - Andrea Schmitz
- Interdisciplinary Centre for Palliative Medicine, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany. .,Department of Anesthesiology, Medical Faculty, Heinrich Heine University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
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Sleeman KE, Koffman J, Bristowe K, Rumble C, Burman R, Leonard S, Noble J, Dampier O, Bernal W, Morgan M, Hopkins P, Prentice W, Higginson IJ. 'It doesn't do the care for you': a qualitative study of health care professionals' perceptions of the benefits and harms of integrated care pathways for end of life care. BMJ Open 2015; 5:e008242. [PMID: 26369795 PMCID: PMC4577969 DOI: 10.1136/bmjopen-2015-008242] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES To understand healthcare professionals' perceptions of the benefits and potential harms of integrated care pathways for end-of-life care, to inform the development of future interventions that aim to improve care of the dying. DESIGN Qualitative interview study with maximum variation sampling and thematic analysis. PARTICIPANTS 25 healthcare professionals, including doctors, nurses and allied health professionals, interviewed in 2009. SETTING A 950-bed South London teaching hospital. RESULTS 4 main themes emerged, each including 2 subthemes. Participants were divided between (1) those who described mainly the benefits of integrated care pathways, and (2) those who talked about potential harms. Benefits focused on processes of care, for example, clearer, consistent and comprehensive actions. The recipients of these benefits were staff members themselves, particularly juniors. For others, this perceived clarity was interpreted as of potential harm to patients, where over-reliance on paperwork lead to prescriptive, less thoughtful care, and an absolution from decision-making. Independent of their effects on patient care, integrated care pathways for dying had (3) a symbolic value: they legitimised death as a potential outcome and were used as a signal that the focus of care had changed. However, (4) a weak infrastructure, including scanty education and training in end-of-life care and a poor evidence base, that appeared to undermine the foundations on which the Liverpool Care Pathway was built. CONCLUSIONS The potential harms of integrated care pathways for the dying identified in this study were reminiscent of criticisms subsequently published by the Neuberger review. These data highlight: (1) the importance of collecting, reporting and using qualitative data when developing and evaluating complex interventions; (2) that comprehensive education and training in palliative care is critical for the success of any new intervention; (3) the need for future interventions to be grounded in patient-centred outcomes, not just processes of care.
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Affiliation(s)
- Katherine E Sleeman
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Jonathan Koffman
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Katherine Bristowe
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Caroline Rumble
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Rachel Burman
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Sara Leonard
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Jo Noble
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Odette Dampier
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - William Bernal
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Myfanwy Morgan
- Division of Health and Social Care Research, King's College London, London, UK
| | - Philip Hopkins
- Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Wendy Prentice
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
| | - Irene J Higginson
- Department of Palliative Care Policy & Rehabilitation, King's College London, Cicely Saunders Institute, London, UK
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Rady MY, Verheijde JL. Liverpool Care Pathway: life-ending pathway or palliative care pathway? JOURNAL OF MEDICAL ETHICS 2015; 41:644. [PMID: 25038086 DOI: 10.1136/medethics-2014-102314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Accepted: 06/27/2014] [Indexed: 06/03/2023]
Affiliation(s)
- Mohamed Y Rady
- Department of Critical Care Medicine, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Joseph L Verheijde
- Department Physical Medicine and Rehabilitation, Mayo Clinic, Phoenix, Arizona, USA
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Abstract
Good end of life care (EOLC) for patients with incurable cancer is becoming a greater priority for oncologists in recent years. Frameworks such as the Liverpool Care Pathway (LCP) have often been helpful in guiding good care at the end of life. However, in the past year, the LCP has been phased out of use in the United Kingdom (UK), following concerns that it was poorly implemented. This review describes the LCP's origins in the UK, its strengths and limitations, and the concerns that prompted a review of its use. It describes the recommendations for change made by an independent review, and the alternative strategies now being developed in the UK to guide good EOLC. Although the LCP is still being widely used worldwide, the lessons learned from the UK can be widely applied in other countries.
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Affiliation(s)
- Katrine Cauldwell
- Specialist Registrar, Palliative Care, London Deanery, University College London, UK
| | - Paddy Stone
- Marie Curie Chair of Palliative and end-of-life Care, Marie Curie Palliative Care Research Department, University College London, UK
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Abstract
PURPOSE OF REVIEW Studies in different countries and settings of care have reported the quality of care for the dying patients as suboptimal. Care pathways have been developed with the aim of ensuring that dying patients and their family members received by health professionals the most appropriate care. This review presents and discusses the evidence supporting the effectiveness of the end-of-life care pathways. RECENT FINDINGS Two Cochrane systematic reviews updated at June 2013 did not identify studies that met minimal criteria for inclusion. One randomized cluster trial aimed at assessing the effectiveness of the Liverpool Care Pathway in hospitalized cancer patients was subsequently published. The trial did not find a significant difference in the overall quality of care, the primary end-point, but two out of nine secondary outcomes - respect, dignity, and kindness, and control of breathlessness showed significant improvements. Afterwards, we did not find any other potentially eligible published study. SUMMARY The overall amount of evidence supporting the dissemination of end-of-life care pathways is rather poor. One negative randomized trial suggests the pathways have the potential to reduce the gap between hospital and hospices. Further research is needed to understand the potential benefit of end-of-life care pathways.
