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Volberg C, Schmidt-Semisch H, Maul J, Nadig J, Gschnell M. Pain management in German hospices: a cross-sectional study. BMC Palliat Care 2024; 23:7. [PMID: 38172899 PMCID: PMC10763107 DOI: 10.1186/s12904-023-01291-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 10/18/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pain management is a necessary component of palliative care as most patients suffer from pain during the final phase of life. Due to the complex causation of pain in the last phase of life, it is important to utilize methods other than pharmacotherapeutic options in order to achieve adequate pain control. As little is known about treatment of pain in German hospices, a nationwide survey was conducted. MATERIALS AND METHODS All German hospices (259) were contacted by post in June 2020 and asked to participate in an anonymous cross-sectional survey. RESULTS A total of 148 (57%) German hospices took part in the survey. A broad variety of medication is used in the hospice setting. Metamizole is the most commonly used non-opiod analgesic , hydromorphone the most commonly used opioid, and pregabalin is the most commonly prescribed co-analgesic drug. The pain medication is usually prescribed as an oral slow-release substance. Standardized treatment schemes are rare among the responding hospices. Most of the respondents also use complementary treatment options, such as aroma (oil) therapy or music therapy, in the treatment of pain. Palliative sedation is used by nearly all responding hospices if all other treatment options fail. CONCLUSION This survey provides an overview of the treatment options for pain management in German hospices. A broad variety of pain medication is used. Compared to international literature, it is debatable whether such a large variety of different types of pain medication is necessary, or whether a reduction in the type of medication available and the use of standardized treatment schemes could benefit everyone involved.
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Affiliation(s)
- Christian Volberg
- Department of Anesthesia and Intensive Care, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany.
- Research Group Medical Ethics, Department of Medicine, Philipps University of Marburg, Marburg, Germany.
| | - Henning Schmidt-Semisch
- Institute of Public Health and Nursing Research, Department of Health and Society, University of Bremen, Bremen, Germany
| | - Julian Maul
- Department of Anesthesia and Intensive Care, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
| | - Jens Nadig
- University Children's Hospital Marburg, Philipps University of Marburg, Marburg, Germany
| | - Martin Gschnell
- Department of Dermatology und Allergology, University Hospital Giessen and Marburg, Philipps University of Marburg, Marburg, Germany
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Autrey AK, James C, Sarvode Mothi S, Stafford C, Morvant A, Miller EG, Kaye EC. The Landscape of Outpatient Pediatric Palliative Care: A National Cross-Sectional Assessment. J Pain Symptom Manage 2023; 66:1-23. [PMID: 36870378 PMCID: PMC10330509 DOI: 10.1016/j.jpainsymman.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 02/02/2023] [Accepted: 02/04/2023] [Indexed: 03/06/2023]
Abstract
CONTEXT Inpatient pediatric palliative care (PPC) has grown substantially over the past 20 years; however, PPC in the outpatient setting remains underdeveloped. Outpatient PPC (OPPC) offers opportunities to improve access to PPC as well as facilitate care coordination and transitions for children with serious illness. OBJECTIVES This study aimed to characterize the national status of OPPC programmatic development and operationalization in the United States. METHODS Utilizing a national report, freestanding children's hospitals with existing PPC programs were identified to query OPPC status. An electronic survey was developed and distributed to PPC participants at each site. Survey domains included hospital and PPC program demographics; OPPC development, structure, staffing, and workflow; metrics of successful OPPC implementation; and other services/partnerships. RESULTS Of 48 eligible sites, 36 (75%) completed the survey. Clinic-based OPPC programs were identified at 28 (78%) sites. OPPC programs reported a median age of 9 years [range: 1-18 years] with growth peaks in 2011, 2012 and 2020. OPPC availability was significantly associated with increased hospital size [P = 0.05] and inpatient PPC billable full time equivalent staff [P = 0.01]. Top referral indications included pain management, goals of care, and advance care planning. Funding primarily came from institutional support and billing revenue. CONCLUSIONS Although OPPC remains a young field, many inpatient PPC programs are growing into the outpatient setting. Increasingly, OPPC services have institutional support and diverse referral indications from multiple subspecialties. However, despite high demand, resources remain limited. Characterization of the current OPPC landscape is crucial to optimize future growth.
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Affiliation(s)
- Ashley K Autrey
- Pediatric Palliative Care Service Line, Children's Hospital New Orleans (A.K.A., A.M.), New Orleans, Louisiana, USA; Department of Pediatrics, Louisiana State University Health Sciences Center (A.K.A., C.S., A.M.), New Orleans, Louisiana, USA; Department of Pediatrics, Tulane University School of Medicine (A.K.A., A.M.), New Orleans, Louisiana, USA.
| | - Casie James
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center (C.J.), Cincinnati, Ohio, USA
| | - Suraj Sarvode Mothi
- Department of Biostatistics, St. Jude Children's Research Hospital (S.S.), Memphis, Tennessee, USA
| | - Caroline Stafford
- Department of Pediatrics, Louisiana State University Health Sciences Center (A.K.A., C.S., A.M.), New Orleans, Louisiana, USA
| | - Alexis Morvant
- Pediatric Palliative Care Service Line, Children's Hospital New Orleans (A.K.A., A.M.), New Orleans, Louisiana, USA; Department of Pediatrics, Louisiana State University Health Sciences Center (A.K.A., C.S., A.M.), New Orleans, Louisiana, USA; Department of Pediatrics, Tulane University School of Medicine (A.K.A., A.M.), New Orleans, Louisiana, USA
| | - Elissa G Miller
- Department of Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University (E.G.M.), Philadelphia, Pennsylvania, USA; Division of Palliative Medicine, Nemours Children's Health (E.G.M.), Wilmington, Delaware, USA
| | - Erica C Kaye
- Department of Oncology, St. Jude Children's Research Hospital (E.C.K.), Memphis, Tennessee, USA
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Blum M, Beasley A, Ikejiani D, Goldstein NE, Bakitas MA, Kavalieratos D, Gelfman LP. Building a Cardiac Palliative Care Program: A Qualitative Study of the Experiences of Ten Program Leaders From Across the United States. J Pain Symptom Manage 2023; 66:62-69.e5. [PMID: 36972857 PMCID: PMC10330149 DOI: 10.1016/j.jpainsymman.2023.03.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/14/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023]
Abstract
CONTEXT Palliative care is guideline-recommended for patients with advanced heart failure (HF). However, studies on how cardiac palliative care is provided in the United States are lacking. OBJECTIVES To study how cardiac palliative care programs provide services, and to identify challenges and facilitators they encountered in program development. METHODS In this qualitative descriptive study, we used purposive and snowball sampling approaches to identify cardiac palliative care program leaders across the United States, administered a survey and conducted semi-structured interviews. Interview transcripts were coded and evaluated using thematic analysis. RESULTS While cardiac palliative care programs vary in their organizational setup, they all provide comprehensive interdisciplinary palliative care services, ideally across the care continuum. They predominantly serve HF patients who are evaluated for advanced therapies or have complex needs. The challenges which cardiac palliative care programs face include reaching those cardiac patients who need palliative care the most and collaborating with cardiologists who do not see value added from palliative care for their patients. Facilitators of cardiac palliative care program development include building personal relationships with cardiology providers, proactively assessing local institution needs, and tailoring palliative care services to meet patient and provider needs. CONCLUSION Cardiac palliative care programs vary in their organizational setup but provide similar services and face similar challenges. The challenges and facilitators we identified can inform the development of future cardiac palliative care programs.
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Affiliation(s)
- Moritz Blum
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.B., N.E.G., L.P.G.), New York, New York, USA
| | - Amy Beasley
- School of Nursing and Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care (A.B., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Dara Ikejiani
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (D.I., D.K.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Nathan E Goldstein
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.B., N.E.G., L.P.G.), New York, New York, USA
| | - Marie A Bakitas
- School of Nursing and Department of Medicine, Division of Geriatrics, Gerontology, and Palliative Care (A.B., M.A.B.), University of Alabama at Birmingham, Birmingham, Alabama, USA; Division of Palliative Medicine, Department of Family and Preventive Medicine (D.K.), Emory University, Atlanta, Georgia, USA
| | - Dio Kavalieratos
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine (D.I., D.K.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Division of Palliative Medicine, Department of Family and Preventive Medicine (D.K.), Emory University, Atlanta, Georgia, USA
| | - Laura P Gelfman
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (M.B., N.E.G., L.P.G.), New York, New York, USA; James J. Peters Veterans Affairs Medical Center, Geriatric Research Education and Clinical Center (GRECC) (L.P.G.), Bronx, New York, USA.
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Thery L, de Stampa M, Burnod A, Seban R, Laouisset C, Marchal T, Bouleuc C. Implementation of palliative care day hospital for outpatients with advanced cancer. BMJ Support Palliat Care 2023:spcare-2023-004206. [PMID: 36822846 DOI: 10.1136/spcare-2023-004206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/04/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES To describe the population of a palliative care day hospital (PCDH) in oncology and analyse the end-of-life trajectory. METHODS Monocentric retrospective cohort study of all referred patients for the first time to PCDH over an 8-month period with the data collected in all PCDH in their pathway care. RESULTS 116 patients were included for 319 stays in PCDH. At first referral PCDH, 62 (53.4%) patients had ongoing anticancer therapy. Twenty-four (20.7%) and 63 (54.3%) patients were in an unstable and deteriorating phase, respectively. Mean (SD) Eastern Cooperative Oncology Group performance status score was 2.8 (0.7). Mean (SD) stay per patient was 2.8 (2.2). For all stays, mean (SD) of joint intervention of palliative care team and oncologist was 1.2 (1.2) per patient. Mean (SD) of technical acts performed was 0.2 (0.6) per patient. Among the 109 deceased patients, 16 patients (14.7%) and 7 patients (6.4%) had received chemotherapy in the last month and 15 days before death, respectively. CONCLUSION Our PCDH is a suitable place for a complex population still living at home. The reported patients' demographics and PCDH's organisation lead to a hybrid outpatient intervention between outpatient clinics and hospice care services. A randomised multicentric trial is ongoing to explore the impact of PCDH on patients' trajectory and the use of resources.
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Affiliation(s)
- Laura Thery
- Palliative Care Department, Institut Curie, Paris, France
- INSERM, CESP U1018, Paris-Saclay University, Gif-sur-Yvette, France
| | - Matthieu de Stampa
- INSERM, CESP U1018, Paris-Saclay University, Gif-sur-Yvette, France
- Gerontology Department, Centre Gerontologique Departemental, Marseille, France
| | - Alexis Burnod
- Palliative Care Department, Institut Curie, Paris, France
| | - Romain Seban
- Palliative Care Department, Institut Curie, Paris, France
| | | | | | - Carole Bouleuc
- Palliative Care Department, Institut Curie, Paris, France
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5
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Volberg C, Corzilius J, Maul J, Morin A, Gschnell M. [Pain management in German specialized outpatient palliative care : A cross-sectional study to present the current pain management of palliative patients in the home environment]. Schmerz 2023:10.1007/s00482-023-00693-x. [PMID: 36752874 DOI: 10.1007/s00482-023-00693-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 12/18/2022] [Accepted: 12/28/2022] [Indexed: 02/09/2023]
Abstract
BACKGROUND With the help of specialized outpatient palliative care teams (German abbreviation: SAPV), seriously ill and dying patients in Germany can be adequately cared for in their home environment until the end of their lives; however, there are no uniform standards or guidelines for well-executed pain management right now. OBJECTIVE This approach serves as basic research in the field of public health research. This is intended to present which methods (use of different professional groups, use of pain medications, alternative medical treatment etc.) the individual SAPV teams use for pain management. From this it can be deduced which procedures can be considered particularly effective. MATERIAL AND METHODS This cross-sectional study was conducted in May 2021. All German SAPV teams (n = 307) listed on the homepage of the German Association for Palliative Medicine (DGP) were contacted by post and invited to participate. A total of 175 teams (57%) responded to the request and were included in the evaluation. A descriptive data analysis was performed. RESULTS Pain management in the German outpatient care of palliative patients is based on several components. All common pain medications are used, but primarily metamizole (99.4%) as a non-opioid analgesic, morphine (98.3%) from the opiate series and pregabalin (96.6%) as a co-analgesic are mainly prescribed. If pain therapy fails, 22.5% of the SAPV teams perform palliative sedation for symptom control on a regular basis. CONCLUSION This cross-sectional study is the first of its kind to provide a general overview of the treatment options for pain management in German outpatient palliative care. In comparison with international studies, the question arises as to whether uniform therapy schemes and a reduction in the medication available in the individual SAPV teams could lead to an improvement in patient care.
