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Yen YF, Huang SF, Chen ST, Deng CY. The utility of the surprise question by nurses to identify hospitalised older patients nearing the end-of-life and promotion of advance care planning: An interventional study. J Clin Nurs 2024. [PMID: 38459702 DOI: 10.1111/jocn.17096] [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: 11/17/2023] [Revised: 01/04/2024] [Accepted: 02/28/2024] [Indexed: 03/10/2024]
Abstract
AIMS AND OBJECTIVES To assess the prognostic accuracy of the surprise question (SQ) when used by nurses working in hospital wards to determine 1-year mortality in acutely hospitalised older patients. BACKGROUND The predictive accuracy of the SQ, when used by general nurses caring for older hospitalised patients, has not been comprehensively studied. DESIGN A prospective cohort study. METHODS This cohort study recruited consecutive 10,139 older patients (aged ≥65 years) who were admitted to Taipei City Hospital and were evaluated for the needs of palliative care in 2015. All patients were followed up for 12 months or until their death. The c-statistic value was calculated to indicate the predictive accuracy of the SQ and Palliative Care Screening Tool (PCST). RESULTS Of all participants, 18.8% and 18.6% had a SQ response of 'no' and a PCST score ≥4, respectively. After controlling for other covariates, an SQ response of 'no' (adjusted hazard ratio [aHR], 2.05; 95% confidence interval [CI], 1.83-2.31) and a PCST score ≥4 (AHR = 1.50; 95% CI: 1.29-1.75) were found to be the independent predictors for patients' 12-month mortality. The C-statistic values of the SQ and the PCST at recognising patients in their last year of life were .663 and .670, respectively. Moreover, there was moderate concordance (k = .44) between the SQ and the PCST in predicting 12-month mortality. CONCLUSIONS SQ response of 'no' and a PCST score ≥4 were independent predictors of 12-month mortality in older patients. RELEVANCE TO CLINICAL PRACTICE The SQ, when used by nurses working in hospital wards, is effective in identifying older patients nearing the end of life, as well as in providing advance care planning for patients. PATIENT OR PUBLIC CONTRIBUTION Patients' palliative care needs at admission were assessed by general nurses using the SQ and PCST.
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Affiliation(s)
- Yung-Feng Yen
- Section of Infectious Diseases, Taipei City Hospital, Taipei, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- Department of Education and Research, Taipei City Hospital, Taipei, Taiwan
- University of Taipei, Taipei, Taiwan
| | - Shu-Fen Huang
- Department of Nursing, Taipei City Hospital, Taipei, Taiwan
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Ting Chen
- Section of Infectious Diseases, Taipei City Hospital, Taipei, Taiwan
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Section of Hospice and Palliative, Taipei City Hospital, Taipei, Taiwan
| | - Chung-Yeh Deng
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei, Taiwan
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2
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Castelo-Loureiro A, Perez-de-Acha A, Torres-Perez AC, Cunha V, García-Valdés P, Cárdenas-Reyes P, Soto-Perez-de-Celis E. Delivering Palliative and Supportive Care for Older Adults with Cancer: Interactions between Palliative Medicine and Geriatrics. Cancers (Basel) 2023; 15:3858. [PMID: 37568674 PMCID: PMC10417379 DOI: 10.3390/cancers15153858] [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: 07/03/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/13/2023] Open
Abstract
The world's population is aging rapidly, with projections indicating that by 2050 one in six people will be aged ≥65 years. As a result, the number of cancer cases in older people is expected to increase significantly. Palliative care is an essential component of cancer care with a direct impact on quality of life. However, older adults with cancer often suffer from multiple comorbidities, cognitive impairment, and frailty, posing unique challenges in the delivery of palliative care. The complex healthcare needs of older patients with cancer therefore require a comprehensive assessment, including a geriatric evaluation. Collaboration between geriatrics and palliative care can offer a solution to the challenges faced by older people with cancer, since this is a population with overlapping concerns for both disciplines. This review highlights the importance of palliative care for older adults with cancer and the benefits of a multidisciplinary approach. It also addresses the coordination of palliative care and geriatrics for specific symptom management and decision making.
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Affiliation(s)
| | - Andrea Perez-de-Acha
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Ana Cristina Torres-Perez
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Vanessa Cunha
- School of Medicine, University of Toronto, Toronto, ON M5S 3G5, Canada
| | - Paola García-Valdés
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Department of Palliative Care, Hospital Gea González, Mexico City 14080, Mexico
| | - Paula Cárdenas-Reyes
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
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3
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Saretta M, Doñate-Martínez A, Alhambra-Borrás T. Barriers and facilitators for an effective palliative care communication with older people: A systematic review. PATIENT EDUCATION AND COUNSELING 2022; 105:2671-2682. [PMID: 35459530 DOI: 10.1016/j.pec.2022.04.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/30/2022] [Accepted: 04/04/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVES The present mixed-method systematic review identifies facilitators and barriers in palliative care communication among health professionals and older people. METHODS The review process was conducted by three reviewers who searched studies in four different databases (January 2009-January 2022), exploring experiences of communication among health professionals and older people without cognitive impairments. Relevant articles were quality assessed with a standardized tool. RESULTS Twenty-eight articles were included and the following 5 clusters were identified: 1) training and education for health professionals, 2) team working and coordination among health professionals, 3) communication skills, 4) time and availability, 5) emotional, cultural and psychological factors. The articles highlighted the need for greater preparation of health professionals around the management of palliative care communication with older people. CONCLUSION Palliative care communication among health professionals and older people are characterized by several challenges. However, there are facilitating aspects that may be considered to improve the quality of communication. PRACTICE IMPLICATIONS Facilitators are promising approaches to support health professionals in providing high-quality palliative care communication to older people, developing a person-centred practice. Facilitators include palliative care training and educational opportunities for health professionals, like ELNEC Geriatric Curriculum, permitting them to develop specific competences in communication and aging.
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Affiliation(s)
- Michela Saretta
- Polibienestar Research Institute, University of Valencia, Valencia, Spain.
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4
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Fettes L, Neo J, Ashford S, Higginson IJ, Maddocks M. Trajectories of disability in activities of daily living in advanced cancer or respiratory disease: a systematic review. Disabil Rehabil 2022; 44:1790-1801. [PMID: 32961067 DOI: 10.1080/09638288.2020.1820587] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 09/01/2020] [Accepted: 09/03/2020] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Advanced cancer and/or respiratory disease threaten a person's independence in activities of daily living (ADL). Understanding how disability develops can help direct appropriate and timely interventions. AIM To identify different trajectories and associations of disability in ADL and appraise its measurement. METHODS Medline, Embase, PsychINFO, and CINAHL databases were searched for cohort studies with measures of disability in ADL in advanced cancer or respiratory disease at three or more timepoints. Data were narratively synthesized to produce a typology of disability trajectories and a model of factors and outcomes associated with increasing disability. RESULTS Of 5702 publications screened, 11 were included. Seventy-four disability trajectories were categorized into typologies of unchanging (n = 20), fluctuating (n = 21), and increasing disability (n = 33). Respiratory disease did not predict any particular disability trajectory. Advanced cancer frequently followed trajectories of increasing disability. Factors associated with increasing disability included: frailty, multi-morbidity, cognitive impairment, and infection. Increased disability led to recurrent hospital admissions, long-term care, and/or death. Methodological limitations included use of non-validated measures. CONCLUSIONS Increasing disability trajectories in advanced cancer and/or respiratory disease is related to potentially modifiable personal and environmental factors. We recommend future studies using validated disability instruments.Implications for rehabilitationDisability in activities of daily living (ADL) is a common unmet need in advanced cancer or respiratory disease and represents an important outcome for patients, caregivers and health and social care services.Trajectories of ADL disability can be categorized into increasing, fluctuating, and unchanging disability, which could help planning of rehabilitation services in advanced cancer or respiratory disease.Increasing disability in advanced cancer or respiratory disease relates to personal and environmental factors as well as bodily impairments, which can all be modifiable by intervention.This review highlights implications for the measurement of ADL disability in advanced cancer or respiratory disease and recommends use of validated measures of ADL to understand what factors can be modified through rehabilitation interventions.
