Rethinking palliative care in a public health context: addressing the needs of persons with non-communicable chronic diseases

Competences of internal medicine specialists for the management of patients with multimorbidity. EFIM multimorbidity working group position paper

Patients with multimorbidity increasingly impact healthcare systems, both in primary care and in hospitals. This is particularly true in Internal Medicine. This population associates with higher mortality rates, polypharmacy, hospital readmissions, post-discharge syndrome, anxiety, depression, accelerated age-related functional decline, and development of geriatric syndromes, amongst others. Internists and Hospitalists, in one of their roles as Generalists, are increasingly asked to attend to these patients, both in their own Departments as well as in surgical areas. The management of polypathology and multimorbidity, however, is often complex, and requires specific clinical skills and corresponding experience. In addition, patients' needs, health-care environment, and routines have changed, so emerging and re-emerging specific competences and approaches are required to offer the best coordinated, continuous, and comprehensive integrated care to these populations, to achieve optimal health outcomes and satisfaction of patients, their relatives, and staff. This position paper proposes a set of emerging and re-emerging competences for internal medicine specialists, which are needed to optimally address multimorbidity now and in the future.

Factors associated with attitudes toward advance directives in nurses and comparisons of the levels between emergency nurses and palliative care nurses

AIM

Little is known about attitudes toward advance directives and factors associated with them among emergency and palliative care nurses who often or daily face end-of-life circumstances. Thus, we aimed to compare the levels of attitudes toward advance directives, communication skills, knowledge about end-of-life care (knowledge), and awareness of the concept of a good death (good death awareness) between emergency and palliative care nurses, and to examine factors associated with attitudes toward advance directives in the total sample.

METHODS

In this cross-sectional, correlational study, data were collected from 153 nurses (59 emergency and 94 palliative care nurses) at three tertiary hospitals using online or offline surveys and were analyzed using t-tests and multiple linear regression analysis.

RESULTS

The levels of attitudes, communication skills, knowledge, and good death awareness were moderate in both groups. Attitudes in emergency compared to palliative care nurses were less positive (46.78 vs. 48.38; p = .044), and knowledge was significantly lower (13.64 vs. 15.00; p = .004). Communication skills and good death awareness between the two groups were similar. In the total sample, emergency practice (B = -1.59, p = .024), and lower levels of good death awareness (B = 0.30, p < .001), communication skills (B = 0.18, p = .001), and education (B = -2.84, p = .015) were associated with less positive attitudes (F = 9.52, p < .001; R²  = 0.35).

CONCLUSIONS

The findings demonstrate the need for improvements in attitudes, knowledge, communication skills, and good death awareness in both groups, especially emergency nurses. Two modifiable targets of interventions to improve nurses' attitudes were also noted.

When freedom of choice leads to bias: How threat fosters selective exposure to health information

Selective exposure to online health information can be ascribed to two related defense motives: the motivation to confirm one's subjective perceptions and the motivation to protect relevant parts of the self-image, such as physical integrity. Our aim was to identify how these motives come into effect in the context of a health threat (fictitious feedback on an alleged heart disease risk). In a preregistered online study with N = 763 participants, we analyzed the impact of perceived and suggested risk on the degree of bias in selecting risk-related information on a fictitious Google search results page. Applying a 2 × 2 design with the experimental factor "risk feedback" and the quasi-experimental factor "perceived risk," we formulated six hypotheses. First, we expected a main effect of perceived risk on selective exposure to information suggesting no risk, and second, we hypothesized a main effect of perceived risk on mean quality rating of information suggesting a risk. Third, we proposed a main effect of risk feedback on selective exposure to information which suggests no risk, and fourth, we proposed a main effect of risk feedback on mean quality rating of information suggesting a risk. Fifth, we expected an interaction effect between perceived and suggested risk, and sixth, we proposed an interaction effect between perceived and suggested risk in different forms for each of the four conditions on quality ratings. Only the third hypothesis was confirmed: Receiving information which suggested a health risk increased the tendency to select information denying the risk. Additional exploratory analyses revealed moderator effects of health information literacy and participant age on the aforementioned relationships. In sum, our results underline the crucial role of defense motives in the context of a suggested health threat.