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Affiliation(s)
- Christian Volberg
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland.
- AG Ethik in der Medizin, Fachbereich 20, Dekanat Humanmedizin, Philipps-Universität Marburg, Marburg, Deutschland.
| | - Julien Corzilius
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Julian Maul
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Astrid Morin
- Klinik für Anästhesie und Intensivtherapie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
| | - Martin Gschnell
- Klinik für Dermatologie und Allergologie, Hauttumorzentrum, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg, Deutschland
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6
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Kogan AC, Rahman A, Lomeli S, Enguidanos S. "You cannot stop talking about palliative care:" Perspectives and Learnings from Providers on Communicating about Home-based Palliative Care to Patients and Physicians. Am J Hosp Palliat Care 2023; 40:122-128. [PMID: 35574597 DOI: 10.1177/10499091221090498] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Home-based palliative care (HBPC) programs are proliferating across the U.S, yet face significant, documented challenges in promoting uptake of services and sustaining sufficient patient referrals. There is a huge need to understand effective methods for engaging physicians, patients, and caregivers in palliative care. Thus, the purpose of this study was to elicit successful practices on how to best communicate about HBPC to both healthcare providers and patients/caregivers. METHOD Focus groups with nine California-based HBPC organizations were conducted between January and April 2020. Discussions lasted approximately 54 minutes, were guided by a semi-structured protocol, audio-recorded, and transcribed verbatim. Thematic analysis was used to identify themes and codes from the data. RESULTS Twenty-five interdisciplinary HBPC staff members participated in a focus group. Most identified as white (76%), female (76%), and working in their current position for 5 years or less (56%). Three themes were identified from the data: (1) value of relationships; (2) communication do's and don'ts; and (3) need for education. Participants discussed actionable recommendations for each theme. DISCUSSION Study findings highlight several successful practices for HBPC programs to communicate- and foster relationships with healthcare professionals and patients/families about palliative care, with education at the crux. Lessons learned about key words and phrases to say and to avoid are particularly valuable for budding HBPC programs. Our results suggest that HBPC providers exert enormous efforts to increase patient referrals and enrollment through strategic, continuous outreach and education to physicians, patients, and their caregivers; however, palliative care educational interventions are needed.
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Affiliation(s)
- Alexis Coulourides Kogan
- Department of Family Medicine and Geriatrics, 12223Keck School of Medicine of the University of Southern California, Alhambra, CA, USA.,Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Anna Rahman
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Sindy Lomeli
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
| | - Susan Enguidanos
- Leonard Davis School of Gerontology, 5116University of Southern California, Los Angeles, CA, USA
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Pasanen L, Le Gautier R, Wong A, Wawryk O, Collins A, Schwetlik S, Philip J. Telehealth in outpatient delivery of palliative care: A qualitative study of patient and physician views. Palliat Support Care 2022; 21:1-8. [PMID: 35818898 DOI: 10.1017/s1478951522000670] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The COVID-19 pandemic has widened the funded use of telehealth in Australia to support telehealth delivery to all patients in any setting. Increasing the use and experience of telehealth brings to light unique insights into the advantages and challenges of this new model of healthcare delivery This study aimed to qualitatively explore the experiences of both palliative care physicians and patients setting, including their views on its future role in healthcare. METHODS This qualitative study was conducted across three metropolitan tertiary palliative care centers in Victoria, Australia between November 2020 and March 2021. Purposive sampling identified 23 participants (12 physicians and 11 patients). Semi-structured interviews focused on the last telehealth consultation, thoughts and impressions of telehealth, and the possibility of telehealth remaining in palliative care. A thematic approach was adopted to code and analyze the data. RESULTS Telehealth transformed the ways physicians and patients in this study perceived and engaged with outpatient palliative care across the entire continuum of care. Four key themes were identified: (1) access to care; (2) delivery of care; (3) engagement with care; and (4) the future. SIGNIFICANCE OF RESULTS This study provides novel data bringing together the perspective of patients and physicians, which confirms the utility of telehealth in palliative care. Its convenience enables more frequent review, enables reviews to occur in response to lower levels of concern, and adds toward enhancing the continuity of care across and between settings. Moving forward, support seemed strongest for a hybrid model of telehealth and face-to-face consultations guided by key parameters relating to the level of anticipated complexity.
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Affiliation(s)
- Leeanne Pasanen
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Roslyn Le Gautier
- Department of Medicine, St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, VIC, Australia
| | - Aaron Wong
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Olivia Wawryk
- Department of Medicine, St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, VIC, Australia
| | - Anna Collins
- Department of Medicine, St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, VIC, Australia
| | - Stephanie Schwetlik
- North Adelaide Palliative Service, Modbury Hospital, Modbury, South Australia
| | - Jennifer Philip
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- Department of Medicine, St Vincent's Hospital Melbourne, University of Melbourne, Melbourne, VIC, Australia
- Royal Melbourne Hospital, Parkville, VIC, Australia
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Alcalde Castro MJ, Pope A, Zhang Y, Al-Awamer A, Banerjee S, Lau J, Mak E, O'Connor B, Saltman A, Wentlandt K, Zimmermann C, Hannon B. Palliative medicine outpatient clinic 'no-shows': retrospective review. BMJ Support Palliat Care 2021:bmjspcare-2021-003414. [PMID: 34732473 DOI: 10.1136/bmjspcare-2021-003414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 10/07/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Patients who do not attend outpatient palliative care clinic appointments ('no-shows') may have unmet needs and can impact wait times. We aimed to describe the characteristics and outcomes associated with no-shows. METHODS We retrospectively reviewed new no-show referrals to the Princess Margaret Cancer Centre Oncology Palliative Care Clinic (OPCC) in Toronto, Canada, between January 2017 and December 2018, compared with a random selection of patients who attended their first appointment, in a 1:2 ratio. We collected patient information, symptoms, performance status (Eastern Cooperative Oncology Group (ECOG) and outcomes. Univariable and multivariable logistic regression analyses were used to identify significant factors. RESULTS Compared with those who attended (n=214), no-shows (n=103), on multivariable analysis, were at higher odds than those who attended of being younger (OR 0.98, 95% CI 0.96 to 1.00, p=0.019), living outside Toronto (OR 2.67, 95% CI 1.54 to 4.62, p<0.001) and having ECOG ≥2 (OR 2.98, 95% CI 1.41 to 6.29, p=0.004). No-shows had a shorter median survival compared with those who attended their first appointment (2.3 vs 8.7 months, p<0.001). CONCLUSION Compared with patients who attended, no-shows lived further from the OPCC, were younger, and had a poorer ECOG. Strategies such as virtual visits should be explored to reduce no-shows and enable attendance at OPCCs.
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Affiliation(s)
| | - Ashley Pope
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Yuhua Zhang
- Biostatistics, University Health Network, Toronto, Ontario, Canada
| | - Ahmed Al-Awamer
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Subrata Banerjee
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jenny Lau
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ernie Mak
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Brenda O'Connor
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Alexandra Saltman
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
- Medicine, Rheumatology, Sinai Health System, Toronto, Ontario, Canada
| | | | - Camilla Zimmermann
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Breffni Hannon
- Supportive Care, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Sethi A, Everett E, Mehta A, Besbris J, Burke C, Pedowitz E, Kilpatrick M, Foster L, Maiser S. The Role of Specialty Palliative Care for Amyotrophic Lateral Sclerosis. Am J Hosp Palliat Care 2021; 39:865-873. [PMID: 34583569 DOI: 10.1177/10499091211049386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Amyotrophic Lateral Sclerosis (ALS) is a progressive and incurable neurodegenerative disease resulting in the loss of motor neurons, eventually leading to death. ALS results in complex physical, emotional, and spiritual care needs. Specialty Palliative Care (SPC) is a medical specialty for patients with serious illness that provides an extra layer of support through complicated symptom management, goals of care conversations, and support to patients and families during hard times. Using MEDLINE, APA Psychinfo, and Dynamed databases, we reviewed the literature of SPC in ALS to inform and support an expert opinion perspective on this topic. This manuscript focuses on several key areas of SPC for ALS including insurance and care models, advance care planning, symptom management, quality of life, caregiver support, and end-of-life care. Recommendations to improve specialty palliative care for patients with ALS are reviewed in the discussion section.
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Affiliation(s)
- Anish Sethi
- University of Minnesota College of Biological Sciences, Minneapolis, MN, USA
| | - Elyse Everett
- John T. Milliken Department of Medicine, Washington University School of Medicine in St. Louis, MO, USA
| | - Ambereen Mehta
- Department of Medicine, John Hopkins Medicine, Baltimore, MD, USA
| | - Jessica Besbris
- Department of Neurology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Christa Burke
- Division of Palliative Medicine, John T. Milliken Department of Medicine, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Elizabeth Pedowitz
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Molly Kilpatrick
- Palliative Care and Supportive Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Laura Foster
- Department of Neurology, University of Colorado School of Medicine, Boulder, CO, USA
| | - Sam Maiser
- University of Minnesota College of Biological Sciences, Minneapolis, MN, USA.,Department of Neurology, Hennepin Healthcare, Minneapolis, MN, USA
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10
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Smith GM, Calton BA, Rabow MW, Marks AK, Bischoff KE, Pantilat SZ, O'Riordan DL. Comparing the Palliative Care Needs of Patients Seen by Specialty Palliative Care Teams at Home Versus in Clinic. J Pain Symptom Manage 2021; 62:28-38. [PMID: 33246071 DOI: 10.1016/j.jpainsymman.2020.11.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 11/06/2020] [Accepted: 11/17/2020] [Indexed: 12/25/2022]
Abstract
CONTEXT Understanding the unique needs of patients seen in clinic versus at home can help palliative care (PC) teams choose how to maximize available resources. OBJECTIVES To compare the characteristics and PC needs of patients seen by PC teams in clinic versus at home. METHODS We analyzed data from the Palliative Care Quality Network between August 2016 and September 2019 and compared demographics, diagnosis, reason for referral, PC needs, functional status, self-reported symptoms, and patient-reported quality of life. RESULTS Compared to patients receiving PC in clinic, patients receiving PC at home were more likely to be of age 80 years or older (odds ratio [OR] 7.5, 95% CI 5.0, 10.9, P < 0.0001), have lower functional status (mean Palliative Performance Scale score 53% vs. 68%, P < 0.0001), and were less likely to screen positive for needing pain management (OR 0.31, 95% CI 0.22, 0.42, P < 0.0001) or other symptom management (OR 0.61, 95% CI 0.41, 0.90, P = 0.01). Patients receiving care at home were more likely to be referred for care planning (goals of care discussions or advance care planning) (OR 11.5, 95% CI 8.3, 16.0 P < 0.0001) and patient/family support (OR 5.9, 95% CI 4.2, 8.3, P < 0.0001). CONCLUSION Patients seen by PC teams at home had worse function and were more likely to be referred for care planning, while patients seen in clinic had more PC needs related to pain and symptom management. Despite these differences, both populations have significant PC needs that support routine assessment and require appropriately staffed interdisciplinary teams to address these needs.