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Affiliation(s)
- Lucy Fettes
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | | | - Stephen Ashford
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
- Regional Hyper-acute Rehabilitation Unit, London North West University Healthcare NHS Trust, Northwick Park Hospital, Harrow, UK
- University College London Hospitals, National Hospital for Neurology and Neurosurgery, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
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5
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Patient-Level Factors Influencing Palliative Care Consultation at a Safety-Net Urban Hospital. Am J Hosp Palliat Care 2020; 38:1299-1307. [PMID: 33325245 DOI: 10.1177/1049909120981764] [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] [Indexed: 12/21/2022] Open
Abstract
The influence of patient-level factors on palliative and hospice care is unclear. We conducted a retrospective review of 2321 patients aged ≥18 that died within 6 months of admission to our institution between 2012 and 2017. Patients were included for analysis if their chart was complete, their length of stay was ≥48 hours, and if based on their diagnoses, they would have benefited from palliative care consultation (PCC). Bayesian regression with a weakly informative prior was used to find the odds ratio (OR) and 99% credible interval (CrI) of receiving PCC based on race/ethnicity, education, language, insurance status, and income. 730 patients fit our inclusion criteria and 30% (n = 211) received PCC. The OR of receiving PCC was 1.26 (99% CrI, 0.73-2.12) for Blacks, 0.81 (99% CrI, 0.31-1.86) for Hispanics, and 0.69 (99% CrI, 0.19-2.46) for other minorities. Less than high school education was associated with greater odds of PCC (OR 2.28, 99% CrI, 1.09-4.93) compared to no schooling. Compared to English speakers, non-English speakers had higher odds of receiving PCC when cared for by medical services (OR 3.01 [99% CrI, 1.44-5.32]) but lower odds of PCC when cared for by surgical services (0.22 [99% CrI, <0.01-3.42]). Insurance status and income were not associated with differences in PCC. At our institution, we found no evidence of racial/ethnic, insurance, or income status affecting PCC while primary language spoken and educational status did. Further investigation is warranted to examine the system and provider-level factors influencing PCC's low utilization by medical and surgical specialties.
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Affiliation(s)
| | - Timothy Feeney
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - F Thurston Drake
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- 12259Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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6
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Fischer SM, Tropeano L, Lahoff D, Owens B, Nielsen E, Retrum J, Jensen E, Ross C, Mancuso M, Drace M, Plata A, Melnyk A, Golub M, Gozansky W. Integrating Palliative Care Social Workers into Subacute Settings: Feasibility of the Assessing & Listening to Individual Goals and Needs Intervention Trial. J Palliat Med 2020; 24:830-837. [PMID: 33181046 DOI: 10.1089/jpm.2020.0322] [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] [Indexed: 12/22/2022] Open
Abstract
Objectives: Determine feasibility, acceptability, and preliminary effects of the Palliative Care Social Worker-led ALIGN (Assessing & Listening to Individual Goals and Needs) intervention in older persons admitted to Skilled Nursing Facility (SNF) and their caregivers. Design: A pilot pragmatic randomized stepped wedge design of ALIGN versus usual care in three SNFs. Setting and Participants: One hundred and twenty older adults and caregivers (optional) with advanced medical illnesses. Measures: Primary outcomes were feasibility and acceptability. We collected exploratory patient-/caregiver-centered outcomes at baseline and three months and conducted a medical record review at six months to assess documentation of Advance Directives (AD). We also collected exploratory health care utilization data, including hospitalizations, mortality, and hospice utilization. Results: Of 179 patients approached, 120 enrolled (60 ALIGN patients with 15 caregivers and 60 usual care patients and 21 caregivers). Four intervention patients refused ALIGN visits, 8 patients died or discharged before initial visit, and 48 intervention patients received ALIGN visits, with ∼80% having caregivers participating in visits, regardless of caregiver study enrollment. Quantitative exploratory outcomes were not powered to detect a difference between groups. We found 91% of ALIGN patients had a completed AD in medical record compared to 39.6% of usual care patients (p < 0.001). Qualitative feedback from participants and SNF staff supported high acceptability and satisfaction with ALIGN. Conclusion and Clinical Implications: A pragmatic trial of the ALIGN intervention is feasible and preliminary effects suggest ALIGN is effective in increasing AD documentation. Further research is warranted to understand effects on caregivers and health care utilization. The current model for SNF does not address the palliative care needs of patients. ALIGN has potential to be an effective, scalable, acceptable, and reproducible intervention to improve certain palliative care outcomes within subacute settings.
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Affiliation(s)
- Stacy M Fischer
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | | | - Bree Owens
- The Holding Group, Denver, Colorado, USA
| | | | - Jessica Retrum
- Metropolitan State University of Denver, Denver, Colorado, USA
| | | | - Colleen Ross
- Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Mary Mancuso
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Angela Plata
- Kaiser Permanente Colorado, Denver, Colorado, USA
| | - Aurora Melnyk
- Metropolitan State University of Denver, Denver, Colorado, USA
| | - Matthew Golub
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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7
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Pais R, Lee P, Cross S, Gebski V, Aggarwal R. Bladder Care in Palliative Care Inpatients: A Prospective Dual Site Cohort Study. Palliat Med Rep 2020; 1:251-258. [PMID: 34223485 PMCID: PMC8241358 DOI: 10.1089/pmr.2020.0060] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 11/24/2022] Open
Abstract
Background: Urinary catheterization is often undertaken to relieve distressing bladder symptoms in palliative care. Objective: The primary aim of this study was to determine the incidence of, and clinical indications that predispose patients admitted to palliative care units to, urinary catheterization. The secondary aims were to determine causal factors, including the type of malignancy, antecedent medications, and duration of admission in these patients. Methods: This was a prospective observational dual site cohort study in palliative care inpatients. Univariate categorical chi-square analysis was performed to compare patients with and without urinary catheterization, and to identify risk factors associated with urinary catheter use. Results: The incidence of catheterization in this cohort was 41% (43/104) and urinary retention (63%) was the most common cause. Agitation (47%) and urinary incontinence (70%) were common symptoms in those catheterized. Medications that were significantly associated with the need for urinary catheterization were benzodiazepines (p < 0.01) and antipsychotics (p = 0.01). All measures that define poor functional status were found to be significant (p < 0.01). Patients with prolonged hospitalization of greater than three weeks were catheterized more frequently (p = 0.017). The majority of patients catheterized (79%) were admitted for terminal care. Conclusions: The high incidence of urinary catheterization highlights the need for good bladder care for all patients in the palliative care setting. Patients with risk factors include the use of antipsychotics and benzodiazepines, declining functional status and prolonged hospital admission are more likely to be catheterized.
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Affiliation(s)
- Riona Pais
- Department of Palliative Medicine, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Supportive and Palliative Medicine, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Philip Lee
- Department of Supportive and Palliative Medicine, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Shamira Cross
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Val Gebski
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rajesh Aggarwal
- Department of Palliative Medicine, Bankstown Hospital, Sydney, New South Wales, Australia
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8
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Espinoza Suarez NR, Walker LE, Jeffery MM, Stanich JA, Campbell RL, Lohse CM, Takahashi PY, Bellolio F. Validation of the Elderly Risk Assessment Index in the Emergency Department. Am J Emerg Med 2019; 38:1441-1445. [PMID: 31839521 DOI: 10.1016/j.ajem.2019.11.048] [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] [Received: 10/22/2019] [Revised: 11/27/2019] [Accepted: 11/30/2019] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVES The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients. METHODS Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85). CONCLUSION The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.