Achieving holistic, quality-of-life focused care: description of a Compassion Care Community initiative in Canada

The compassionate community movement as both a public health approach and a social model of care for various life stages is gaining traction in Canada and elsewhere. One example is the Windsor-Essex Compassion Care Community (WECCC), an evidence-based model and set of tools to improve the quality of life, health and wellness of vulnerable and aging populations by identifying and addressing upstream and downstream social and other risks to physical and mental health. This paper presents findings from the WECCC pilot evaluation. The WECCC initiative provided one-on-one volunteer-supported quality of life assessment, resource navigation and goals support program (Catalyzing Community Connections). This was augmented with public education sessions on social connection and loneliness (Importance of Being Connected) for the broader population. The RE-AIM framework was used to frame evaluation of WECCC through the first 4 years. Questionnaires were used to evaluate participant outcomes related to implementation and effectiveness. Interviews and focus groups were completed to understand impacts. From 2017 to 2020, WECCC has engaged over 2,500 individuals, 65 organizations and 400 volunteers combined in both programs. Nearly all (82% to 95%) participants reported positive changes to health, quality of life and/or social connections. This developmental phase of a compassionate community initiative has allowed piloting of an evaluation framework focusing on reach, adoption, implementation and early signals of effectiveness and maintenance. This demonstration provides information on feasibility, acceptability and potential impacts of this type of over-arching community initiative.

Public Health Perspective of Primary Palliative Care: A Review through the Lenses of General Practitioners

The rising trend of chronic life-threatening illnesses is accompanied by an exponential increase in serious health-related suffering. Palliative care is known to ameliorate physical and psychosocial suffering and restore quality of life. However, the contemporary challenges of palliative care delivery, such as changing demographics, social isolation, inequity in service delivery, and professionalisation of dying, have prompted many to adopt a public health approach to palliative care delivery. A more decentralised approach in which palliative care is integrated into primary care will ensure that the care is available locally to those who need it and at a cost that they can afford. General practitioners (GPs) play a pivotal role in providing primary palliative care in the community. They ensure that care is provided in alignment with patients’ and their families’ wishes along the trajectory of the life-threatening illness and at the patient’s preferred place. GPs use an interdisciplinary approach by collaborating with specialist palliative care teams and other healthcare professionals. However, they face challenges in providing end-of-life care in the community, which include identification of patients in need of palliative care, interpersonal communication, addressing patients’ and caregivers’ needs, clarity in roles and responsibilities between GPs and specialist palliative care teams, coordination of service with specialists and lack of confidence in providing palliative care in view of deficiencies in knowledge and skills in palliative care. Multiple training formats and learning styles for GPs in end-of-life care have been explored across studies. The research has yielded mixed results in terms of physician performance and patient outcomes. This calls for more research on GPs’ views on end-of-life care learning preferences, as this might inform policy and practice and facilitate future training programs in end-of-life care.

Psychodrama with persons with dementia on zoom: Proof of concept

COVID-19 pandemic and subsequent lockdowns created a global public health crisis generating mental health problems including social isolation, stress, and anxiety especially for persons with dementia and their carers. This article reports on the use of digital technology to maintain social connectivity via a virtual group session that focused on the topic of "what is home." Participants in this session included 16 day-care center clients representing an immigrant community identified with mild to moderate cognitive impairment. A trained psychodrama therapist conducted the virtual group meeting based on five key techniques: spectrogram, role reversal, doubling, mirroring, and soliloquy. The NVivo software was used for the qualitative analysis of the transcribed video recording to identify key themes based on grounded theory methodology. Zooming from home, clients engaged in significant social interaction. Findings of the NVivo analysis identified the following themes of "what is home": Emotions and home, Home is family, Home is community, and Reminiscence (with objects and traditions). Findings suggest that digital interactive technologies, like Zoom, enhance social connectivity thus mitigating the negative impact of social isolation for persons with dementia especially during pandemic lockdowns. Our pilot findings based on virtual group meetings from home demonstrate that participants can express significant emotive capacity and enhanced connectivity with one another despite a diagnosis of mild to moderate dementia. While larger studies are needed to confirm these findings, we suggest that this methodology may be used to support persons with dementia not only in times of pandemics but also as an addition to other community and home care services. Changes in reimbursement policies to include these innovative home services may be helpful in building more resilient communities for the more highly vulnerable populations.