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Affiliation(s)
- Grant M Smith
- Stanford Section of Palliative Medicine, Division of Primary Care and Population Health, Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA.
| | - Brook A Calton
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Michael W Rabow
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Angela K Marks
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Kara E Bischoff
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Steven Z Pantilat
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - David L O'Riordan
- Division of Palliative Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California, USA
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11
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Nandwani J, Maguire JM, Rogers M, Meier DE, Kamal AH. Palliative Care Specialist Access is Associated With Rankings of Hospital Quality. J Pain Symptom Manage 2021; 62:149-152. [PMID: 33607209 DOI: 10.1016/j.jpainsymman.2021.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 10/22/2022]
Abstract
CONTEXT Increasing evidence has shown that access to specialty palliative care, particularly outpatient palliative care clinics, can yield improved health outcomes and be a marker of hospital quality. OBJECTIVE To determine whether an association exists between access to specialty palliative care programs and hospital rankings found in the 2020-2021 U.S. News & World Report Best Hospitals. METHODS This study used publicly available data from the Center to Advance Palliative Care (CAPC) Provider Directory to determine access to in-patient and out-patient palliative care in the 2020-2021 U.S. News & World Report Best Hospitals Rankings. Descriptive statistics and chi-squares were performed. Data were also analyzed across the four U.S. Census Bureau regions (Northeast, South, Midwest, West). RESULTS Around 100% of the Top 20 hospitals include hospital-based palliative care consultation teams, and 95% offered outpatient palliative care. Of the second cohort of 83 hospitals, 99% offered inpatient palliative care, and 65% offered outpatient palliative care. Of the third cohort of 75 hospitals ranked, 96% had inpatient palliative care services, while only 41.3% offered outpatient palliative care. This represents a significant association between rank position and access to outpatient palliative care (P < 0.01). Ranked hospitals also have significantly higher access to hospital-based palliative care teams compared to the national prevalence rate (P < 0.01). CONCLUSION These findings reflect the association of access to specialty palliative care with USNWR rankings for hospital quality. Further study is necessary to determine the specific influence of access to palliative care and USNWR rank position.
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Affiliation(s)
- Jaan Nandwani
- Trinity College of Arts and Sciences, Duke University, Durham, North Carolina
| | | | - Maggie Rogers
- Center to Advance Palliative Care, New York, New York
| | - Diane E Meier
- Center to Advance Palliative Care, New York, New York; Icahn School of Medicine at Mount Sinai, New York, New York
| | - Arif H Kamal
- Duke Cancer Institute, Duke University, Durham, North Carolina; Duke Fuqua School of Business, Duke University, Durham, North Carolina.
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12
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Rabow MW, Parrish M, Kinderman A, Freedman J, Harris H, Cox D, Liao S, Yu K, Ward K, Landau C, Kerr K. Staffing in California Public Hospital Palliative Care Clinics: A Report from the California Health Care Foundation Palliative Care in Public Hospitals Learning Community. J Palliat Med 2021; 24:1045-1050. [PMID: 33400906 DOI: 10.1089/jpm.2020.0562] [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: 11/13/2022] Open
Abstract
Background: Although clinic-based palliative care (PC) services have spread in the United States, little is known about how they function, and no studies have examined clinics that predominantly serve safety net populations. Objectives: To describe the PC clinics operating in safety net institutions in California. Design: Survey completed by PC program leaders Setting/Subjects: PC programs in California, USA, safety net medical centers. Measurements: Descriptive statistics regarding staffing, clinic processes, patients served, and finances. Results: Twelve of 15 programs responded; 10 clinics that met inclusion criteria. All 10 programs use multiple disciplines to deliver care. Average full-time equivalent (FTE) used to staff an average of 2.75 half-day clinics per week includes 0.69 physician FTE, 0.51 nurse practitioner FTE, 1.37 nurse FTE, 0.79 social worker FTE, and 0.52 chaplain FTE. Clinic session schedules include an average of 1.88 new patient appointment slots (standard deviation [SD] = 0.44) and four follow-up appointment slots (SD = 1.95). The nine programs that reported on clinic volumes see 1081 patients annually combined, with an annual average of 120 (SD = 48.53) per program. Encounters per patient averaged 3.04 (SD = 1.59; eight programs reporting). All reported offering seven core PC services: pain/symptom management, comprehensive assessment, care coordination, advance care planning, PC plan of care, emotional support, and social service referrals. An average of 77.4% (SD = 26.81) of clinic financing came from the health systems. Conclusions: Our respondents report using an interdisciplinary team approach to deliver guideline-concordant specialty PC. More research is needed to understand the most effective and efficient staffing models for meeting the PC needs of the safety net population.
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Affiliation(s)
- Michael W Rabow
- Division of Palliative Medicine, University of California San Francisco, San Francisco, California, USA
| | | | - Anne Kinderman
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital/University of California San Francisco, San Francisco, California, USA
| | - Julie Freedman
- Department of Hospital Medicine, Contra Costa Regional Medical Center, Martinez, California, USA
| | - Heather Harris
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital/University of California San Francisco, San Francisco, California, USA
| | - Daniel Cox
- Palliative Care Service, Ventura County Medical Center, Ventura, California, USA
| | - Solomon Liao
- Palliative Care Service, University California, Irvine, Orange, California, USA
| | - Katherine Yu
- Palliative Care Service, Olive View-UCLA Medical Center, Sylmar, California, USA
| | - Katherine Ward
- Division of General Internal Medicine, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, California, USA
| | - Claudia Landau
- Division of Geriatrics, Alameda Health System, Oakland, California, USA
| | - Kathleen Kerr
- Kerr Health Care Analytics, Mill Valley, California, USA
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13
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DeGroot L, Koirala B, Pavlovic N, Nelson K, Allen J, Davidson P, Abshire M. Outpatient Palliative Care in Heart Failure: An Integrative Review. J Palliat Med 2020; 23:1257-1269. [PMID: 32522132 PMCID: PMC7469696 DOI: 10.1089/jpm.2020.0031] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: Early integration of palliative care (PC) for patients with heart failure (HF) improves patient outcomes and decreases health care utilization. PC provided outside of an acute hospitalization is not well understood. Objective: To synthesize the literature of outpatient PC in HF to identify the current landscape, the impact on patient health outcomes, key stakeholders' perspectives, and future implications for research and practice. Design: A systematic search of PubMed, Embase, CINAHL, Cochrane, and Web of Science was conducted from inception to February 2019 for studies of outpatient PC in adults with HF. Each study was analyzed to describe study characteristics, location of PC, types of providers involved, participant characteristics, and main findings, and to characterize domains of PC addressed. Results: Most studies (N = 19) employed a quantitative design and were conducted in the United States. The most common locations of PC were the home or PC clinic and providers were mainly PC specialists. Outpatient PC improved quality of life, alleviated symptoms, and decreased rehospitalizations for patients with HF. No study addressed all eight domains of PC. The structural, physical, and psychological domains were commonly addressed, whereas, least commonly addressed domains were the cultural and ethical/legal domain. Women and ethnic minorities were underrepresented in the majority of samples. Conclusions: This integrative review highlights the need to promote primary PC and future PC research focusing on a holistic, integrated, team-based approach addressing all domains of PC in representative samples.
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Affiliation(s)
- Lyndsay DeGroot
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Binu Koirala
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Noelle Pavlovic
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Katie Nelson
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Jerilyn Allen
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Patricia Davidson
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
| | - Martha Abshire
- Johns Hopkins University School of Nursing, Baltimore, Maryland, USA
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14
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Temel JS, Sloan J, Zemla T, Greer JA, Jackson VA, El-Jawahri A, Kamdar M, Kamal A, Blinderman CD, Strand J, Zylla D, Daugherty C, Furqan M, Obel J, Razaq M, Roeland EJ, Loprinzi C. Multisite, Randomized Trial of Early Integrated Palliative and Oncology Care in Patients with Advanced Lung and Gastrointestinal Cancer: Alliance A221303. J Palliat Med 2020; 23:922-929. [PMID: 32031887 PMCID: PMC7307668 DOI: 10.1089/jpm.2019.0377] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: We conducted a multicenter, randomized trial of early integrated palliative and oncology care in patients with advanced cancer to confirm the benefits of early palliative care (PC) seen in prior single-center studies. Methods: We randomly assigned patients with newly diagnosed incurable cancer to early integrated palliative and oncology care (n = 195) or usual oncology care (n = 196) at sites through the Alliance for Clinical Trials in Oncology. Patients assigned to the intervention were expected to meet with a PC clinician at least monthly until death, whereas usual care patients consulted PC on request. The primary endpoint was the change in quality of life from baseline to week 12 per the Functional Assessment of Cancer Therapy-General (FACT-G). Secondary outcomes included anxiety, depression, and communication about prognosis and end-of-life care. Results: Due to significant morbidity and a high proportion of measures that were not completed within the protocol window or for unknown reasons, the rate of missing data was high. We anticipated that 70% of patients (n = 280) would complete the FACT-G at baseline and week 12, but only 49.3% (n = 193/391) completed the measure. Delivery of the intervention was also suboptimal, as 14.9% (n = 29/195) of intervention patients had no PC visits by week 12. Intervention patients reported a mean 3.35 (standard deviation [SD] = 14.7) increase in FACT-G scores from baseline to week 12 compared with usual care patients who reported a 0.12 (SD = 12.7) increase from baseline (p = 0.10). Conclusion: This study highlights the difficulties of conducting multicenter trials of supportive care interventions in patients with advanced cancer. Clinical Trials Registration: NCT02349412.
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Affiliation(s)
- Jennifer S. Temel
- Massachusetts General Hospital, Boston, Massachusetts, USA.,Address correspondence to: Jennifer S. Temel, MD, Massachusetts General Hospital, Boston, MA 02114, USA
| | | | | | | | | | | | - Mihir Kamdar
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Arif Kamal
- Duke University Medical Center, Durham, North Carolina, USA
| | | | | | - Dylan Zylla
- Park Nicollet/HealthPartners, Metro-Minnesota Community Oncology Research Consortium, Minneapolis, Minnesota, USA
| | | | - Muhummad Furqan
- University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Jennifer Obel
- NorthShore University HealthSystem CCOP, Evanston, Illinois, USA
| | - Mohammad Razaq
- University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Eric J. Roeland
- University of California San Diego Moores Cancer Center, La Jolla, California, USA
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15
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Brenne AT, Knudsen AK, Raj SX, Skjelvan L, Lund JÅ, Thronæs M, Løhre ET, Hågensen LÅ, Brunelli C, Kaasa S. Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and Operation of an Innovative Care Delivery Model. Pain Ther 2020; 9:297-318. [PMID: 32274655 PMCID: PMC7203320 DOI: 10.1007/s40122-020-00163-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Early access to cancer palliative care is recommended. Descriptions of structures and processes of outpatient palliative care clinics operated within smaller hospitals are scarce. This paper presents the development and operation of a fully integrated cancer and palliative care outpatient clinic at a local hospital in a rural region of Mid-Norway offering palliative care concurrent with cancer treatment. A standardized care pathway was applied. METHODS Palliative care is in Norway part of the public healthcare system. Official recommendations recent years point out action points to improve delivery of palliative care. An integrated cancer and palliative care outpatient clinic at a local hospital and an innovative care delivery model was developed and operated in this setting. Patients were recruited for a descriptive study of the patient population. Clinical data were collected by clinical staff and 13 symptom intensities were reported by the patients. RESULTS Cancer and palliative care were provided by one team of healthcare professionals trained in both fields. There was a close collaboration with the other departments at the hospital, with its affiliated tertiary hospital, and with community health and care services to provide timely referral, enhanced continuity, and improved coordination of care. Eighty-eight patients were included. Mean age was 65.6 years, the most common cancer diagnoses were digestive organs (22.7%), male genital organs (20.5%) or breast (25.0%), 75.0% had metastatic or locally advanced cancer, 59.1% were treated with non-curative intention and 93.1% had Karnofsky Performance Status ≥ 80%. Median scores of individual symptoms ranged from 0 to 3 (numerical rating scale, 0-10) and 61.0% reported at least one clinically significant symptom rating (≥ 4). CONCLUSION This delivery model of integrated outpatient cancer and palliative care is particularly relevant in rural regions allowing cancer patients access to palliative care earlier in the disease trajectory and closer to home.