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Affiliation(s)
| | - Laura E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | | | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christine M Lohse
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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9
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Espinoza Suarez NR, Walker LE, Jeffery MM, Stanich JA, Campbell RL, Lohse CM, Takahashi PY, Bellolio F. Validation of the Elderly Risk Assessment Index in the Emergency Department. Am J Emerg Med 2019. [PMID: 31839521 DOI: 10.1016/j.ajem.2019.11.048.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES The Elderly Risk Assessment (ERA) score is a validated index for primary care patients that predict hospitalizations, mortality, and Emergency Department (ED) visits. The score incorporates age, prior hospital days, marital status, and comorbidities. Our aim was to validate the ERA score in ED patients. METHODS Observational cohort study of patients age ≥ 60 presenting to an academic ED over a 1-year period. Regression analyses were performed for associations with outcomes (hospitalization, return visits and death). Medians, interquartile range (IQR), odds ratios (OR) and 95% confidence intervals (CI) were calculated. RESULTS The cohort included 27,397 visits among 18,607 patients. Median age 74 years (66-82), 48% were female and 59% were married. Patients from 54% of visits were admitted to the hospital, 16% returned to the ED within 30 days, and 18% died within one year. Higher ERA scores were associated with: hospital admission (score 10 [4-16] vs 5 [1-11], p < 0.0001), return visits (11 [5-17] vs 7 [2-13], p < 0.0001); and death within one year (14 [7-20] vs 6 [2-13], p < 0.0001). Patients with ERA score ≥ 16 were more likely to be admitted to the hospital, OR 2.14 (2.02-2.28, p < 0.0001), return within 30 days OR 1.99 (1.85-2.14), and to die within a year, OR 2.69 (2.54-2.85). CONCLUSION The ERA score can be automatically calculated within the electronic health record and helps identify patients at increased risk of death, hospitalization and return ED visits. The ERA score can be applied to ED patients, and may help prognosticate the need for advanced care planning.
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Affiliation(s)
| | - Laura E Walker
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | | | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA
| | - Christine M Lohse
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Paul Y Takahashi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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10
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Nguyen MT, Feeney T, Kim C, Drake FT, Mitchell SE, Bednarczyk M, Sanchez SE. Differential Utilization of Palliative Care Consultation Between Medical and Surgical Services. Am J Hosp Palliat Care 2019; 37:250-257. [PMID: 31387366 DOI: 10.1177/1049909119867904] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
There is a paucity of data regarding the utilization of palliative care consultation (PCC) in surgical specialties. We conducted a retrospective review of 2321 adult patients (age ≥18) who died within 6 months of admission to Boston Medical Center from 2012 to 2017. Patients were included for analysis if their length of stay was more than 48 hours and if, based on their diagnoses as determined by literature review and expert consensus, they would have benefited from PCC. Bayesian regression was used to estimate the odds ratio (OR) and 99% credible intervals (CrI) of receiving PCC adjusted for age, sex, race, insurance status, median income, and comorbidity status. Among the 739 patients who fit the inclusion criteria, only 30% (n = 222) received PCC even though 664 (90%) and 75 (10%) of these patients were identified as warranting PCC on medical and surgical services, respectively. Of the 222 patients who received PCC, 214 (96%) were cared for by medical services and 8 (4%) were cared for by surgical services. Patients cared for primarily by surgical were significantly less likely to receive PCC than primary patients of medical service providers (OR, 0.19, 99% CrI, 0.056-0.48). At our institution, many surgical patients appropriate for PCC are unable to benefit from this service due to low consultation numbers. Further investigation is warranted to examine if this phenomenon is observed at other institutions, elucidate the reasons for this disparity, and develop interventions to increase the appropriate use of PCC throughout all medical specialties.
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Affiliation(s)
| | - Timothy Feeney
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Chanmin Kim
- Boston University School of Public Health, Boston, MA, USA
| | - F Thurston Drake
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | - Suzanne E Mitchell
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
| | | | - Sabrina E Sanchez
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Boston, MA, USA
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12
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Arcanjo SP, Saporetti LA, Curiati JAE, Jacob-Filho W, Avelino-Silva TJ. Clinical and laboratory characteristics associated with referral of hospitalized elderly to palliative care. ACTA ACUST UNITED AC 2018; 16:eAO4092. [PMID: 29694607 PMCID: PMC5968794 DOI: 10.1590/s1679-45082018ao4092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 10/31/2017] [Indexed: 12/20/2022]
Abstract
Objective To investigate clinical and laboratory characteristics associated with referral of acutely ill older adults to exclusive palliative care. Methods A retrospective cohort study based on 572 admissions of acutely ill patients aged 60 years or over to a university hospital located in São Paulo, Brazil, from 2009 to 2013. The primary outcome was the clinical indication for exclusive palliative care. Comprehensive geriatric assessments were used to measure target predictors, such as sociodemographic, clinical, cognitive, functional and laboratory data. Stepwise logistic regression was used to identify independent predictors of palliative care. Results Exclusive palliative care was indicated in 152 (27%) cases. In the palliative care group, in-hospital mortality and 12 month cumulative mortality amounted to 50% and 66%, respectively. Major conditions prompting referral to palliative care were advanced dementia (45%), cancer (38%), congestive heart failure (25%), stage IV and V renal dysfunction (24%), chronic obstructive pulmonary disease (8%) and cirrhosis (4%). Major complications observed in the palliative care group included delirium (p<0.001), infections (p<0.001) and pressure ulcers (p<0.001). Following multivariate analysis, male sex (OR=2.12; 95%CI: 1.32-3.40), cancer (OR=7.36; 95%CI: 4.26-13.03), advanced dementia (OR=12.6; 95%CI: 7.5-21.2), and albumin levels (OR=0.25; 95%CI: 0.17-0.38) were identified as independent predictors of referral to exclusive palliative care. Conclusion Advanced dementia and cancer were the major clinical conditions associated with referral of hospitalized older adults to exclusive palliative care. High short-term mortality suggests prognosis should be better assessed and discussed with patients and families in primary care settings.
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Affiliation(s)
- Suelen Pereira Arcanjo
- Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Luis Alberto Saporetti
- Faculdade de Medicina, Hospital das Clínicas, Universidade de São Paulo, São Paulo, SP, Brazil
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Meeker MA, Waldrop DP. Changing Focus: End-of-Life Care in a New York State Managed Long-Term Care Program. J Appl Gerontol 2017; 38:1371-1390. [PMID: 29165012 DOI: 10.1177/0733464817737620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
In the United States, managed long-term care programs offer a noninstitutional approach to meeting the needs of increasing numbers of frail elders. Providing services that support both quality of life and quality of dying poses unique challenges. Using a qualitative descriptive design, we explored these challenges from the perspectives of care providers. Themes were identified using qualitative content analysis techniques applied to transcripts of 33 semistructured interviews. Professionals comprising an interdisciplinary care team and home health aide direct care providers described cues by which they identified movement into the end-of-life phase, their understandings of how care changed, and their concerns and recommendations for improvement. When the changing care needs could be met, a "good death" ensued, but that was not always possible. Managed long-term care programs are called upon to develop the capacity to integrate the phase of dying into the full story of each life for which they care.
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Affiliation(s)
- Mary Ann Meeker
- 1 University at Buffalo, the State University of New York, Buffalo, NY, USA
| | - Deborah P Waldrop
- 1 University at Buffalo, the State University of New York, Buffalo, NY, USA
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Geriatric palliative care: Meeting the needs of a growing population. Geriatr Nurs 2017; 39:225-229. [PMID: 29042070 DOI: 10.1016/j.gerinurse.2017.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Revised: 09/05/2017] [Accepted: 09/08/2017] [Indexed: 11/23/2022]
Abstract
The implementation of effective geriatric palliative care (PC) services will be increasingly important as the number of patients ages ≥65 years continues to grow. However, literature characterizing the utilization of PC services by older adults remains scant. The objective of these analyses was to characterize the nature and outcomes of PC services for older adults. A retrospective analysis of records of inpatient PC consultations provided to patients ≥65 years at an academic hospital was performed (N = 743). Logistic regressions identified factors associated with goals of care discussions (GOC), end-of-life (EOL) coordination, and hospital readmission. Differences between older adult subgroups (i.e., 65-84 years and 85 years and older) were also examined. Discharge to home was associated with higher odds of readmission and discharge to hospice or having a GOC discussion was associated with lower odds of readmission. Those patients who were 85 years or older were significantly less likely to have cancer or to be referred for pain management, and more likely to be referred for GOC discussions and discharged to hospice. This study revealed dynamic factors associated with PC consultation for older adults. GOC discussions in initial PC consultations for older patients might reduce the odds of hospital readmission. Additionally, the needs of patients ages 85 and older appear distinct from the traditional PC cancer model.
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Abstract
End-of-life discussions with geriatric oncology patients are a vital part of the comprehensive care of the senior adult patient. Developing a roadmap for these conversations can be challenging. Patients and caregivers may have expectations that are not concordant with what is reasonably achievable if the patient is frail. Measuring baseline cognition, nutritional status, and physical function and discussing goals of care are all essential pieces of information that can be obtained through a comprehensive geriatric assessment (CGA). Objective findings from the CGA can be crucial in developing end-of-life care plans that reflect both the patient's health status and personal values.