New public health approaches to palliative care, a brave new horizon or an impractical ideal? An Integrative literature review with thematic synthesis

Access to palliative care for marginalized communities is frequently problematized as a major challenge facing palliative care services. The traditional response of asking what services can do for the disadvantaged has been invigorated by a new wave of public health measures that embrace death and dying as social processes and ask, what can be done together with such communities as partners working in palliative care. Such work has generated a significant amount of academic, social and political interests over the last 20 years; however, we are yet to see a consistent and sustained change in approach from providers. We argue that this is due to inherent tensions that arise when modelling death, dying and loss as a unified and shared social process. Unresolved tensions destabilize the theoretical foundations and risk misrepresentation of core philosophies. In this integrative review of 75 articles, we present previously undiscussed areas of contention drawing from a pan-disciplinary field of theoretical and empirical evidence. We conclude that new public health approaches lack a consistent and unified theoretical approach. From philosophical, ontological and existential ideas relating to how different stakeholders conceptualize death, to the processes by which communities are motivated and their constituent members empowered through responsibilized notions of duty and reciprocity, there is little acknowledgement of the complex tensions at hand. Increasing academic and political initiative alone is not enough to progress this movement in a manner that achieves its full potential. Instead, we must pay greater attention to the tensions described. This article aims to work with such tensions to better define the landscape of collective moral responsibility in end-of-life care. We believe that this is crucial if palliative care is to avoid becoming a technical speciality with community and communitization reduced to a mere technical solution to more profound questions.

Description of e-Health Initiatives to Reduce Chronic Non-Communicable Disease Burden on Brazilian Health System

Chronic non-communicable diseases (NCD) account for 72% of the causes of death in Brazil. In 2013, 54 million Brazilians reported having at least one NCD. The implementation of e-Health in the Unified Health System (SUS) could fill gaps in access to health in primary health care (PHC). Objective: to demonstrate telehealth strategies carried out within the scope of the Institutional Development Support Program of the Unified Health System (PROADI-SUS) and developed by Hospital Alemão Oswaldo Cruz, between 2018 and 2021, on evaluation, supply, and problem-solving capacity for patients with NCDs. Methodology: a prospective and descriptive study of three projects in the telehealth areas, using document analysis. The Brasil Redes project used availability, implementation, and cost-effectiveness analysis, TELEconsulta Diabetes is a randomized clinical trial, and Regula Mais Brasil is focused on the waiting list for regulation of specialties. All those strategies were developed within the scope of the SUS. Results: 161 patients were attended by endocrinology teleconsultation in one project and another two research projects, one evaluating Brazil’s Telehealth Network Program, and another evaluating effectiveness and safety of teleconsultation in patients with diabetes mellitus referred from primary care to specialized care in SUS. Despite the discrepancy in the provision of telehealth services in the country, there was an increase in access to specialized care on the three projects and especially on the Regula Mais Brasil Collaborative project; we observed a reduction on waiting time and favored distance education processes. Conclusion: the three projects offered subsidies for decision-making by the Ministry of Health in e-Health and two developed technologies that could be incorporated into SUS.

Big Data-Enabled Analysis of Factors Affecting Patient Waiting Time in the Nephrology Department of a Large Tertiary Hospital

The length of waiting time has become an important indicator of the efficiency of medical services and the quality of medical care. Lengthy waiting times for patients will inevitably affect their mood and reduce satisfaction. For patients who are in urgent need of hospitalization, delayed admission often leads to exacerbation of the patient's condition and may threaten the patient's life. We gathered patients' information about outpatient visits and hospital admissions in the Nephrology Department of a large tertiary hospital in western China from January 1st, 2014, to December 31st, 2016, and we used big data-enabled analysis methods, including univariate analysis and multivariate linear regression models, to explore the factors affecting waiting time. We found that gender (P=0.048), the day of issuing the admission card (Saturday, P=0.028), the applied period for admission (P < 0.001), and the registration interval (P < 0.001) were positive influencing factors of patients' waiting time. Disease type (after kidney transplantation, P < 0.001), number of diagnoses (P=0.037), and the day of issuing the admission card (Sunday, P=0.001) were negative factors. A linear regression model built using these data performed well in the identification of factors affecting the waiting time of patients in the Nephrology Department. These results can be extended to other departments and could be valuable for improving patient satisfaction and hospital service quality by identifying the factors affecting waiting time.