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Affiliation(s)
- Anne-Tove Brenne
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
| | - Anne Kari Knudsen
- European Palliative Care Research Centre (PRC), Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Sunil Xavier Raj
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Laila Skjelvan
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Jo-Åsmund Lund
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Oncology, Ålesund Hospital, Møre og Romsdal Hospital Trust, Ålesund, Norway
| | - Morten Thronæs
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erik Torbjørn Løhre
- European Palliative Care Research Centre (PRC), Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
- Cancer Clinic, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | | | - Cinzia Brunelli
- Palliative Care, Pain Therapy and Rehabilitation Unit, Fondazione IRCCS Instituto Nazionale dei Tumori, Milan, Italy
| | - Stein Kaasa
- European Palliative Care Research Centre (PRC), Oslo University Hospital and University of Oslo, Oslo, Norway
- Department of Oncology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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Abstract
Palliative care has evolved over the past five decades as an interprofessional specialty to improve quality of life and quality of care for patients with cancer and their families. Existing evidence supports that timely involvement of specialist palliative care teams can enhance the care delivered by oncology teams. This review provides a state-of-the-science synopsis of the literature that supports each of the five clinical models of specialist palliative care delivery, including outpatient clinics, inpatient consultation teams, acute palliative care units, community-based palliative care, and hospice care. The roles of embedded clinics, nurse-led models, telehealth interventions, and primary palliative care also will be discussed. Outpatient clinics represent the key point of entry for timely access to palliative care. In this setting, patient care can be enhanced longitudinally through impeccable symptom management, monitoring, education, and advance care planning. Inpatient consultation teams provide expert symptom management and facilitate discharge planning for acutely symptomatic hospitalized patients. Patients with the highest level of distress and complexity may benefit from an admission to acute palliative care units. In contrast, community-based palliative care and hospice care are more appropriate for patients with a poor performance status and low to moderate symptom burden. Each of these five models of specialist palliative care serve a different patient population along the disease continuum and complement one another to provide comprehensive supportive care. Additional research is needed to define the standards for palliative care interventions and to refine the models to further improve access to quality palliative care.
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Affiliation(s)
- David Hui
- University of Texas MD Anderson Cancer Center, Houston, TX
| | - Eduardo Bruera
- University of Texas MD Anderson Cancer Center, Houston, TX
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17
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Lau J, Flamer D, Murphy-Kane P. Interventional anesthesia and palliative care collaboration to manage cancer pain: a narrative review. Can J Anaesth 2020; 67:235-246. [PMID: 31571119 DOI: 10.1007/s12630-019-01482-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 12/20/2022] Open
Abstract
Pain is a common symptom associated with advanced cancer. An estimated 66.4% of people with advanced cancer experience pain from their disease or treatment. Pain management is an essential component of palliative care. Opioids and adjuvant therapies are the mainstay of cancer pain management. Nevertheless, a proportion of patients may experience complex pain that is not responsive to conventional analgesia. Interventional analgesia procedures may be appropriate and necessary to manage complex, cancer-related pain. This narrative review uses a theoretical case to highlight core principles of palliative care and interventional anesthesia, and the importance of collaborative, interdisciplinary care. An overview and discussion of pragmatic considerations of peripheral nervous system interventional analgesic procedures and neuraxial analgesia infusions are provided.
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Affiliation(s)
- Jenny Lau
- Department of Supportive Care, University Health Network, Toronto, ON, Canada.
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada.
- Division of Palliative Care, Department of Family and Community Medicine, Toronto, ON, Canada.
| | - David Flamer
- Department of Anesthesia and Pain Medicine, University Health Network, Toronto, ON, Canada
- Toronto Western Hospital, Toronto, ON, Canada
- Mount Sinai Hospital, Toronto, ON, Canada
| | - Patricia Murphy-Kane
- Department of Supportive Care, University Health Network, Toronto, ON, Canada
- Acute Palliative Care Unit, Princess Margaret Cancer Center, Toronto, ON, Canada
- Department of Nursing, Princess Margaret Cancer Center, Toronto, ON, Canada
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18
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Adisa R, Anifowose AT. Pharmacists' knowledge, attitude and involvement in palliative care in selected tertiary hospitals in southwestern Nigeria. BMC Palliat Care 2019; 18:107. [PMID: 31783834 PMCID: PMC6884848 DOI: 10.1186/s12904-019-0492-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 11/20/2019] [Indexed: 02/08/2023] Open
Abstract
Background The growing number of people living with life-limiting illness is a global health concern. This study therefore aimed to explore the involvement of pharmacists in selected tertiary hospitals in Nigeria in palliative care (PC). It also sought to evaluate their knowledge and attitude to PC as well as factors that hinder pharmacists’ participation in PC. Method Questionnaire-guided survey among pharmacists working in three-tertiary hospitals in southwestern Nigeria. The self-administered questionnaire comprised 18-item general knowledge questions related to PC, attitude statements with 5-point Likert-scale options and question-items that clarify extent of involvement in PC and barriers to participation. Overall score by pharmacists in the knowledge and attitude domains developed for the purpose of this study was assigned into binary categories of “adequate” and “inadequate” knowledge (score > 75% versus≤75%), as well as “positive” and “negative” attitude (ranked score > 75% versus≤75%), respectively. Descriptive statistics, Mann-Whitney-U and Kruskal-Wallis tests were used for analysis at p < 0.05. Results All the 110 pharmacists enrolled responded to the questionnaire, given a response rate of 100%. Overall, our study showed that 23(21.1%) had adequate general knowledge in PC, while 14(12.8%) demonstrated positive attitude, with 45(41.3%) who enjoyed working in PC. Counselling on therapy adherence (100;90.9%) was the most frequently engaged activity by pharmacists; attending clinical meetings to advise health team members (45;40.9%) and giving educational sessions (47;42.7%) were largely cited as occasionally performed duties, while patient home visit was mostly cited (60;54.5%) as a duty not done at all. Pharmacists’ unawareness of their need in PC (86;79.6%) was a major factor hindering participation, while pharmacists with PC training significantly felt more relaxed around people receiving PC compared to those without training (p = 0.003). Conclusion Hospital pharmacists in selected tertiary care institutions demonstrate inadequate knowledge, as well as negative attitude towards PC. Also, extent of involvement in core PC service is generally low, with pharmacists’ unawareness of their need in PC constituting a major barrier. Thus, a need for inclusion of PC concept into pharmacy education curriculum, while mandatory professional development programme for pharmacists should also incorporate aspects detailing fundamental principles of PC, in order to bridge the knowledge and practice gaps.
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Affiliation(s)
- Rasaq Adisa
- Department of Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy, University of Ibadan, Ibadan, Nigeria.
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Abstract
Researchers have established associations between the stressors of providing informal care and caregiver health risks. Despite the negative consequences, researchers have identified the existence of protective factors that have the potential to buffer or prevent stress. The purpose of this study was to determine the relationship between self-efficacy and stress in adult informal caregivers providing end-of-life care. This cross-sectional, associational study analyzed data from questionnaires completed by adult informal caregivers providing end-of-life care for an adult in North Texas. Questionnaires provided measures of self-efficacy, stress, and caregiver perceived health. Findings indicated caregiver self-efficacy globally had a significant correlation with stress, whereas caregivers' confidence in caring for themselves had a significant negative relationship with perceived stress. Specifically, study findings indicate caregivers with greater confidence in managing demands of caregiving have lower levels of stress, and caregivers with greater confidence in caring for themselves, specifically, have lower levels of perceived stress. Study findings highlight the importance of caregivers' self-care needs. Health care practitioners should recognize and intervene to support caregivers' self-care needs in order to prevent additional, needless health problems in this population.
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Electronic Health Record Mortality Prediction Model for Targeted Palliative Care Among Hospitalized Medical Patients: a Pilot Quasi-experimental Study. J Gen Intern Med 2019; 34:1841-1847. [PMID: 31313110 PMCID: PMC6712114 DOI: 10.1007/s11606-019-05169-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/11/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Development of electronic health record (EHR) prediction models to improve palliative care delivery is on the rise, yet the clinical impact of such models has not been evaluated. OBJECTIVE To assess the clinical impact of triggering palliative care using an EHR prediction model. DESIGN Pilot prospective before-after study on the general medical wards at an urban academic medical center. PARTICIPANTS Adults with a predicted probability of 6-month mortality of ≥ 0.3. INTERVENTION Triggered (with opt-out) palliative care consult on hospital day 2. MAIN MEASURES Frequencies of consults, advance care planning (ACP) documentation, home palliative care and hospice referrals, code status changes, and pre-consult length of stay (LOS). KEY RESULTS The control and intervention periods included 8 weeks each and 138 admissions and 134 admissions, respectively. Characteristics between the groups were similar, with a mean (standard deviation) risk of 6-month mortality of 0.5 (0.2). Seventy-seven (57%) triggered consults were accepted by the primary team and 8 consults were requested per usual care during the intervention period. Compared to historical controls, consultation increased by 74% (22 [16%] vs 85 [63%], P < .001), median (interquartile range) pre-consult LOS decreased by 1.4 days (2.6 [1.1, 6.2] vs 1.2 [0.8, 2.7], P = .02), ACP documentation increased by 38% (23 [17%] vs 37 [28%], P = .03), and home palliative care referrals increased by 61% (9 [7%] vs 23 [17%], P = .01). There were no differences between the control and intervention groups in hospice referrals (14 [10] vs 22 [16], P = .13), code status changes (42 [30] vs 39 [29]; P = .81), or consult requests for lower risk (< 0.3) patients (48/1004 [5] vs 33/798 [4]; P = .48). CONCLUSIONS Targeting hospital-based palliative care using an EHR mortality prediction model is a clinically promising approach to improve the quality of care among seriously ill medical patients. More evidence is needed to determine the generalizability of this approach and its impact on patient- and caregiver-reported outcomes.
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Grudzen CR, Schmucker AM, Shim DJ, Ibikunle A, Cho J, Chung FR, Cohen SE. Development of an Outpatient Palliative Care Protocol to Monitor Fidelity in the Emergency Medicine Palliative Care Access Trial. J Palliat Med 2019; 22:66-71. [PMID: 31486726 PMCID: PMC7366256 DOI: 10.1089/jpm.2019.0115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2019] [Indexed: 11/12/2022] Open
Abstract
Introduction: Palliative care is recommended for patients with life-limiting illnesses; however, there are few standardized protocols for outpatient palliative care visits. To address the paucity of data, this article aims to: (1) describe the elements of outpatient palliative care that are generalizable across clinical sites; (2) achieve consensus about standardized instruments used to assess domains within outpatient palliative care; and (3) develop a protocol and intervention checklist for palliative care clinicians to document outpatient visit elements that might not normally be recorded in the electronic heath record. Methods: As part of a randomized control trial of nurse-led telephonic case management versus specialty, outpatient palliative care in older adults with serious life-limiting illnesses in the Emergency Department, we assessed the structural characteristics of outpatient care clinics across nine participating health care systems. In addition, direct observation of outpatient palliative care visits, consultation from content experts, and survey data were used to develop an outpatient palliative care protocol and intervention checklist. Implementation: The protocol and checklist are being used to document the contents of each outpatient palliative care visit conducted as a part of the Emergency Medicine Palliative Care Access (EMPallA) trial. Variation across palliative care team staffing, clinic session capacity, and physical clinic model presents a challenge to standardizing the delivery of outpatient palliative care.
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Affiliation(s)
- Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York
| | - Abigail M. Schmucker
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Deborah J. Shim
- Augusta University Medical College of Georgia, Augusta, Georgia
| | | | - Jeanne Cho
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, New York, New York
| | - Frank R. Chung
- New York University School of Medicine, New York, New York
| | - Susan E. Cohen
- Department of Internal Medicine, New York University School of Medicine, New York, New York
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Epstein AS, Desai AV, Bernal C, Romano D, Wan PJ, Okpako M, Anderson K, Chow K, Kramer D, Calderon C, Klimek VV, Rawlins-Duell R, Reidy DL, Goldberg JI, Cruz E, Nelson JE. Giving Voice to Patient Values Throughout Cancer: A Novel Nurse-Led Intervention. J Pain Symptom Manage 2019; 58:72-79.e2. [PMID: 31034869 PMCID: PMC6849206 DOI: 10.1016/j.jpainsymman.2019.04.028] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 04/18/2019] [Accepted: 04/19/2019] [Indexed: 12/22/2022]
Abstract
CONTEXT Optimal advance care planning allows patients to articulate their values as a touchstone for medical decision making. Ideally, this occurs when patients are clinically stable, and with opportunities for iteration as the clinical situation unfolds. OBJECTIVES Testing feasibility and acceptability in busy outpatient oncology clinics of a novel program of systematic, oncology nurse-led values discussions with all new cancer patients. METHODS Within an institutional initiative integrating primary and specialist palliative care from diagnosis for all cancer patients, oncology nurses were trained to use specific questions and an empathic communication framework to discuss health-related values during outpatient clinic visits. Nurses summarized discussions on a template for patient verification, oncologist review, and electronic medical record documentation. Summaries were reviewed with the patient at least quarterly. Feasibility and acceptability were evaluated in three clinics for patients with hematologic or gastrointestinal malignancies. RESULTS Oncology nurses conducted 177 total discussions with 67 newly diagnosed cancer patients (17 with hematologic and 50 with gastrointestinal malignancies) over two years. No patient declined participation. Discussions averaged eight minutes, and all patients verified values summaries. Clinic patient volume was maintained. Of 31 patients surveyed, 30 (97%) reported feeling comfortable with the process, considered it helpful, and would recommend it to others. Clinicians strongly endorsed the values discussion process. CONCLUSION Nurse-led discussions of patient values soon after diagnosis are feasible and acceptable in busy oncology clinics. Further research will evaluate the impact of this novel approach on additional patient-oriented outcomes after broader dissemination of this initiative throughout our institution.