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Frey R, Boyd M, Robinson J, Foster S, Gott M. The Supportive Hospice and Aged Residential Exchange (SHARE) programme in New Zealand. Nurse Educ Pract 2017; 25:80-88. [PMID: 28554068 DOI: 10.1016/j.nepr.2017.05.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 05/04/2017] [Accepted: 05/15/2017] [Indexed: 11/26/2022]
Abstract
Research indicates that staff in aged residential care may be unprepared for their role in palliative care provision. In collaboration with a local hospice, the project piloted an innovative problem-based experiential learning intervention Supportive Hospice and Aged Residential Exchange (SHARE) to enhance aged residential care staff palliative care skills. The aim was to explore the impact of SHARE for staff. SHARE was implemented in two aged residential care facilities in one urban centre for six months. Measurement of the impact of the intervention consisted of 1) pre-test-post-test questionnaires (n = 27) to assess changes in staff confidence in palliative care delivery 2) Eleven post-intervention interviews to describe staff perceptions of SHARE. Results from the SHARE pilot indicate that the intervention overall is seen as a success, especially in relation to advanced care planning documentation. Relationships between hospice and facility staff, and consequently facility staff and residents are seen as the key to the success of the project. Staff survey results indicated increased confidence in palliative care delivery and decreased depression. Key lessons learnt from for the development of any palliative care intervention within aged residential care include the importance of reciprocal learning, as well as the necessity of a strong partnership with key stakeholders.
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Affiliation(s)
- Rosemary Frey
- Faculty of Medical and Health Sciences, The University of Auckland, New Zealand.
| | - Michal Boyd
- Faculty of Medical and Health Sciences, The University of Auckland, New Zealand; Waitemata District Health Board, New Zealand
| | - Jackie Robinson
- Faculty of Medical and Health Sciences, The University of Auckland, New Zealand; Auckland District Health Board, New Zealand
| | - Sue Foster
- Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
| | - Merryn Gott
- Faculty of Medical and Health Sciences, The University of Auckland, New Zealand
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Oosterhouse KJ, Vincent C, Foreman MD, Gruss VA, Corte C, Berger B. Intensive Care Unit Nurses' Beliefs About Delirium Assessment and Management. AACN Adv Crit Care 2017; 27:379-393. [PMID: 27959294 DOI: 10.4037/aacnacc2016535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Delirium, the most frequent complication of hospitalized older adults, particularly in intensive care units (ICUs), can result in increased mortality rates and length of stay. Nurses are neither consistently identifying nor managing delirium in these patients. The purpose of this study was to explore ICU nurses' identification of delirium, actions they would take for patients with signs or symptoms of delirium, and beliefs about delirium assessment and management. In this cross-sectional study using qualitative descriptive methods guided by the theory of planned behavior, 30 ICU nurses' responses to patient vignettes depicting different delirium subtypes were explored. Descriptive and content analyses revealed that nurses did not consistently identify delirium; their actions varied in different vignettes. Nurses believed that they needed adequate staffing, balanced workload, interprofessional collaboration, and established policy and protocols to identify and manage delirium successfully. Research is needed to determine if implementing these changes increases recognition and decreases consequences of delirium.
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Affiliation(s)
- Kimberly J Oosterhouse
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Catherine Vincent
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Marquis D Foreman
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Valerie A Gruss
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Colleen Corte
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
| | - Barbara Berger
- Kimberly J. Oosterhouse is Assistant Professor, Loyola University Chicago, 1032 W. Sheridan Road, BVM Hall 1008, Chicago, IL 60661 . Catherine Vincent is Associate Professor, University of Illinois at Chicago, Illinois. Marquis D. Foreman is John L. and Helen Kellogg Dean of Nursing, Rush University, Chicago, Illinois. Valerie A. Gruss is Clinical Assistant Professor, University of Illinois at Chicago, Illinois. Colleen Corte is Associate Professor, University of Illinois at Chicago, Illinois. Barbara Berger is Clinical Assistant Professor, University of Illinois at Chicago, Illinois
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Verhofstede R, Smets T, Cohen J, Eecloo K, Costantini M, Van Den Noortgate N, Deliens L. End-of-Life Care and Quality of Dying in 23 Acute Geriatric Hospital Wards in Flanders, Belgium. J Pain Symptom Manage 2017; 53:693-702. [PMID: 28042062 DOI: 10.1016/j.jpainsymman.2016.10.363] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 10/18/2016] [Accepted: 10/30/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the nursing and medical interventions performed in the last 48 hours of life and the quality of dying of patients dying in acute geriatric hospital wards. METHODS Cross-sectional descriptive study between October 1, 2012 and September 30, 2013. Twenty-three acute geriatric wards in 13 hospitals in Flanders, Belgium. Patients hospitalized for more than 48 hours before dying in the participating wards. Structured after-death questionnaires, filled out by the nurse, the physician, and the family carer most involved in end-of-life care. Main outcome measures were several nursing and medical interventions reported to be performed in the last 48 hours of life and the quality of dying. RESULTS Of 993 patients, we included 338 (mean age 85.7 years; 173 women). Almost 58% had dementia and nearly half were unable to communicate in the last 48 hours of their life. The most frequently continued or started nursing and medical interventions in the last 48 hours of life were measuring temperature (91.6%), repositioning (83.3%), washing (89.5%), oxygen therapy (49.7%), and intravenous fluids and nutrition (30%). Shortness of breath, lack of serenity, lack of peace, and lack of calm were symptoms reported most frequently by nurses and family carers. CONCLUSION Many nursing and medical interventions are continued or started in the last hours of a patient's life, which may not always be in their best interests. Furthermore, patients dying in acute geriatric wards are often affected by several symptoms.
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Affiliation(s)
- Rebecca Verhofstede
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Tinne Smets
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium.
| | - Joachim Cohen
- End-of-Life Care Research Group, Vrije Universiteit Brussel & Ghent University, Brussels, Belgium
| | - Kim Eecloo
- End-of-Life Care Research Group, Vrije Universiteit Brussel & 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 & Ghent University, Brussels, Belgium; Department of Medical Oncology, Ghent University Hospital, Ghent, Belgium
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Clement L, Painter Q, Shaffer JA. Meeting the Unmet Needs of Aging Heart Failure Patients: A Role for Palliative Care. CURRENT CARDIOVASCULAR RISK REPORTS 2016. [DOI: 10.1007/s12170-016-0515-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Wilson O, Avalos G, Dowling M. Knowledge of palliative care and attitudes towards nursing the dying patient. ACTA ACUST UNITED AC 2016; 25:600-5. [PMID: 27281593 DOI: 10.12968/bjon.2016.25.11.600] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
AIMS This study examines the palliative care knowledge and attitudes towards caring for the dying patient of nurses working in care of older people settings in one rural region in Ireland. DESIGN A cross-sectional survey design was used combining two questionnaires: the palliative care quiz for nurses (PCQN) and the thanatophobia scale (TS). RESULTS A total of 61 nurses completed the questionnaire. There was a significant correlation found between level of knowledge and attitudes towards palliative care (p=0.007), highlighting that as participants' level of palliative care knowledge increased, attitudes become more positive. While palliative care training did not impact on the mean overall scores, there was a significant difference in the PCQN scores of those who had completed the European Certificate in Essential Palliative Care (ECEPC) compared with those who had attended information sessions within their unit. Furthermore, increasing years as a registered nurse improved palliative care knowledge and attitudes towards caring for the dying. CONCLUSION Nurses who completed the ECEPC had better knowledge of palliative care when compared with nurses who had not undertaken the programme. This article also considers areas of focus for palliative care training.