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Di Leo S, Romoli V, Higginson IJ, Bulli F, Fantini S, Sguazzotti E, Costantini M. 'Less ticking the boxes, more providing support': A qualitative study on health professionals' concerns towards the Liverpool Care of the Dying Pathway. Palliat Med 2015; 29:529-37. [PMID: 25690601 DOI: 10.1177/0269216315570408] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite being widely used, research into the effectiveness of the Liverpool Care of the Dying Pathway (LCP) and associated cases of malpractice does not match dissemination. No study exists focusing on concerns voiced by professionals. AIM To explore the views of professionals who, during the hospital implementation of the Italian version of the Liverpool Care of the Dying Pathway (LCP-I), voiced or showed concerns towards it. DESIGN A qualitative study nested within the LCP-I randomized cluster trial, with semi-structured interviews analysed using thematic analysis. SETTING AND PARTICIPANTS Six nurses and five physicians from six out of the eight hospital wards who completed the LCP-I implementation were interviewed. Eligibility criteria were having taken part in all steps of the LCP-I Programme, voiced or somehow shown concerns, or failed to fully engage with the implementation process. RESULTS A total of 12 categories were identified, referring to four topics: the Implementation Programme, the LCP-I clinical documentation, the hospital environment and the educational and professional background of hospital healthcare staff. Issues raised by participants concerned both 'real' characteristics of the LCP-I and a misinterpretation of the LCP-I approach and clinical documentation. Furthermore, difficulties were reported which were not linked to the Programme but rather to end-of-life care. CONCLUSION This study provides insights into the experience of professionals with negative opinions of or concerns with the LCP-I. A more comprehensive approach to professional training in palliative care is needed and may envisage the development of new interventions aimed at improving the quality of care throughout the illness trajectory.
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Affiliation(s)
- Silvia Di Leo
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
| | - Vittoria Romoli
- Regional Palliative Care Network, IRCCS AOU San Martino-IST, Genoa, Italy
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation, London, UK
| | - Francesco Bulli
- Istituto per lo Studio e la Prevenzione Oncologica, Florence, Italy
| | - Susanna Fantini
- Istituto di Tanatologia e Medicina Psicologica, Bologna, Italy
| | - Erica Sguazzotti
- Departments of Mental Health and Clinical and Biological Sciences, University of Turin, Turin, Italy Azienda Ospedaliera Universitaria San Luigi Gonzaga, Orbassano, Italy
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy
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Verhofstede R, Smets T, Cohen J, Costantini M, Van Den Noortgate N, van der Heide A, Deliens L. Development of the care programme for the last days of life for older patients in acute geriatric hospital wards: a phase 0-1 study according to the Medical Research Council Framework. BMC Palliat Care 2015; 14:24. [PMID: 25956386 PMCID: PMC4464229 DOI: 10.1186/s12904-015-0025-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 04/30/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The effects of the Liverpool Care Pathway (LCP) have never been investigated in older patients dying in acute geriatric hospital wards and its content and implementation have never been adapted to this specific setting. Moreover, the LCP has recently been phased out in the UK hospitals. For that reason, this study aims to develop a new care programme to improve care in the last days of life for older patients dying in acute geriatric wards. METHODS We conducted a phase 0-1 study according to the Medical Research Council Framework. Phase 0 consisted of a review of existing LCP programmes from the UK, Italy, and the Netherlands, a literature review to identify key factors for a successful LCP implementation and an analysis of the concerns raised in the UK. In phase 1, we developed a care programme for the last days of life for older patients dying in acute geriatric wards based on the results of phase 0. The care programme was reviewed and refined by two nurses and two physicians working in an acute geriatric ward and by two experts from Italy and the Netherlands. RESULTS Phase 0 resulted in the identification of nine important components within the LCP programmes, five key factors for a successful LCP implementation and a summary of the LCP concerns raised in the UK. Based on these findings we developed a new care programme consisting of (1) an adapted LCP document or Care Guide for the older patients dying in an acute geriatric ward, (2) supportive documentation, and (3) an implementation guide to assist health care staff in implementing the care programme on the acute geriatric ward. CONCLUSIONS Based on the existing LCP programmes and taking into account the key factors for successful LCP implementation as well as the concerns raised in the UK, we developed a care programme for the last days of life and modelled it to the acute geriatric hospital wards after gaining feedback from health professionals caring for older hospitalized patients.
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Affiliation(s)
- Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
| | - Massimo Costantini
- Palliative Care Unit, IRCCS Arcispedale S. Maria Nuova, Reggio Emilia, Italy.
| | | | | | - Luc Deliens
- End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB) & Ghent University, Brussels, Belgium.
- Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium.
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Reply by Authors. J Urol 2015. [DOI: 10.1016/j.juro.2014.09.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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