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Affiliation(s)
- Andrew S Epstein
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA.
| | - Anjali V Desai
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | - Camila Bernal
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Danielle Romano
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Peter J Wan
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Molly Okpako
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kelly Anderson
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Kimberly Chow
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Dana Kramer
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | | | - Virginia V Klimek
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | | | - Diane L Reidy
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
| | | | - Elizabeth Cruz
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Judith E Nelson
- Memorial Sloan Kettering Cancer Center, New York, New York, USA; Weill Cornell Medical College, New York, New York, USA
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Finlay E, Newport K, Sivendran S, Kilpatrick L, Owens M, Buss MK. Models of Outpatient Palliative Care Clinics for Patients With Cancer. J Oncol Pract 2019; 15:187-193. [DOI: 10.1200/jop.18.00634] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE: Early integration of outpatient palliative care (OPC) benefits patients with advanced cancer and also the health care systems in which these patients are seen. Successful development and implementation of models of OPC require attention to the needs and values of both the patients being served and the institution providing service. SUMMARY: In the 2016 clinical guideline, ASCO recommended integrating palliative care early in the disease trajectory alongside cancer-directed treatment. Despite strong endorsement and robust evidence of benefit, many patients with cancer lack access to OPC. Here we define different models of care delivery in four successful palliative care clinics in four distinct health care settings: an academic medical center, a safety net hospital, a community health system, and a hospice-staffed clinic embedded in a community cancer center. The description of each clinic includes details on setting, staffing, volume, policies, and processes. CONCLUSION: The development of robust and capable OPC clinics is necessary to meet the growing demand for these services among patients with advanced cancer. This summary of key aspects of functional OPC clinics will enable health care institutions to evaluate their specific needs and develop programs that will be successful within the environment of an individual institution.
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Affiliation(s)
- Esme Finlay
- University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Kristina Newport
- Penn State Hershey, Hershey, PA
- Hospice & Community Care, York, PA
| | - Shanthi Sivendran
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA
| | | | | | - Mary K. Buss
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Boucher NA, Bull JH, Cross SH, Kirby C, Davis JK, Taylor DH. Patient, Caregiver, and Taxpayer Knowledge of Palliative Care and Views on a Model of Community-Based Palliative Care. J Pain Symptom Manage 2018; 56:951-956. [PMID: 30149059 DOI: 10.1016/j.jpainsymman.2018.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 11/21/2022]
Abstract
CONTEXT Palliative care (PC) model delivered by two large hospices and PC providers. OBJECTIVES To understand study participants' knowledge of PC and acceptability of a new community-based PC model. METHODS Semistructured interview with patients and caregivers; focus groups with taxpayers. Descriptive content analysis with an inductive approach. RESULTS Across 10 interviews and four focus groups (n = 4-10 per group), there was varying knowledge of PC. Gaps in interview and focus group participants' knowledge related to knowing the services available in PC, how PC is paid for, how to initiate PC, and how PC affects the patient's relationship with existing providers. Regarding the model, negative feedback from interview participants included not having PC explained adequately and PC providers seen as consultants and not as full-time providers. Focus group participants indicated that the model sounded promising but noted the likely difficulty in enacting it in our current health care system. Positive feedback from interview participants included the perception that clinicians spent more time and provided more support for patients and families and the developing ability of PC services to provide care more broadly than at the very end of life. Focus group participants had similar observations related to perceived attention to care and broader application of PC. Perceptions of time-constrained care delivery and suboptimal provider-patient communication persist for some patients getting PC services. CONCLUSION Education for patients, caregivers, and community members about the roles and benefits of PC will be needed to successfully expand community-based PC.
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Affiliation(s)
- Nathan A Boucher
- Durham Veteran Affairs Medical Center, Durham, North Carolina, USA; Duke University Sanford School of Public Policy, Durham, North Carolina, USA; Duke-Margolis Center for Public Policy, Durham, North Carolina, USA.
| | - Janet H Bull
- Four Seasons Hospice and Palliative Care, Flat Rock, North Carolina, USA
| | - Sarah H Cross
- Duke University Sanford School of Public Policy, Durham, North Carolina, USA
| | - Christine Kirby
- Duke-Margolis Center for Public Policy, Durham, North Carolina, USA
| | - J Kelly Davis
- Duke-Margolis Center for Public Policy, Durham, North Carolina, USA
| | - Donald H Taylor
- Duke University Sanford School of Public Policy, Durham, North Carolina, USA; Duke-Margolis Center for Public Policy, Durham, North Carolina, USA
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Finlay E, Rabow MW, Buss MK. Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution. Am Soc Clin Oncol Educ Book 2018; 38:111-121. [PMID: 30231351 DOI: 10.1200/edbk_200775] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.
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Affiliation(s)
- Esme Finlay
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael W Rabow
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mary K Buss
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Hui D, Hannon B, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: Team-based, timely, and targeted palliative care. CA Cancer J Clin 2018; 68:356-376. [PMID: 30277572 PMCID: PMC6179926 DOI: 10.3322/caac.21490] [Citation(s) in RCA: 198] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state-of-the-science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team-based, timely, and targeted palliative care. Team-based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse-led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00-00. 2018 American Cancer Society, Inc.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Breffni Hannon
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Wells R, Ejem D, Dionne-Odom JN, Bagcivan G, Keebler K, Frost J, Azuero A, Kono A, Swetz KM, Bakitas M. Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study. Heart Lung 2018; 47:533-538. [PMID: 30143363 DOI: 10.1016/j.hrtlng.2018.06.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 06/12/2018] [Accepted: 06/14/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF). OBJECTIVES To describe evaluation practices and treatment recommendations made during protocol-driven OPCCs for advanced HF. METHODS We performed content analysis of OPCCs completed as part of ENABLE CHF-PC, an early palliative care HF intervention, conducted at sites in the Northeast and Southeast. T-tests, Fisher's exact, and Chi-square tests were used to evaluate sociodemographic, outcome measures, and site content differences. RESULTS Of 61 ENABLE CHF-PC participants, 39 (64%) had an OPCC (Northeast, n=27; Southeast, n=12). Social and medical history assessed most were close relationships (n=35, 90%), family support (n=33, 85%), advance directive status (n=33, 85%), functional status (n=30, 77%); and symptoms were mood (n= 35, 90%), breathlessness (n=28, 72%), and chest pain (n=24, 62%). Treatment recommendations focused on care coordination (n=13, 33%) and specialty referrals (n=12, 31%). Between-site OPCC differences included assessment of family support (Northeast vs. Southeast: 100% vs. 50%), code status (96% vs. 58%), goals of care discussions (89% vs. 41.7%), and prognosis understanding (85% vs. 33%). CONCLUSION OPCCs for HF focused on evaluating medical and social history, along with goals of care and code status discussions. Symptom evaluation commonly included mood disorders, pain, dyspnea, and fatigue. Notable regional differences were found in topics evaluated and OPCC completion rates.
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Affiliation(s)
- Rachel Wells
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA.
| | - Deborah Ejem
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - J Nicholas Dionne-Odom
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Gulcan Bagcivan
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Konda Keebler
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Jennifer Frost
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA
| | - Alan Kono
- Cardiology, Dartmouth-Hitchcock Medical Center/Geisel School of Medicine at Dartmouth, Heart and Vascular Center DHMC, 1 Medical Center Drive, Lebanon, NH 03756, USA
| | - Keith M Swetz
- Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB Center for Palliative & Supportive Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-0012, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Marie Bakitas
- School of Nursing, University of Alabama at Birmingham, MT412B, 1720 2nd Avenue South, Birmingham, AL 35294-1210, USA; Department of Medicine, Division of Gerontology, Geriatrics, and Palliative Care, UAB Center for Palliative & Supportive Care, University of Alabama at Birmingham, 1720 2nd Avenue South, Birmingham, AL 35294-0012, USA
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Izumi S(S, Basin B, Presley M, McCalmont J, Furuno JP, Noble B, Baggs JG, Curtis JR. Feasibility and Acceptability of Nurse-Led Primary Palliative Care for Older Adults with Chronic Conditions: A Pilot Study. J Palliat Med 2018; 21:1114-1121. [PMID: 29792733 PMCID: PMC6916529 DOI: 10.1089/jpm.2017.0666] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Many older adults live with serious illness for years before their death. Nurse-led primary palliative care could improve their quality of life and ability to stay in their community. OBJECTIVES To assess feasibility and acceptability of a nurse-led Transitional Palliative Care (TPC) program for older adults with serious illness. METHODS The study was a pilot trial of the TPC program in which registered nurses assisted patients with symptom management, communication with care providers, and advance care planning. Forty-one older adults with chronic conditions were enrolled in TPC or standard care groups. Feasibility was assessed through enrollment and attrition rates and degree of intervention execution. Acceptability was assessed through surveys and exit interviews with participants and intervention nurses. RESULTS Enrollment rate for those approached was 68%, and completion rate for those enrolled was 71%. The TPC group found the intervention acceptable and helpful and was more satisfied with care received than the control group. However, one-third of participants perceived that TPC was more than they needed, despite the number of symptoms they experienced and the burdensomeness of their symptoms. More than half of the participants had little to no difficulty participating in daily activities. CONCLUSION This study demonstrated that the nurse-led TPC program is feasible, acceptable, and perceived as helpful. However, further refinement is needed in selection criteria to identify the population who would most benefit from primary palliative care before future test of the efficacy of this intervention.
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Affiliation(s)
| | - Basilia Basin
- Oregon Health and Science University School of Nursing, Portland, Oregon
| | - Margo Presley
- Department of Multnomah County Health, Portland, Oregon
| | | | - Jon P. Furuno
- Department of Pharmacy Practice, OSU/OHSU College of Pharmacy, Portland, Oregon
| | - Brie Noble
- Department of Pharmacy Practice, OSU/OHSU College of Pharmacy, Portland, Oregon
| | - Judith G. Baggs
- Oregon Health and Science University School of Nursing, Portland, Oregon
| | - J. Randall Curtis
- Division of Pulmonary and Critical Care Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
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Bischoff K, Yang E, Kojimoto G, Shepard Lopez N, Holland S, Calton B, Adkins SH, Cheng S, Miller BJ, Rabow MW. What We Do: Key Activities of an Outpatient Palliative Care Team at an Academic Cancer Center. J Palliat Med 2018; 21:999-1004. [PMID: 29431580 DOI: 10.1089/jpm.2017.0441] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Outpatient palliative care (PC) has been shown to positively impact quality of life and decrease healthcare utilization, but there are limited data describing what activities render these benefits. OBJECTIVE Describe the topics addressed by an outpatient PC team during scheduled visits. DESIGN Longitudinal cohort study. SETTING The Symptom Management Service, an ambulatory PC program at an academic comprehensive cancer center. MEASUREMENT Between March 23, 2015 and June 14, 2016, outpatient PC providers completed a checklist after each clinic visit, documenting topics covered during the visit. RESULTS During the study period, 1243 visits were conducted for 577 unique patients. Symptom management was the topic most commonly addressed during initial visits (in 92% of visits), followed by an introduction of PC (69%), support for family caregivers (47%), and communication with other clinicians (38%). Providers also supported patients to understand their prognosis (28%), treatment options (36%), and to make care decisions (22%). Formal advance care planning activities occurred infrequently, however, including designation of a Durable Power of Attorney for Healthcare (26%), completion of an advance directive or Provider Orders for Life-Sustaining Treatment form (10%), and discussing hospice (8%). Follow-up visits were dominated by symptom management (93%) and caregiver support (27%). CONCLUSIONS Symptom management, support for family and caregivers, and care coordination are the most common activities that occurred during scheduled outpatient PC visits. These findings can guide developing PC practices, as well as clinicians who provide primary PC.