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Affiliation(s)
| | - Gloria Avalos
- Lecturer, School of Medicine, Medical Informatics and Medical Education, National University of Ireland, Galway, Ireland
| | - Maura Dowling
- Lecturer, School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
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21
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What Makes a Good Palliative Care Physician? A Qualitative Study about the Patient's Expectations and Needs when Being Admitted to a Palliative Care Unit. PLoS One 2016; 11:e0158830. [PMID: 27389693 PMCID: PMC4936709 DOI: 10.1371/journal.pone.0158830] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 06/22/2016] [Indexed: 11/19/2022] Open
Abstract
Objective The aims of the study were to examine a) patients’ knowledge of palliative care, b) patients’ expectations and needs when being admitted to a palliative care unit, and c) patient’s concept of a good palliative care physician. Methods The study was based on a qualitative methodology, comprising 32 semistructured interviews with advanced cancer patients admitted to the palliative care unit of the Medical University of Vienna. Interviews were conducted with 20 patients during the first three days after admission to the unit and after one week, recorded digitally, and transcribed verbatim. Data were analyzed using NVivo 10 software, based on thematic analysis enhanced with grounded theory techniques. Results The results revealed four themes: (1) information about palliative care, (2) supportive care needs, (3) being treated in a palliative care unit, and (4) qualities required of palliative care physicians. The data showed that patients lack information about palliative care, that help in social concerns plays a central role in palliative care, and attentiveness as well as symptom management are important to patients. Patients desire a personal patient-physician relationship. The qualities of a good palliative care physician were honesty, the ability to listen, taking time, being experienced in their field, speaking the patient’s language, being human, and being gentle. Patients experienced relief when being treated in a palliative care unit, perceived their care as an interdisciplinary activity, and felt that their burdensome symptoms were being attended to with emotional care. Negative perceptions included the overtly intense treatment. Conclusions The results of the present study offer an insight into what patients expect from palliative care teams. Being aware of patient’s needs will enable medical teams to improve professional and individualized care.
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Reduction of Behavioral Psychological Symptoms of Dementia by Multimodal Comprehensive Care for Vulnerable Geriatric Patients in an Acute Care Hospital: A Case Series. Case Rep Med 2016; 2016:4813196. [PMID: 27069478 PMCID: PMC4812219 DOI: 10.1155/2016/4813196] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Revised: 02/15/2016] [Accepted: 02/16/2016] [Indexed: 11/23/2022] Open
Abstract
Management of Behavioral and Psychological Symptoms of Dementia (BPSD) is a key challenge in geriatric dementia care. A multimodal comprehensive care methodology, Humanitude, with eye contact, verbal communication, and touch as its elements, was provided to three geriatric dementia patients for whom conventional nursing care failed in an acute care hospital. Each episode was evaluated by video analysis. All patients had advanced dementia with BPSD. Failure of care was identified by patient's shouting, screaming, or abrupt movements of limbs. In this case series, conventional care failed for all three patients. Each element of care communication was much shorter than in Humanitude care, which was accepted by the patients. The average of the elements performed during the care was eye contact 0.6%, verbal communication 15.7%, and touch 0.1% in conventional care and 12.5%, 54.8%, and 44.5% in Humanitude care, respectively. The duration of aggressive behavior of each patient during care was 25.0%, 25.4%, and 66.3% in conventional care and 0%, 0%, and 0.3% in Humanitude, respectively. In our case series, conventional care was provided by less eye contact, verbal communication, and touch. The multimodal comprehensive care approach, Humanitude, decreased BPSD and showed success by patients' acceptance of care.
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Lillyman S, Bruce M. Palliative care for people with dementia: a literature review. Int J Palliat Nurs 2016; 22:76-81. [DOI: 10.12968/ijpn.2016.22.2.76] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Sue Lillyman
- Senior Lecturer, at the University of Worcester, Worcester, UK
| | - Mary Bruce
- Senior Lecturer, at the University of Worcester, Worcester, UK
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24
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A Need for More Palliative Focused Care: A Survey of Colorado Skilled Care Facilities. J Am Med Dir Assoc 2015; 16:712-3. [DOI: 10.1016/j.jamda.2015.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 05/27/2015] [Indexed: 11/21/2022]
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Stabenau HF, Morrison LJ, Gahbauer EA, Leo-Summers L, Allore HG, Gill TM. Functional trajectories in the year before hospice. Ann Fam Med 2015; 13:33-40. [PMID: 25583890 PMCID: PMC4291263 DOI: 10.1370/afm.1720] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
PURPOSE We undertook a study to identify distinct functional trajectories in the year before hospice, to determine how patients with these trajectories differ according to demographic characteristics and hospice diagnosis, and to evaluate the association between these trajectories and subsequent outcomes. METHODS From an ongoing cohort study of 754 community-living persons aged 70 years or older, we evaluated data on 213 persons who were subsequently enrolled in hospice from March 1998 to December 2011. Disability in 13 basic, instrumental, and mobility activities was assessed during monthly telephone interviews through June 2012. RESULTS In the year before hospice, we identified 5 clinically distinct functional trajectories, representing worsening cumulative burden of disability: late decline (10.8%), accelerated (10.8%), moderate (21.1%), progressively severe (24.9%), and persistently severe (32.4%). Participants with a cancer diagnosis (34.7%) had the most favorable functional trajectories (ie, lowest burden of disability), whereas those with neurodegenerative disease (21.1%) had the worst. Median survival in hospice was only 14 days and did not differ significantly by functional trajectory. Compared with participants in the persistently severe trajectory, those in the moderate trajectory had the highest likelihood of surviving and being independent in at least 1 activity in the month after hospice admission (adjusted odds ratio = 5.5; 95% CI, 1.9-35.9). CONCLUSIONS The course of disability in the year before hospice differs greatly among older persons but is particularly poor among those with neurodegenerative disease. Late admission to hospice (as shown by the short survival), coupled with high levels of severe disability before hospice, highlight potential unmet palliative care needs for many older persons at the end of life.
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Affiliation(s)
- Hans F Stabenau
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Laura J Morrison
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Evelyne A Gahbauer
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Linda Leo-Summers
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Heather G Allore
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
| | - Thomas M Gill
- Yale School of Medicine, Department of Internal Medicine, New Haven, Connecticut
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Fariña-López E, Estévez-Guerra GJ, Gandoy-Crego M, Polo-Luque LM, Gómez-Cantorna C, Capezuti EA. Perception of spanish nursing staff on the use of physical restraints. J Nurs Scholarsh 2014; 46:322-30. [PMID: 24754778 DOI: 10.1111/jnu.12087] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE To examine the perception of registered nurses and nursing assistants regarding the use of physical restraints with residents of nursing homes located in four of the regions of Spain; and to evaluate the relationship of these perceptions to the staff respondents' level of training. DESIGN Cross-sectional multicenter and correlational study. The research was conducted in 2013 in 19 Spanish nursing homes with 2,940 residential beds. A total of 785 nurses (170 registered nurses and 615 nursing assistants) participated in the study. METHODS The Perception of Restraint Use Questionnaire (PRUQ), consisting of 17 of the most cited reasons for using these devices, was used, as was a questionnaire capturing the sociodemographic characteristics and educational or experience level of staff respondents. FINDINGS Nurses reported the most important uses for restraints as prevention of falls and avoidance of medical device interference. As indicated by an average PRUQ score of 3.47, staff respondents supported restraint use, especially nursing assistants (3.59) as compared to registered nurses (3.00). With regard to training: 83.7% had participated in little, if any, training and only 29.2% had read three or more documents related to restraint use; 66.6% believed that their training was inadequate. No correlation was found between the results of the PRUQ and the respondents´ sociodemographic characteristics or participation in training activities. No differences were found among nurses by region. CONCLUSIONS In contrast to papers published in other countries, nurses in this study still consider it necessary to apply restraints in everyday practice. The education of nursing staff regarding restraint and knowledge of alternatives is needed; they should at least be aware of international standards of care regarding physical restraint use. CLINICAL RELEVANCE Most of the staff perceived their training related to the use of these devices as insufficient. Nursing assistants considered the use of restraints more important than did the registered nurses.