"One Health" Approach for Health Innovation and Active Aging in Campania (Italy)

This article describes how innovations are exploited in Campania (Italy) to improve health outcomes, quality of life, and sustainability of social and healthcare services. Campania's strategy for digitalization of health and care and for healthy aging is based on a person-centered, life-course, “One Health” approach, where demographic change is considered capable of stimulating a growth dynamic linked to the opportunities of combining the “Silver Economy” with local assets and the specific health needs of the population. The end-users (citizens, patients, and professionals) contribute to the co-creation of products and services, being involved in the identification of unmet needs and test-bed activity. The Campania Reference Site of the European Innovation Partnership on Active and Healthy Aging is a flexible regional ecosystem to address the challenge of an aging population with a life-course approach. The good practices, developed in the context of research and innovation projects and innovative procurements by local stakeholders and collaborations with international networks, have been allowing the transfer of innovative solutions, knowledge, and skills to the stakeholders of such a multi-sectoral ecosystem for health.

Caring Advanced Cancer Patients at Home During COVID-19 Outbreak: Burnout and Psychological Morbidity Among Palliative Care Professionals in Italy

CONTEXT

Providing palliative care (PC) at home for patients with advanced cancer has become essential during the COVID-19 emergency. Nevertheless, the home PC professionals (PCPs) faced a challenging situation because of increased number of discharged patients, reduced availability of health-care facilities, and physical/relational barriers between them and patients.

OBJECTIVES

This study aimed to investigate the impact of COVID-19 pandemic on burnout and psychological morbidity among home PCPs in Italy.

METHODS

One hundred and ninety-eight PC physicians and nurses working in home assistance in Italy were invited to participate. The results obtained by the investigation conducted during the COVID-19 emergency (COVID2020) were compared with data collected in 2016 in the same setting (BURNOUT2016). The questionnaires (socio-demographics, Maslach Burnout Inventory and General Health Questionnaire-12) were the same for both the surveys. The PCPs participating in COVID2020 survey (n = 145) were mostly the same (70%) who participated in the BURNOUT2016 study (n = 179).

RESULTS

One hundred and forty-five PCPs participated in the study (response rate 73.2%). During the COVID-19 emergency, home PCPs presented a lower burnout frequency (P < .001) and higher level of personal accomplishment than in 2016 (P = .047). Conversely, the risk for psychological morbidity was significantly higher during the pandemic (P < .001).

CONCLUSIONS

In the age of COVID-19, the awareness of being at the forefront of containing the pandemic along with the sense of responsibility toward their high-risk patients may arouse PCPs' psychological distress, but, on the other hand, this condition may improve their sense of professional satisfaction and personal accomplishment.

Implementing Advance Care Planning in 'The Age of Deferred Death'- the Hong Kong Experience over 4 Years

OBJECTIVES

To plan, implement and evaluate a series of initiatives to improve patient centred quality of end of life care through raising public awareness, promoting the concept that all health and social care professionals should be engaged in this practice, and carrying out pilot of community care models.

DESIGN

Pilot studies of community models of care, training programs for health and social care professionals, public education programmes.

SETTING

Selected hospitals, residential care homes for the elderly, and community centres in Hong Kong.

PARTICIPANTS

Patients and their families at the end of life stage.

MEASUREMENTS

Combination of quantitative and qualitative studies according to different components of the initiative.

RESULTS

Effective training for professional staff occurred using training videos, role play, rather than lectures, and when concepts are integrated into daily practice and quality assurance programmes. Members of the public welcomed end of life care discussions and the implementation of advance care planning. The pilot community care program was found to reduce anxiety, depression, physical symptoms, improve communication within the family as well as promoting a feeling of peace among recipients of the service. It also reduced care giver strain and anxiety, as well as hospital visits and duration of stay. Similar findings were also observed among recipients of care in the residential care setting.

CONCLUSION

A sustainable model would require uptake by policy makers and chief executives of Social Welfare and Health Bureaus, supported by amendments of relevant legal ordinances, which is in progress after public consultation.