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Affiliation(s)
- Kara Bischoff
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Eleanor Yang
- 2 Department of Medicine, Northwestern University Feinberg School of Medicine , Chicago, Illinois
| | - Gayle Kojimoto
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Nancy Shepard Lopez
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Sarah Holland
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Brook Calton
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Sarah H Adkins
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Stephanie Cheng
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Bruce J Miller
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
| | - Michael W Rabow
- 1 Symptom Management Service, Department of Medicine, University of California , San Francisco, San Francisco, California
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Rationale and Design of the Randomized Evaluation of Default Access to Palliative Services (REDAPS) Trial. Ann Am Thorac Soc 2018; 13:1629-39. [PMID: 27348271 DOI: 10.1513/annalsats.201604-308ot] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
The substantial nationwide investment in inpatient palliative care services stems from their great promise to improve patient-centered outcomes and reduce costs. However, robust experimental evidence of these benefits is lacking. The Randomized Evaluation of Default Access to Palliative Services (REDAPS) study is a pragmatic, stepped-wedge, cluster randomized trial designed to test the efficacy and costs of specialized palliative care consultative services for hospitalized patients with advanced chronic obstructive pulmonary disease, dementia, or end-stage renal disease, as well as the overall effectiveness of ordering such services by default. Additional aims are to identify the types of services that are most beneficial and the types of patients most likely to benefit, including comparisons between ward and intensive care unit patients. We hypothesize that patient-centered outcomes can be improved without increasing costs by simply changing the default option for palliative care consultation from opt-in to opt-out for patients with life-limiting illnesses. Patients aged 65 years or older are enrolled at 11 hospitals using an integrated electronic health record. As a pragmatic trial designed to enroll between 12,000 and 15,000 patients, eligibility is determined using a validated, electronic health record-based algorithm, and all outcomes are captured via the electronic health record and billing systems data. The time at which each hospital transitions from control, opt-in palliative care consultation to intervention, opt-out consultation is randomly assigned. The primary outcome is a composite measure of in-hospital mortality and length of stay. Secondary outcomes include palliative care process measures and clinical and economic outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT02505035).
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Interactive Online Module Failed to Improve Sustained Knowledge of the Maryland Medical Orders for Life-Sustaining Treatment Form. Ann Am Thorac Soc 2018; 13:926-32. [PMID: 26967023 DOI: 10.1513/annalsats.201511-738oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Legal documents similar to the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form requiring physician endorsement are increasingly used by critically ill patients. OBJECTIVES To evaluate whether an interactive, online training module on completion and interpretation of the MOLST form leads to a sustained increase in knowledge among house staff. METHODS Pre/post survey of 329 house staff at Johns Hopkins Hospital who admit and discharge patients between June 2014 and July 2015. House staff were encouraged to complete a voluntary, interactive, online educational module on completing and interpreting MOLST forms. Participants received $25 for accessing the module and $10 for completing each survey. MEASUREMENTS AND MAIN RESULTS The primary outcome was the change in the number of questions answered correctly on the post- versus presurvey comparing house staff who viewed the module for at least 20 minutes with house staff who never viewed or never completed the module. Overall, 329 (69%) house staff completed the knowledge assessment survey both before and after the module was available, and 201 (61%) of these house staff completed the voluntary module. The median score on the presurvey conducted in July and August of 2014 was 14 out of 21 (interquartile range [IQR] 12, 16). The median (IQR) score on the postsurvey conducted in May and June of 2015 was 15 out of 21 (13, 17). The median (IQR) change in score among those who spent at least 20 minutes completing the module was 1 question (-1, 3), and among those who never viewed or never completed the module it was also 1 (IQR -1, 2). The postsurvey was completed a median (IQR) of 59 (52, 62) days after viewing the module. After adjusting for years of postgraduate clinical training, self-reported baseline experience completing MOLST forms, and self-reported responsibility for discharging patients, viewing the module for at least 20 minutes was associated with a nonsignificant increase in score of 0.41 questions (95% confidence interval, -0.25, 1.06; P = 0.23). CONCLUSIONS An interactive, online educational module had no effect on trainee knowledge of completing and interpreting MOLST forms approximately 2 months after completion. Information conveyed via online modules alone may have minimal sustained impact on house staff knowledge.
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Schoenborn NL, Cayea D, McNabney M, Ray A, Boyd C. Prognosis communication with older patients with multimorbidity: Assessment after an educational intervention. GERONTOLOGY & GERIATRICS EDUCATION 2017; 38:471-481. [PMID: 26885757 PMCID: PMC5826548 DOI: 10.1080/02701960.2015.1115983] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
This study aimed to assess how internal medicine residents incorporated prognosis to inform clinical decisions and communicated prognosis in primary care visits with older patients with multimorbidity after an educational intervention, and resident and patient perspectives regarding these visits. Assessment used mixed-methods. The authors assessed the frequency and content of prognosis discussions through residents' self-report and qualitative content analysis of audio-recorded clinic visits. The authors assessed the residents' perceived effect of incorporating prognosis on patient care and patient relationship through a resident survey. The authors assessed the patients' perceived quality of communication and trust in physicians through a patient survey. The study included 21 clinic visits that involved 12 first-year residents and 21 patients. Residents reported incorporating patients' prognoses to inform clinical decisions in 13/21 visits and perceived positive effects on patient care (in 11/13 visits) and patient relationship (in 7/13 visits). Prognosis communication occurred in 9/21 visits by self-report, but only in six of these nine visits by content analysis of audio-recordings. Patient ratings were high regardless of whether or not prognosis was communicated. In summary, after training, residents often incorporated patients' prognoses to inform clinical decisions, but sometimes did so without communicating prognosis to the patients. Residents and patients reported positive perceptions regarding the visits.
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Affiliation(s)
- Nancy L. Schoenborn
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
| | - Danelle Cayea
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
| | - Matthew McNabney
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
| | - Anushree Ray
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
- Ms. Ray was working as research assistant during this project at the Johns Hopkins School of Medicine but has since moved. She currently works as project manager at Medline Industries
| | - Cynthia Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine
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Walling AM, D'Ambruoso SF, Malin JL, Hurvitz S, Zisser A, Coscarelli A, Clarke R, Hackbarth A, Pietras C, Watts F, Ferrell B, Skootsky S, Wenger NS. Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic. J Oncol Pract 2017; 13:e792-e799. [PMID: 28813191 DOI: 10.1200/jop.2017.020990] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic. METHODS We evaluated the effect of the intervention in two oncologists' clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies. RESULTS Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff). CONCLUSION An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.
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Affiliation(s)
- Anne M Walling
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Sarah F D'Ambruoso
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Jennifer L Malin
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Sara Hurvitz
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Ann Zisser
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Anne Coscarelli
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Robin Clarke
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Andrew Hackbarth
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Christopher Pietras
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Frances Watts
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Bruce Ferrell
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Samuel Skootsky
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
| | - Neil S Wenger
- Greater Los Angeles Veterans Affairs Healthcare System; University of California at Los Angeles (UCLA); UCLA Center for Integrative Oncology; UCLA Health, Los Angeles, CA; and Anthem, Indianapolis, IN
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Hui D, Mori M, Watanabe SM, Caraceni A, Strasser F, Saarto T, Cherny N, Glare P, Kaasa S, Bruera E. Referral criteria for outpatient specialty palliative cancer care: an international consensus. Lancet Oncol 2017; 17:e552-e559. [PMID: 27924753 DOI: 10.1016/s1470-2045(16)30577-0] [Citation(s) in RCA: 164] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/26/2016] [Accepted: 07/26/2016] [Indexed: 12/25/2022]
Abstract
Although outpatient specialty palliative-care clinics improve outcomes, there is no consensus on who should be referred or the optimal timing for referral. In response to this issue, we did a Delphi study to develop consensus on a list of criteria for referral of patients with advanced cancer at secondary or tertiary care hospitals to outpatient palliative care. 60 international experts (26 from North America, 19 from Asia and Australia, and 11 from Europe) on palliative cancer care rated 39 needs-based criteria and 22 time-based criteria in three iterative rounds. Nearly all experts responded in each round. Consensus was defined by an a-priori agreement of 70% or more. Panellists reached consensus on 11 major criteria for referral: severe physical symptoms, severe emotional symptoms, request for hastened death, spiritual or existential crisis, assistance with decision making or care planning, patient request for referral, delirium, spinal cord compression, brain or leptomeningeal metastases, within 3 months of advanced cancer diagnosis for patients with median survival of 1 year or less, and progressive disease despite second-line therapy. Consensus was also reached on 36 minor criteria for specialist palliative-care referral. These criteria, if validated, could provide guidance for identification of patients suitable for outpatient specialty palliative care.
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Affiliation(s)
- David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Sharon M Watanabe
- Division of Palliative Care Medicine, Department of Oncology, University of Alberta, Edmonton, AB, Canada
| | - Augusto Caraceni
- Palliative Care, Pain Therapy and Rehabilitation, Fondazione IRCCS Istituto Nazionale dei Tumori di Milano, Milan, Italy
| | - Florian Strasser
- Oncological Palliative Medicine, Hematology-Oncology, Cantonal Hospital, St Gallen, Switzerland
| | - Tiina Saarto
- Department of Palliative Care, Helsinki University Central Hospital, Cancer Center, Helsinki, Finland
| | - Nathan Cherny
- Cancer Pain and Palliative Medicine Service, Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Paul Glare
- Pain and Palliative Care Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stein Kaasa
- European Palliative Care Research Centre, Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway; Department of Oncology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Eduardo Bruera
- Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Hickey TR, Cooper Z, Urman RD, Hepner DL, Bader AM. An Agenda for Improving Perioperative Code Status Discussion. ACTA ACUST UNITED AC 2017; 6:411-5. [PMID: 27301059 DOI: 10.1213/xaa.0000000000000327] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Code status discussions (CSDs) clarify patient preferences for cardiopulmonary resuscitation in the event of cardiac or respiratory arrest. CSDs are a key component of perioperative care, particularly at the end of life, and must be both patient-centered and shared. Physicians at all levels of training are insufficiently trained in and inappropriately perform CSD; this may be particularly true of perioperative physicians. In this article, we describe the difficulty of achieving a patient-centered, shared perioperative CSD in the case of a medical professional with a do-not-resuscitate order. We provide a brief background in cardiopulmonary resuscitation, do-not-resuscitate, and CSD before proposing an agenda for improving perioperative CSD.
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Affiliation(s)
- Thomas R Hickey
- From the *Yale University School of Medicine, Department of Anesthesiology, VA Connecticut Healthcare System, West Haven, Connecticut; †Department of Surgery, Division of Trauma, Burns, and Surgical Critical Care, and the Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; ‡Ariadne Labs, Boston, Massachusetts; §Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts; and ‖Harvard Medical School, Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Yoong J, MacPhail A, Trytel G, Rajendram PY, Winbolt M, Ibrahim JE. Completion of Limitation of Medical Treatment forms by junior doctors for patients with dementia: clinical, medicolegal and education perspectives. AUST HEALTH REV 2016; 41:519-526. [PMID: 27736633 DOI: 10.1071/ah16116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 08/23/2016] [Indexed: 11/23/2022]
Abstract
Objective Limitation of Medical Treatment (LMT) forms are an essential element of end-of-life care. Decision making around LMT is complex and often involves patients with dementia. Despite the complexity, junior doctors frequently play a central role in completing LMT forms. The present study sought perspectives from a range of stakeholders (hospital clinicians, medical education personnel, legal and advocacy staff) about junior doctors' roles in completing LMT forms in general and for patients with dementia. Methods Qualitative data were gathered in semi-structured interviews (SSI) and theoretical concepts were explored in roundtable discussion (RD). Participants were recruited through purposive and convenience sampling drawing on healthcare and legal personnel employed in the public hospital and aged care systems, selected from major metropolitan hospitals, healthcare and legal professional bodies and advocacy organisations in Victoria, Australia. The contents of the SSIs and RD were subject to thematic analysis using a framework approach. Data were indexed according to the topics established in the study aim; categories were systematically scrutinised, from which key themes were distilled. Results Stakeholders reported that completing LMT forms was difficult for junior doctors because of a lack of medical and legal knowledge, as well as clinical inexperience and inadequate training. Healthcare organisations (HCOs) either lacked policies about the role of junior doctors or had practices that were discordant with policy. In this process, there were substantial gaps pertaining to patients with dementia. Recommendations made by the study participants included the provision of supervised clinical exposure and additional training for junior doctors, strengthening HCO policies and explicit consideration of the needs of patients with dementia. Conclusions LMT forms should be designed for clarity and consistency across HCOs. Enhancing patient care requires appropriate and sensitive completion of LMT. Relevant HCO policy and clinical practice changes are discussed herein, and recommendations are made for junior doctors in this arena, specifically in the context of patients with dementia. What is known about the topic? Junior doctors continue to play a central role in LMT orders, a highly complex decision-making task that they are poorly prepared to complete. LMT decision making in Australia's aging population and for people with dementia is especially challenging. What does this paper add? A broad range of stakeholders, including hospital clinicians, medical education personnel and legal and advocacy staff, identified ongoing substantial gaps in education and training of junior doctors (despite what is already known in the literature). Furthermore, LMT decision making for patients with dementia is not explicitly considered in policy of practice. What are the implications for practitioners? Current policy and practice are not at the desired level to deliver appropriate end-of-life care with regard to LMT orders, especially for patients with dementia. Greater involvement of executives and senior clinicians is required to improve both practice at the bed side and the training and support of junior doctors, as well as creating more robust policy.