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Affiliation(s)
- Emilio Fariña-López
- Associate Professor, Nursing Department, University of Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
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Delgado-Guay MO, De La Cruz MG, Epner DE. 'I don't want to burden my family': handling communication challenges in geriatric oncology. Ann Oncol 2014; 24 Suppl 7:vii30-35. [PMID: 24001760 DOI: 10.1093/annonc/mdt263] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Oncologists need excellent communication skills to effectively handle challenging conversations regarding prognosis, transition to palliative care, code status, and other sensitive topics. Foundational skills include: 1) posing open-ended, exploratory questions, 2) allowing for appropriate silence in the conversation, 3) listening actively, 4) recognizing emotions, 5) responding to emotions with empathy rather than biomedical information, and 6) speaking with clarity by avoiding technical jargon and offering small chunks of information. Conversations about sensitive topics can be particularly challenging with geriatric patients, who experience functional and sensory limitations. The risk-benefit ratio of diagnostic and therapeutic interventions tips precariously in older patients as many develop geriatric syndromes. Older cancer patients have the unique perspective of looking back on a long life and looking forward to impending death. Higher order skills can be very powerful in helping geriatric cancer patients find meaning and dignity at the end of life. These skills include exploring spirituality and coping strategies and engaging the patient in conversation and reflection about their legacy.
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Affiliation(s)
- M O Delgado-Guay
- The University of Texas M D Anderson Cancer Center, 1400 Pressler, Houston, TX 77030, USA
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Cancer in the elderly: is it time for palliative care in geriatric oncology? J Geriatr Oncol 2014; 5:197-203. [PMID: 24560041 DOI: 10.1016/j.jgo.2014.01.007] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 09/26/2013] [Accepted: 01/28/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Persons aged 65 and over are the fastest growing segment of the population in most Western countries. Although cancer-related death occurs far more commonly in older people than in any age group, studies on palliative care in older adults are lacking. OBJECTIVE This paper aims at evaluating the needs in elderly patients affected by cancer and the state of the art of the research in palliative care in this setting. MATERIALS AND METHODS A literature search was performed (PubMed) to identify relevant studies. Papers were reviewed for relevance to palliative care in the elderly. RESULTS Elderly who need palliative care are frequently disregarded as individuals and may experience discrimination because of their age. Palliative care for older patients relates particularly to multiple treatments for various conditions. This causes extra complexities for the researchers. CONCLUSIONS The aim of the study was not fully achieved due to the paucity of literature focusing upon these issues. The areas of investigation that need to be addressed comprise: establishing the prevailing symptoms in elderly patients, understanding patients' psychological/spiritual well-being and quality of life and elucidating the sources of caregiver burden, adapting research methodologies specifically for palliative care and comparing the needs and the outcomes of this age group to younger patients.
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Piers RD, van Eechoud IJ, Van Camp S, Grypdonck M, Deveugele M, Verbeke NC, Van Den Noortgate NJ. Advance Care Planning in terminally ill and frail older persons. PATIENT EDUCATION AND COUNSELING 2013; 90:323-329. [PMID: 21813261 DOI: 10.1016/j.pec.2011.07.008] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 06/23/2011] [Accepted: 07/08/2011] [Indexed: 05/31/2023]
Abstract
OBJECTIVE Advance Care Planning (ACP) - the communication process by which patients establish goals and preferences for future care - is encouraged to improve the quality of end-of-life care. Gaining insight into the views of elderly on ACP was the aim of this study, as most studies concern younger patients. METHODS We conducted and analysed 38 semi-structured interviews in elderly patients with limited prognosis. RESULTS The majority of participants were willing to talk about dying. In some elderly, however, non-acceptance of their nearing death made ACP conversations impossible. Most of the participants wanted to plan those issues of end-of-life care related to personal experiences and fears. They were less interested in planning other end-of-life situations being outside of their power of imagination. Other factors determining if patients proceed to ACP were trust in family and/or physician and the need for control. CONCLUSIONS ACP is considered important by most elderly. However, there is a risk of pseudo-participation in case of non-acceptance of the nearing death or planning end-of-life situations outside the patient's power of imagination. This may result in end-of-life decisions not reflecting the patient's true wishes. PRACTICE IMPLICATIONS Before engaging in ACP conversations, physicians should explore if the patient accepts dying as a likely outcome. Also the experiences and fears concerning death and dying, trust and the need for control should be assessed.
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Affiliation(s)
- Ruth D Piers
- Department of Geriatrics, Ghent University Hospital, Ghent, Belgium.
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Woitha K, Van Beek K, Ahmed N, Hasselaar J, Mollard JM, Colombet I, Radbruch L, Vissers K, Engels Y. Development of a set of process and structure indicators for palliative care: the Europall project. BMC Health Serv Res 2012; 12:381. [PMID: 23122255 PMCID: PMC3529116 DOI: 10.1186/1472-6963-12-381] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2011] [Accepted: 10/31/2012] [Indexed: 01/27/2023] Open
Abstract
Background By measuring the quality of the organisation of palliative care with process and structure quality indicators (QIs), patients, caregivers and policy makers are able to monitor to what extent recommendations are met, like those of the council of the WHO on palliative care and guidelines. This will support the implementation of public programmes, and will enable comparisons between organisations or countries. Methods As no European set of indicators for the organisation of palliative care existed, such a set of QIs was developed. An update of a previous systematic review was made and extended with more databases and grey literature. In two project meetings with practitioners and experts in palliative care the development process of a QI set was finalised and the QIs were categorized in a framework, covering the recommendations of the Council of Europe. Results The searches resulted in 151 structure and process indicators, which were discussed in steering group meetings. Of those QIs, 110 were eligible for the final framework. Conclusions We developed the first set of QIs for the organisation of palliative care. This article is the first step in a multi step project to identify, validate and pilot QIs.
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Affiliation(s)
- Kathrin Woitha
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Nijmegen Medical Centre, Geert Grote Plein 10, Nijmegen 6500 HB, The Netherlands.
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Racial Disparities in End-of-Life Planning and Services for Deceased Nursing Home Residents. J Am Med Dir Assoc 2012; 13:819.e7-11. [DOI: 10.1016/j.jamda.2012.07.021] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2012] [Revised: 05/22/2012] [Accepted: 07/31/2012] [Indexed: 11/22/2022]
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McCormick E, Chai E, Meier DE. Integrating Palliative Care Into Primary Care. ACTA ACUST UNITED AC 2012; 79:579-85. [DOI: 10.1002/msj.21338] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Cline DD, Manchester J, Tagliareni ME. Gerontological nursing content in general medical/surgical textbooks: where is it? Nurs Educ Perspect 2012; 33:150-5. [PMID: 22860476 DOI: 10.5480/1536-5026-33.3.150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
To provide quality care to the rapidly growing aging population, nursing education will need to be transformed. Although several approaches will be used to meet this challenge, fundamental to most nursing programs is the use of a general medical/surgical nursing textbook. This article examines the quantity and quality of gerontological nursing content found in five general medical/surgical nursing textbooks published between 2009 and 2011. The analysis shows that gerontological nursing content is poorly covered and of low quality. The findings point to the need to work with publishers to improve the quality and depth of content related to care of older adults in nursing textbooks.
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An Educational Intervention for Nurse Practitioners Providing Palliative Care in Nursing Homes. J Hosp Palliat Nurs 2012. [DOI: 10.1097/njh.0b013e3182508db7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- Jean Correll Munn
- College of Social Work, Florida State University, Tallahassee, FL, USA
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Marshall B, Clark J, Sheward K, Allan S. Staff perceptions of end-of-life care in aged residential care: a New Zealand perspective. J Palliat Med 2011; 14:688-95. [PMID: 21495851 DOI: 10.1089/jpm.2010.0471] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Increasingly, aged residential care (ARC) facilities are places where the lives of older people with complex care needs end. Hence, end-of-life (EOL) care is a significant component of work for ARC staff. In the absence of New Zealand research, staff perceptions of EOL care were sought at three aged-care facilities in a New Zealand District Health Board region. The research provided valuable data regarding care delivery and can be used to inform the introduction of an integrated care pathway (ICP). EOL care pathways are not commonly used in New Zealand ARC facilities and the influence of ICPs, such as the Liverpool Care Pathway (LCP) for the dying patient has not been investigated. Additionally, most international studies report on the introduction of the LCP without baseline preimplementation data. DESIGN In the present study, staff (n = 195) involved in caring for residents, their families, and whānau at EOL were surveyed to obtain demographic data and staff perceptions of EOL care via Likert scale and open ended questions. RESULTS A response rate of 32% was obtained. Respondents indicated a relatively high level of confidence regarding their care of the dying, including aspects of communication, teamwork and use of documentation. However, this was often contradicted by their written responses. Written comments were analyzed thematically and six themes identified: the naturalness of dying; the character of care; care relationships; emotional response; knowledge; and the organizational environment. Data analysis provided a rich and informative description of staff perceptions of EOL and issues influencing care.
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Affiliation(s)
- Bridget Marshall
- Education and Research Unit, Arohanui Hospice, Palmerston North, New Zealand
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Kelly K, Thrane S, Virani R, Ferrell B, Malloy P. Expanding palliative care nursing education in California: the ELNEC Geriatric project. Int J Palliat Nurs 2011; 17:188-94. [DOI: 10.12968/ijpn.2011.17.4.188] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Kathe Kelly
- Division of Nursing Research & Education, City of Hope, 1500 East Duarte Road, Duarte, California 91010-3000, USA
| | - Susan Thrane
- Division of Nursing Research & Education, City of Hope, 1500 East Duarte Road, Duarte, California 91010-3000, USA
| | - Rose Virani
- Division of Nursing Research & Education, City of Hope, 1500 East Duarte Road, Duarte, California 91010-3000, USA
| | - Betty Ferrell
- Division of Nursing Research & Education, City of Hope, 1500 East Duarte Road, Duarte, California 91010-3000, USA
| | - Pam Malloy
- American Association of Colleges of Nursing (AACN), USA
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[Palliative care decision making among the elderly and family: a theoretical model]. Can J Aging 2011; 30:127-42. [PMID: 21401975 DOI: 10.1017/s0714980810000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
The elderly in palliative care are confronted with difficult decisions relating to treatments. The philosophy of palliative care, namely, including the patient and his/her family right away, leads the doctor to consult with the two parties involved when choosing a treatment. As no theoretical model allows us to understand how the decision-making process hinges on the trio (a capable elderly person, a family caregiver, and the doctor) in a context of palliative care, we propose one which was developed from three strategies of document analysis: theoretical synthesis, theoretical analysis, and theoretical derivation. According to our model, the decision-making process depends on individual factors influencing the decision of the participant, expectations and attitudes as to the role, the level of confidence amongst the parties involved, the manner in which they communicate with each other, their mutual understanding of the clinical and ethical issues, and, finally, their ability to cooperate.
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Abstract
There is a need to improve the quality of end-of-life care in nursing homes by improving the timely assessment and management of various sources of suffering. Much of the research/discussion in this area has focused on the assessment and treatment of pain. This article reviews the frequency and management of nonpain symptoms in the long-term care setting, particularly focusing on patients at the end of life. Although the long-term care setting presents challenges to effective management, an approach for addressing these challenges is discussed and applied to 3 commonly encountered nonpain symptoms.
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Affiliation(s)
- Matthew J Gonzales
- Division of Hospital Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA 94941, USA.
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Palliative care for the geriatric patient in Europe. Z Gerontol Geriatr 2010; 43:381-5. [DOI: 10.1007/s00391-010-0149-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 09/03/2010] [Indexed: 10/18/2022]
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Just JM, Schulz C, Bongartz M, Schnell MW. Palliative care for the elderly--developing a curriculum for nursing and medical students. BMC Geriatr 2010; 10:66. [PMID: 20854665 PMCID: PMC2955033 DOI: 10.1186/1471-2318-10-66] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 09/20/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delivering palliative care to elderly, dying patients is a present and future challenge. In Germany, this has been underlined by a 2009 legislation implementing palliative care as compulsory in the medical curriculum. While the number of elderly patients is increasing in many western countries multimorbidity, dementia and frailty complicate care. Teaching palliative care of the elderly to an interprofessional group of medical and nursing students can help to provide better care as acknowledged by the ministry of health and its expert panels. In this study we researched and created an interdisciplinary curriculum focussing on the palliative care needs of the elderly which will be presented in this paper. METHODS In order to identify relevant learning goals and objectives for the curriculum, we proceeded in four subsequent stages. We searched international literature for existing undergraduate palliative care curricula focussing on the palliative care situation of elderly patients; we searched international literature for palliative care needs of the elderly. The searches were sensitive and limited in nature. Mesh terms were used where applicable. We then presented the results to a group of geriatrics and palliative care experts for critical appraisal. Finally, the findings were transformed into a curriculum, focussing on learning goals, using the literature found. RESULTS The literature searches and expert feedback produced a primary body of results. The following deduction domains emerged: Geriatrics, Palliative Care, Communication & Patient Autonomy and Organisation & Social Networks. Based on these domains we developed our curriculum. CONCLUSIONS The curriculum was successfully implemented following the Kern approach for medical curricula. The process is documented in this paper. The information given may support curriculum developers in their search for learning goals and objectives.
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Affiliation(s)
- Johannes M Just
- Medical Faculty Witten/Herdecke University, Institute for Ethics and Communication in Health Care, Witten, Germany
| | - Christian Schulz
- Medical Faculty Witten/Herdecke University, Institute for Ethics and Communication in Health Care, Witten, Germany
- Medical Faculty Dusseldorf University, Interdisciplinary Centre for Palliative Care, Dusseldorf, Germany
| | - Maren Bongartz
- Medical Faculty Witten/Herdecke University, Institute for Ethics and Communication in Health Care, Witten, Germany
| | - Martin W Schnell
- Medical Faculty Witten/Herdecke University, Institute for Ethics and Communication in Health Care, Witten, Germany
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Rodriguez KL, Hanlon JT, Perera S, Jaffe EJ, Sevick MA. A cross-sectional analysis of the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients. ACTA ACUST UNITED AC 2010; 8:225-32. [PMID: 20624612 DOI: 10.1016/j.amjopharm.2010.05.002] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Approximately 25% of all US deaths occur in the long-term care setting, and this figure is projected to rise to 40% by the year 2040. Currently, there is limited information on nonpain symptoms and their appropriate treatment in this setting at the end of life. OBJECTIVE This study evaluated the prevalence of undertreatment of nonpain symptoms and factors associated with undertreatment in older nursing home hospice/palliative care patients. METHODS This study used a cross-sectional sample of older (>or=65 years) hospice/palliative care patients to represent all patients from the 2004 National Nursing Home Survey (NNHS) funded by the Centers for Disease Control and Prevention. Nonpain symptoms were determined from facility staff, who used the medical records to answer questions about the residents. Data on medication use were derived from medication administration records. Undertreatment was defined as the omission of a necessary medication for a specific nonpain symptom and was evaluated as a dichotomous variable (yes = the nonpain symptom was not treated with a medication; no = the nonpain symptom was treated with a medication). Cross-sectional bivariate analyses were conducted using chi(2) and regression coefficient tests to determine factors potentially associated with undertreatment of nonpain symptoms. RESULTS The cross-sectional sample included 303 older nursing home hospice/palliative care patients from among the 33,413 (weighted) patients from the 2004 NNHS. Overall, most of the patients were white (91.4% [277/303]) and female (71.9% [218/303]), and nearly half were aged >or=85 years (47.9% [145/303]). One or more nonpain symptoms occurred in 82 patients (22.0% weighted). The most common nonpain symptoms (weighted percentages) were constipation/fecal impaction in 35 patients (8.8%), cough in 34 patients (9.2%), nausea/vomiting in 26 patients (7.2%), fever in 11 patients (3.1%), and diarrhea in 9 patients (1.9%). Medication undertreatment of any of the above symptoms was seen in 47 of 82 patients (60.0% weighted), ranging from a low of 26.4% for constipation/ fecal impaction to a high of 88.0% for nausea/vomiting. Undertreated patients had significantly more problems with bed mobility (n [weighted %], 43 [92.3%] vs 21 [67.2%]; P = 0.013), mood (21 [44.7%] vs 7 [19.7%]; P = 0.017), and pressure ulcers (12 [25.7%] vs 2 [6.1%]; P = 0.023) than did treated patients. The undertreated group also had a significantly greater number of secondary diagnoses (weighted mean [SD], 6.5 [0.7] vs 5.2 [0.5]; P = 0.004) but had a shorter length of stay in hospice/ palliative care (120.5 [20.1] vs 219.4 [51.8] days; P < 0.001) or in the nursing home (552.0 [96.5] vs 1285.4 [268.3] days; P = 0.001). CONCLUSIONS The prevalence of nonpain symptoms was low (22.0% weighted) in older nursing home hospice/palliative care patients. However, medication undertreatment of nonpain symptoms was seen in more than half of these patients. Future quality-improvement initiatives for nursing home hospice/palliative care patients are needed beyond the management of pain symptoms.