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Affiliation(s)
- Jaclyn Yoong
- Monash Health, Department of Supportive and Palliative Care, 246 Clayton Road, Clayton, Vic. 3168, Australia. Email
| | - Aleece MacPhail
- Queen Elizabeth Centre, Ballarat Health Services, 102 Ascot Street Sth, Ballarat, Vic. 3350, Australia. Email
| | - Gael Trytel
- Victorian Institute for Forensic Medicine, Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Vic. 3006, Australia.
| | - Prashanti Yalini Rajendram
- Victorian Institute for Forensic Medicine, Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, Vic. 3006, Australia.
| | - Margaret Winbolt
- Australian Centre for Evidence Based Aged Care, Health Sciences Building 2, La Trobe University, Vic. 3086, Australia. Email
| | - Joseph E Ibrahim
- Queen Elizabeth Centre, Ballarat Health Services, 102 Ascot Street Sth, Ballarat, Vic. 3350, Australia. Email
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Rabow MW, Dahlin C, Calton B, Bischoff K, Ritchie C. New Frontiers in Outpatient Palliative Care for Patients With Cancer. Cancer Control 2016; 22:465-74. [PMID: 26678973 DOI: 10.1177/107327481502200412] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although much evidence has accumulated demonstrating its benefit, relatively little is known about outpatient palliative care in patients with cancer. METHODS This paper reviews the literature and perspectives from content experts to describe the current state of outpatient palliative care in the oncology setting and current areas of innovation and promise in the field. RESULTS Evidence, including from controlled trials, documents the benefits of outpatient palliative care in the oncology setting. As a result, professional medical organizations have guidelines and recommendations based on the key role of palliative care in oncology. Six elements of the practice sit at the frontier of outpatient oncology palliative care, including the setting and timing of palliative care integration into outpatient oncology, the relationships between primary and specialty palliative care, quality and measurement, research, electronic and technical innovations, and finances. CONCLUSIONS Evidence of clinical and health care system benefits supports the recommendations of professional organizations to integrate palliative care into the routine treatment of patients with advanced cancer.
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Improving Resident Communication in the Intensive Care Unit. The Proceduralization of Physician Communication with Patients and Their Surrogates. Ann Am Thorac Soc 2016; 13:1624-8. [DOI: 10.1513/annalsats.201601-029ps] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Lilly EJ, Senderovich H. Palliative care in chronic obstructive pulmonary disease. J Crit Care 2016; 35:150-4. [PMID: 27481751 DOI: 10.1016/j.jcrc.2016.05.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 05/17/2016] [Accepted: 05/20/2016] [Indexed: 11/19/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development.
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Affiliation(s)
- Evan J Lilly
- Western University, Department of Family Medicine, London, Ontario, Canada
| | - Helen Senderovich
- Division of Palliative Care, Department Family and Community Medicine, University of Toronto, Baycrest Health Sciences System, Toronto, Ontario, Canada.
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Chung HO, Oczkowski SJW, Hanvey L, Mbuagbaw L, You JJ. Educational interventions to train healthcare professionals in end-of-life communication: a systematic review and meta-analysis. BMC MEDICAL EDUCATION 2016; 16:131. [PMID: 27129790 PMCID: PMC4850701 DOI: 10.1186/s12909-016-0653-x] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 04/26/2016] [Indexed: 05/15/2023]
Abstract
BACKGROUND Practicing healthcare professionals and graduates exiting training programs are often ill-equipped to facilitate important discussions about end-of-life care with patients and their families. We conducted a systematic review to evaluate the effectiveness of educational interventions aimed at providing healthcare professionals with training in end-of-life communication skills, compared to usual curriculum. METHODS We searched MEDLINE, Embase, CINAHL, ERIC and the Cochrane Central Register of Controlled Trials from the date of inception to July 2014 for randomized control trials (RCT) and prospective observational studies of educational training interventions to train healthcare professionals in end-of-life communication skills. To be eligible, interventions had to provide communication skills training related to end-of-life decision making; other interventions (e.g. breaking bad news, providing palliation) were excluded. Our primary outcomes were self-efficacy, knowledge and end-of-life communication scores with standardized patient encounters. Sufficiently similar studies were pooled in a meta-analysis. The quality of evidence was assessed using GRADE. RESULTS Of 5727 candidate articles, 20 studies (6 RCTs, 14 Observational) were included in this review. Compared to usual teaching, educational interventions to train healthcare professionals in end-of-life communication skills were associated with greater self-efficacy (8 studies, standardized mean difference [SMD] 0.57;95% confidence interval [CI] 0.40-0.75; P < 0.001; very low quality evidence), more knowledge (4 studies, SMD 0.76;95% CI 0.40-1.12; p < 0.001; low quality evidence), and improvements in communication scores (8 studies, SMD 0.69; 95% CI 0.41-0.96; p < 0.001; very low quality evidence). There was insufficient evidence to determine whether these educational interventions affect patient-level outcomes. CONCLUSION Very low to low quality evidence suggests that end-of-life communication training may improve healthcare professionals' self-efficacy, knowledge, and EoL communication scores compared to usual teaching. Further studies comparing two active educational interventions are recommended with a continued focus on contextually relevant high-level outcomes. TRIAL REGISTRATION PROSPERO CRD42014012913.
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Affiliation(s)
- Han-Oh Chung
- , 1280 Main Street West, HSC-2C8, Hamilton, Ontario, L8S 4K1, Canada.
| | - Simon J W Oczkowski
- Hamilton General Hospital, McMaster Clinic 4th floor, Room 434, 237 Barton St East, Hamilton, Ontario, L8L2X2, Canada
| | - Louise Hanvey
- Canadian Hospice Palliative Care Association, Annex D, Saint-Vincent Hospital, 60 Cambridge Street North, Ottawa, ON, K1R 7A5, Canada
| | - Lawrence Mbuagbaw
- , 1280 Main Street West, HSC-2C8, Hamilton, Ontario, L8S 4K1, Canada
- St Joseph's Healthcare, 50 Charlton Avenue East, 3rd Floor Martha Wing, Room H321, Hamilton, Ontario, L8N4A6, Canada
| | - John J You
- , 1280 Main Street West, HSC-2C8, Hamilton, Ontario, L8S 4K1, Canada
- St Joseph's Healthcare, 50 Charlton Avenue East, 3rd Floor Martha Wing, Room H321, Hamilton, Ontario, L8N4A6, Canada
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Abstract
Over the past five decades, palliative care has evolved from serving patients at the end of life into a highly specialized discipline focused on delivering supportive care to patients with life-limiting illnesses throughout the disease trajectory. A growing body of evidence is now available to inform the key domains in the practice of palliative care, including symptom management, psychosocial care, communication, decision-making, and end-of-life care. Findings from multiple studies indicate that integrating palliative care early in the disease trajectory can result in improvements in quality of life, symptom control, patient and caregiver satisfaction, illness understanding, quality of end-of-life care, survival, and costs of care. In this narrative Review, we discuss various strategies to integrate oncology and palliative care by optimizing clinical infrastructures, processes, education, and research. The goal of integration is to maximize patient access to palliative care and, ultimately, to improve patient outcomes. We provide a conceptual model for the integration of supportive and/or palliative care with primary and oncological care. We also discuss how health-care systems and institutions need to tailor integration based on their resources, size, and the level of primary palliative care available.
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Affiliation(s)
- David Hui
- Department of Palliative Care &Rehabilitation Medicine, Unit 1414, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA
| | - Eduardo Bruera
- Department of Palliative Care &Rehabilitation Medicine, Unit 1414, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas 77030, USA
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Pang GSY, Qu LM, Wong YY, Tan YY, Poulouse J, Neo PSH. A Quantitative Framework Classifying the Palliative Care Workforce into Specialist and Generalist Components. J Palliat Med 2015; 18:1063-9. [PMID: 26381855 DOI: 10.1089/jpm.2015.0017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Early referral to palliative care (PC) services has been shown to improve quality of life in advanced cancer. However, limitations in trained PC workforce raise issues with the sustainability of delivering PC with early PC referral. Classifying PC into generalist and specialist components could be one approach to sustainable PC delivery models but a quantitative guide for this classification is presently lacking in the literature. OBJECTIVE To undertake a retrospective examination of clinical data obtained from a PC benchmarking project to develop a quantitative framework guiding classification of PC services into specialist and generalist components. DESIGN A descriptive retrospective study of data from 2726 hospitalized inpatients under the care of a tertiary consultative PC service over a 2-year period was conducted. Daily categorical symptom, overall psychological and social distress scores at the start and end of 3392 palliative care episodes as well as the number of visits made by the PC team to patients were extracted for analysis. RESULTS More than 50% of patients had symptom, overall psychological or social distress scores of nil or mild severity at episode start and end. Approximately 20% of all 2726 patients accounted for approximately half of all visits made by the team regardless of the reasons for review. This patient percentage minority had more PC episodes starting with moderate or severe pain. These findings suggest a Pareto-like distribution in the occurrence of moderate/severe PC problems and the intensity of PC input. CONCLUSIONS Large-scale clinical data supports the use of a Pareto-based quantitative framework for a workforce comprising of mainly generalist PC staff supported by smaller numbers of PC specialists.
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Affiliation(s)
- Grace Su Yin Pang
- 1 Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore .,2 Department of Palliative Medicine, National Cancer Centre Singapore , Singapore
| | - Li Min Qu
- 2 Department of Palliative Medicine, National Cancer Centre Singapore , Singapore
| | - Yin Yee Wong
- 2 Department of Palliative Medicine, National Cancer Centre Singapore , Singapore
| | - Yung Ying Tan
- 2 Department of Palliative Medicine, National Cancer Centre Singapore , Singapore
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Gramling R, Gajary-Coots E, Stanek S, Dougoud N, Pyke H, Thomas M, Cimino J, Sanders M, Alexander SC, Epstein R, Fiscella K, Gramling D, Ladwig S, Anderson W, Pantilat S, Norton SA. Design of, and enrollment in, the palliative care communication research initiative: a direct-observation cohort study. BMC Palliat Care 2015; 14:40. [PMID: 26286538 PMCID: PMC4544824 DOI: 10.1186/s12904-015-0037-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 08/11/2015] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Understanding the characteristics of communication that foster patient-centered outcomes amid serious illness are essential for the science of palliative care. However, epidemiological cohort studies that directly observe clinical conversations can be challenging to conduct in the natural setting. We describe the successful enrollment, observation and data collection methods of the ongoing Palliative Care Communication Research Initiative (PCCRI). METHODS The PCCRI is a multi-site cohort study of naturally occurring inpatient palliative care consultations. The 6-month cohort data includes directly observed and audio-recorded palliative care consultations (up to first 3 visits); patient/proxy/clinician self-report questionnaires both before and the day after consultation; post-consultation in-depth interviews; and medical/administrative records. RESULTS One hundred fourteen patients or their proxies enrolled in PCCRI during Enrollment Year One (of Three). Seventy percent of eligible patients/proxies were invited to hear about a communication research study (188/269); 60% of them ultimately enrolled in the PCCRI (114/188), resulting in a 42% sampling proportion (114/269 eligible). All PC clinicians at study sites were invited to participate; all 45 participated. CONCLUSIONS Epidemiologic study of patient-family-clinician communication in palliative care settings is feasible and acceptable to patients, proxies and clinicians. We detail the successful PCCRI methods for enrollment, direct observation and data collection for this complex "field" environment.