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Affiliation(s)
- Keri L Rodriguez
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Pautex S, Curiale V, Pfisterer M, Rexach L, Ribbe M, Van Den Noortgate N. A Common Definition of Geriatric Palliative Medicine. J Am Geriatr Soc 2010; 58:790-1. [DOI: 10.1111/j.1532-5415.2010.02791.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Factor analysis and internal consistency evaluation of the FAMCARE Scale for use in the long-term care setting. Palliat Support Care 2010; 8:169-76. [DOI: 10.1017/s1478951509990927] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractObjective:The FAMCARE Scale was originally designed to measure family satisfaction with advanced cancer care. The current study evaluated the instrument's psychometric qualities when used in the long-term care (LTC) setting.Method:In a prospective cohort study in 2004, the 20-item instrument was administered via telephone to family members of 51 patients receiving LTC in Veterans Affairs facilities. Satisfaction scores on a 5-point Likert scale were used for factor analysis and internal consistency evaluation.Results:Although 16 patients were in geriatric palliative care and 35 were in nursing home care, scores of their family members did not vary based on care unit. The total satisfaction score was high, with a mean (SD) of 44.7 (11.9) and a Cronbach alpha of 0.94. Inter-item correlations were low for care availability items (range, 0.01–0.59). Two items—availability of a hospital bed and availability of nurses to the family—had low eigenvalues (0.26 and 0.18, respectively) and weak correlations with the total score (0.23 and 0.16, respectively).Significance of results:In the LTC setting, FAMCARE appears to have good internal consistency, but it may be preferable to exclude the two items with weak correlations and to use a 10-point visual analog scale.
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Sizoo EM, Braam L, Postma TJ, Pasman HRW, Heimans JJ, Klein M, Reijneveld JC, Taphoorn MJB. Symptoms and problems in the end-of-life phase of high-grade glioma patients. Neuro Oncol 2010; 12:1162-6. [PMID: 20511193 DOI: 10.1093/neuonc/nop045] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Despite multimodal treatment, it is not possible to cure high-grade glioma (HGG) patients. Therefore, the aim of treatment is not only to prolong life, but also to prevent deterioration of health-related quality of life as much as possible. When the patient's condition declines and no further tumor treatment seems realistic, patients in the Netherlands are often referred to a primary care physician for end-of-life care. This end-of-life phase has not been studied adequately yet. The purpose of this study was to explore specific problems and needs experienced in the end-of-life phase of patients with HGG. We retrospectively examined the files of 55 patients who received treatment in our outpatient clinic and died between January 2005 and August 2008. The clinical nurse specialist in neuro-oncology maintained contact on a regular basis with (relatives of) HGG patients once tumor treatment for recurrence was no longer given. She systematically asked for signs and symptoms. The majority of the patients experienced loss of consciousness and difficulty with swallowing, often arising in the week before death. Seizures occurred in nearly half of the patients in the end-of-life phase and more specifically in one-third of the patients in the week before dying. Other common symptoms reported in the end-of-life phase are progressive neurological deficits, incontinence, progressive cognitive deficits, and headache. Our study demonstrates that HGG patients, unlike the general cancer population, have specific symptoms in the end-of-life phase. Further research is needed in order to develop specific palliative care guidelines for these patients.
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Affiliation(s)
- Eefje M Sizoo
- Department of Neurology, VU University Medical Center, PO Box 7057, 1007 MB Amsterdam, The Netherlands.
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Holley APH, Gorawara-Bhat R, Dale W, Hemmerich J, Cox-Hayley D. Palliative Access Through Care at Home: experiences with an urban, geriatric home palliative care program. J Am Geriatr Soc 2009; 57:1925-31. [PMID: 19702614 DOI: 10.1111/j.1532-5415.2009.02452.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aging of the U.S. population has resulted in a large number of persons with multiple, chronic illnesses and gradual functional decline. Many older adults with these conditions are homebound and have great difficulty accessing medical care. They are also more likely to suffer from unaddressed symptoms and end-of-life care needs. Certain groups, such as African-American patients and patients with dementia, are even less likely to access palliative care and hospice services. Although the informal caregivers attending to such persons may become overwhelmed without adequate support, palliative care, which covers a broad population, is an optimal way to address many of these needs. This article describes a unique, urban, home-based geriatrics palliative care program (Palliative Access Through Care at Home (PATCH)) designed to address some of these unmet needs. After 1 year of providing service, a mixed-methods study consisting of chart review, telephone interviews, and face-to-face interviews was conducted to assess caregiver expectations of and satisfaction with the program. Caregivers for the elderly, mostly African-American patients, more than half of whom had dementia, were overall very satisfied with their experience, despite the large amount of time necessary to provide the care that patients required. Themes extracted during qualitative analysis were the desire to remain at home, the need for easy access to a practitioner specializing in geriatrics and palliative medicine, and the challenges of transitions of care. PATCH was able to address many of these needs and provide high levels of caregiver satisfaction.
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Affiliation(s)
- Abigail P H Holley
- Section of Geriatrics and Palliative Medicine, University of Chicago, Chicago, Illinois, USA.
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Suhrie EM, Hanlon JT, Jaffe EJ, Sevick MA, Ruby CM, Aspinall SL. Impact of a geriatric nursing home palliative care service on unnecessary medication prescribing. ACTA ACUST UNITED AC 2009; 7:20-5. [PMID: 19281937 DOI: 10.1016/j.amjopharm.2009.02.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND There is a lack of studies concerning improvement of medication use in palliative care patients in nursing homes. OBJECTIVE This study was conducted to evaluate whether a geriatric palliative care team reduced unnecessary medication prescribing for elderly veterans residing in a nursing home. METHODS This was a retrospective, descriptive study of patients who died while residing in a geriatric palliative care unit between August 1, 2005, and July 31, 2007. Prescribed medications were evaluated using the Unnecessary Drug Use Measure, which contains 3 items from the Medication Appropriateness Index concerning lack of indication, lack of effectiveness, and therapeutic duplication. This measure was applied at 2 time points: on transfer/admission to the palliative care unit and at the last 30-day pharmacist medication review before death. Paired t tests and McNemar tests were used to compare medication use at these 2 points. RESULTS Eighty-nine patients were included in the study. The majority were male (97.8%) and white (78.7%), with a mean (SD) age of 79.7 (7.8) years. The median length of stay on the unit was 39.0 days, and the mean number of chronic medical conditions was 8.4 (4.3). At baseline, the mean number of scheduled medications was 9.7 (4.3). The number of unnecessary medications per patient decreased from a mean of 1.7 (1.5) at admission to 0.6 (0.8) at closeout (P = 0.003). The decrease was seen in all 3 categories of the Unnecessary Drug Use Measure. CONCLUSIONS The geriatric palliative care team was associated with a reduction in the number of unnecessary medications prescribed for older veterans in this nursing home. Future studies should evaluate the impact of decreasing unnecessary prescribing on clinical outcomes such as adverse drug reactions.
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Affiliation(s)
- Erin M Suhrie
- Pharmacy Department, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Bonin-Scaon S, Sastre MTM, Chasseigne G, Sorum PC, Mullet E. End-of-Life Preferences: A Theory-Driven Inventory. Int J Aging Hum Dev 2009; 68:1-26. [DOI: 10.2190/ag.68.1.a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The study aimed at making a theory-driven inventory of end-of-life preferences. Participants were asked about a variety of preferences representing all eight motivational states described in Apter's Metamotivational Theory (AMT; Apter, 2001). Data from a convenience sample of 965 community participants and a convenience sample of 81 persons suffering from a terminal illness were examined using exploratory and confirmatory factor analysis. Ten factors were evidenced; they were easily interpretable in the AMT framework. In decreasing order of importance, people would, at the time of their death, like to have an understanding doctor, to be at peace with themselves, to remain autonomous, to keep a sense of humor, to remain able to oppose any decision taken without their consent, to remain an object of love, to remain a reference for others, to have resolved conflicts with others, to leave their businesses in good order, and to find themselves at peace with God.
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Abernethy AP, Zhukovsky D. Palliative Care Pharmacotherapy Literature Summaries and Analyses. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/15360280903099091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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