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Affiliation(s)
- Robert Gramling
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Elizabeth Gajary-Coots
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Susan Stanek
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Nathalie Dougoud
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Heather Pyke
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
| | - Marie Thomas
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Jenica Cimino
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Mechelle Sanders
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Stewart C Alexander
- Purdue University, Matthews Hall, 812 West State Street, West Lafayette, IN, 47907-2060, USA.
| | - Ronald Epstein
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - Kevin Fiscella
- Family Medicine Research Programs, University of Rochester, 1381 South Avenue, Rochester, NY, 14620, USA.
| | - David Gramling
- University of Arizona, 301 Learning Services Building, 1512 East First St., Tucson, AZ, 85721, USA.
| | - Susan Ladwig
- Palliative Care Program, University of Rochester Medical Center, 601 Elmwood Avenue, Box 687, Rochester, NY, 14642, USA.
| | - Wendy Anderson
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Stephen Pantilat
- Division of Hospital Medicine and Palliative Care Program, University of California, Clinical Sciences Building Suite C-126, 521 Parnassus Ave, Box 0131, San Francisco, CA, 94143-0131, USA.
| | - Sally A Norton
- School of Nursing, University of Rochester, 601 Elmwood Avenue, Box SON, Rochester, NY, 14642, USA.
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Abstract
BACKGROUND Nurses play a major role all over the world in the palliative care team. AIM The aim of this study was to investigate the knowledge and attitude of nurses toward palliative care in a tertiary level hospital in Nigeria. SUBJECTS AND METHODS SETTING This cross-sectional questionnaire-based study was carried out among nurses at a tertiary health care facility in Ado-Ekiti, South-West Nigeria. A cross-sectional questionnaire-based study was carried out. The questionnaire sought information about the sociodemographic profile of respondents, their knowledge of definition and philosophy of palliative care among other things. Descriptive statistics was used to obtain the general characteristics of the study participants, while Chi-square was used to determine the association between categorical variables. A two-sided P < 0.05 was considered as significant. RESULTS A total of 100 questionnaires were returned with a female preponderance among the respondents with F: M ratio of 9:1. Regarding the definition of palliative care, 71.8% (48/66) of the respondents understood palliative care to be about pain medicine, 55% (33/60) thought it to be geriatric medicine, while 90.2% (83/92) felt palliative care is about the active care of the dying. Exactly 80.5% (66/82) respondents agreed that palliative care recognizes dying as a normal process while 84.1% (74/88) respondents were of the opinion that all dying patients would require palliative care. The use of morphine would improve the quality of life of patients according to 68.9% (42/61) of respondents. CONCLUSION There are gaps in the knowledge of healthcare workers in the area of palliative care and this call for a review of the current nursing curriculum and practice guidelines in Nigeria.
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Affiliation(s)
- Jo Fadare
- Department of Pharmacology, Ekiti State University, Ado-Ekiti, Ekiti State, Nigeria
| | - Am Obimakinde
- Department of Family Medicine, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria
| | - Do Olaogun
- Department of Obstetrics and Gynecology, Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State, Nigeria
| | - Jm Afolayan
- Department of Anesthesia, Ekiti State University, Ado-Ekiti, Ekiti State, Nigeria
| | - O Olatunya
- Department of Pediatrics, Ekiti State University, Ado-Ekiti, Ekiti State, Nigeria
| | - Ko Ogundipe
- Department of Surgery, Ekiti State University, Ado-Ekiti, Ekiti State, Nigeria
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Bakitas MA, Tosteson TD, Li Z, Lyons KD, Hull JG, Li Z, Dionne-Odom JN, Frost J, Dragnev KH, Hegel MT, Azuero A, Ahles TA. Early Versus Delayed Initiation of Concurrent Palliative Oncology Care: Patient Outcomes in the ENABLE III Randomized Controlled Trial. J Clin Oncol 2015; 33:1438-45. [PMID: 25800768 PMCID: PMC4404422 DOI: 10.1200/jco.2014.58.6362] [Citation(s) in RCA: 752] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Randomized controlled trials have supported integrated oncology and palliative care (PC); however, optimal timing has not been evaluated. We investigated the effect of early versus delayed PC on quality of life (QOL), symptom impact, mood, 1-year survival, and resource use. PATIENTS AND METHODS Between October 2010 and March 2013, 207 patients with advanced cancer at a National Cancer Institute cancer center, a Veterans Affairs Medical Center, and community outreach clinics were randomly assigned to receive an in-person PC consultation, structured PC telehealth nurse coaching sessions (once per week for six sessions), and monthly follow-up either early after enrollment or 3 months later. Outcomes were QOL, symptom impact, mood, 1-year survival, and resource use (hospital/intensive care unit days, emergency room visits, chemotherapy in last 14 days, and death location). RESULTS Overall patient-reported outcomes were not statistically significant after enrollment (QOL, P = .34; symptom impact, P = .09; mood, P = .33) or before death (QOL, P = .73; symptom impact, P = .30; mood, P = .82). Kaplan-Meier 1-year survival rates were 63% in the early group and 48% in the delayed group (difference, 15%; P = .038). Relative rates of early to delayed decedents' resource use were similar for hospital days (0.73; 95% CI, 0.41 to 1.27; P = .26), intensive care unit days (0.68; 95% CI, 0.23 to 2.02; P = .49), emergency room visits (0.73; 95% CI, 0.45 to 1.19; P = .21), chemotherapy in last 14 days (1.57; 95% CI, 0.37 to 6.7; P = .27), and home death (27 [54%] v 28 [47%]; P = .60). CONCLUSION Early-entry participants' patient-reported outcomes and resource use were not statistically different; however, their survival 1-year after enrollment was improved compared with those who began 3 months later. Understanding the complex mechanisms whereby PC may improve survival remains an important research priority.
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Affiliation(s)
- Marie A Bakitas
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY.
| | - Tor D Tosteson
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Zhigang Li
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Kathleen D Lyons
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jay G Hull
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Zhongze Li
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - J Nicholas Dionne-Odom
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Jennifer Frost
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Konstantin H Dragnev
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Mark T Hegel
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Andres Azuero
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Tim A Ahles
- Marie A. Bakitas, J. Nicholas Dionne-Odom, and Andres Azuero, University of Alabama at Birmingham, Birmingham, AL; Marie A. Bakitas, Jennifer Frost, and Konstantin H. Dragnev, Dartmouth-Hitchcock Medical Center; Zhongze Li, Norris Cotton Cancer Center, Lebanon; Tor D. Tosteson, Kathleen D. Lyons, and Mark T. Hegel, Geisel School of Medicine at Dartmouth; Zhigang Li and Jay G. Hull, Dartmouth College, Hanover, NH; and Tim A. Ahles, Memorial Sloan-Kettering Cancer Center, New York, NY
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Ko W, Deliens L, Miccinesi G, Giusti F, Moreels S, Donker GA, Onwuteaka-Philipsen B, Zurriaga O, López-Maside A, Van den Block L. Care provided and care setting transitions in the last three months of life of cancer patients: a nationwide monitoring study in four European countries. BMC Cancer 2014; 14:960. [PMID: 25510507 PMCID: PMC4301937 DOI: 10.1186/1471-2407-14-960] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 12/11/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND This is an international study across four European countries (Belgium[BE], the Netherlands[NL], Italy[IT] and Spain[ES]) between 2009 and 2011, describing and comparing care and care setting transitions provided in the last three months of life of cancer patients, using representative GP networks. METHODS General practitioners (GPs) of representative networks in each country reported weekly all non-sudden cancer deaths (+18y) within their practice. GPs reported medical end-of-life care, communication and circumstances of dying on a standardised questionnaire. Multivariate logistic regressions (BE as a reference category) were conducted to compare countries. RESULTS Of 2,037 identified patients from four countries, four out of five lived at home or with family in their last year of life. Over 50% of patients had at least one transition in care settings in the last three months of life; one third of patients in BE, IT and ES had a last week hospital admission and died there. In the last week of life, a treatment goal was adopted for 80-95% of those having palliation/comfort as their treatment goal. Cross-country differences in end-of-life care provision included GPs in NL being more involved in palliative care (67%) than in other countries (35%-49%) (OR 1.9) and end-of-life topics less often discussed in IT or ES. Preference for place of death was less often expressed in IT and ES (32-34%) than in BE and NL (49-74%). Of all patients, 88-98% were estimated to have distress from at least one physical symptom in the final week of life. CONCLUSION Although palliative care was the main treatment goal for most cancer patients at the end of life in all four countries, frequent late hospital admissions and the symptom burden experienced in the last week of life indicates that further integration of palliative care into oncology care is required in many countries.
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Affiliation(s)
- Winne Ko
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
| | - Luc Deliens
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
- />Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium
| | - Guido Miccinesi
- />Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, Florence, Italy
| | - Francesco Giusti
- />Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, Florence, Italy
| | - Sarah Moreels
- />Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium
| | - Gé A Donker
- />NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Bregje Onwuteaka-Philipsen
- />EMGO Institute for Health and Care Research, Department of Public and Occupational Health, and Palliative Care Expertise Centre, VU University Medical Centre, Amsterdam, the Netherlands
| | - Oscar Zurriaga
- />Health Department, Public Health Directorate General, Valencia, Spain
- />Spanish Consortium for Research in Epidemiology and Public Health, CIBERESP, Barcelona, Spain
| | | | - Lieve Van den Block
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
- />Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - on behalf of EURO IMPACT
- />End-of-Life Care Research Group, Vrije Universiteit Brussel (VUB), Brussels and Ghent University, Ghent, Belgium
- />Department of Medical Oncology, University Hospital Ghent, Ghent, Belgium
- />EMGO Institute for Health and Care Research, Department of Public and Occupational Health, and Palliative Care Expertise Centre, VU University Medical Centre, Amsterdam, the Netherlands
- />Clinical and Descriptive Epidemiology Unit, Cancer Prevention and Research Institute, ISPO, Florence, Italy
- />Public Health and Surveillance, Scientific Institute of Public Health, Brussels, Belgium
- />NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
- />Health Department, Public Health Directorate General, Valencia, Spain
- />Spanish Consortium for Research in Epidemiology and Public Health, CIBERESP, Barcelona, Spain
- />Department of Family Medicine and Chronic Care, Vrije Universiteit Brussel (VUB), Brussels, Belgium
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48
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Rabow MW, O'Riordan DL, Pantilat SZ. A Statewide Survey of Adult and Pediatric Outpatient Palliative Care Services. J Palliat Med 2014; 17:1311-6. [DOI: 10.1089/jpm.2014.0144] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Michael W. Rabow
- Division of General Internal Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
- Palliative Care Program, University of California, San Francisco, San Francisco, California
| | - David L. O'Riordan
- Palliative Care Program, University of California, San Francisco, San Francisco, California
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
| | - Steven Z. Pantilat
- Palliative Care Program, University of California, San Francisco, San Francisco, California
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California
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49
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Hannon B, Swami N, Pope A, Rodin G, Dougherty E, Mak E, Banerjee S, Bryson J, Ridley J, Zimmermann C. The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer. Support Care Cancer 2014; 23:1073-80. [DOI: 10.1007/s00520-014-2460-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 09/22/2014] [Indexed: 12/25/2022]
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50
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Abstract
Creating a team of nurse practitioner/physician assistant providers with a supervising physician is one potential model to extend limited physician resources for those medical specialties such as neurology, whose outpatient access is suboptimal. We offered new patient appointments with the access team. Monthly lead time (time to third available appointment) revealed that overall new-patient access improved from an average time-to-appointment wait of 299 days down to 10 days. Patients completed an anonymous satisfaction survey about providers before and after the launch of the new access team; the results demonstrated preserved patient satisfaction with providers in this new team-based model.
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Affiliation(s)
- Stephen C Ross
- Department of Neurology, Penn State University College of Medicine, Hershey, PA
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