Populations and Interventions for Palliative and End-of-Life Care: A Systematic Review

Increasing goals of care conversations in primary care: Study protocol for a cluster randomized, pragmatic, sequential multiple assignment randomized trial

BACKGROUND

Goals of care conversations explore seriously ill patients' values to guide medical decision making and often inform decisions about life sustaining treatments. Ideally, conversations occur before a health crisis between patients and clinicians in the outpatient setting. In the United States Veterans Affairs (VA) healthcare system, most conversations still occur in the inpatient setting. Strategies are needed to improve implementation of outpatient, primary care goals of care conversations.

METHODS

We plan a cluster randomized (clinician-level) sequential, multiple assignment randomized trial to evaluate the effectiveness of patient implementation strategies on the outcome of goals of care conversation documentation when delivered in combination with clinician implementation strategies. Across three VA healthcare system sites, we will enroll primary care clinicians with low rates of goals of care conversations and their patients with serious medical illness in the top 10th percentile of risk of hospitalization or death. We will compare the effectiveness of sequences of implementation strategies and explore how patient and site factors modify implementation strategy effects. Finally, we will conduct a mixed-methods evaluation to understand implementation strategy success or failure. The design includes two key innovations: (1) strategies that target both clinicians and patients and (2) sequential strategies with increased intensity for non-responders.

CONCLUSION

This study aims to determine the effect of different sequences and combinations of implementation strategies on primary care documentation of goals of care conversations. Study partners, including the VA National Center for Ethics in Health Care and Office of Primary Care, can consider policies based on study findings.

Effectiveness and Feasibility of Home-Based Palliative Care Interventions for Geriatric Oncology Patients: A Systematic Review Using Narrative Synthesis

BACKGROUND

Due to an urgent need to develop palliative care services for geriatric patients with advanced cancer, an overview of available information regarding home-based palliative care interventions would be valuable.

AIM

To summarize current literature for interventions targeted to homebound, older patients with incurable cancer, and investigate whether these patients can be benefited from home-based palliative care and achieve improved outcomes.

DESIGN

A search strategy consisting of terms related to home care, palliation, oncology, and geriatrics was employed. A protocol following PRISMA guidelines was prospectively uploaded at PROSPERO (ID = CRD42023404675).

DATA SOURCES

Pubmed (MEDLINE), Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and Epistemonikos.org databases were searched from inception until the present day. Eligibility criteria were selected based on the research question, the population of interest, and the research design. The Risk of Bias Assessment Tool version 2 (RoB-2) was used to appraise study quality.

RESULTS

A total of 10 articles including 871 patients (out of 1236 titles and 141 fully-reviewed texts) were selected. Four studies assessed exercise interventions, two evaluated multi-component home-care models, two focused on supervision services, and two had nutrition and activity components. Eight studies reported improved outcomes in either specified or mixed cancer geriatric populations.

CONCLUSIONS

There is a scarcity of clinical trials regarding home-based palliative care for geriatric oncology patients, resulting in poor information and a lack of evidence. At-home interventions seem feasible and have a positive effect on pain management and functional status, but more high-quality studies are required.

Association of Disease Trajectory and Place of Care with End-of-Life Burdensome Transitions: A Retrospective Cohort Study

OBJECTIVES

End-of-life (EOL) transitions to hospital can be burdensome for older adults and may contribute to poor outcomes. We investigated the association of disease trajectory and place of care with EOL burdensome transitions.

DESIGN

Retrospective cohort study using administrative data.

SETTING/PARTICIPANTS

Ontarians aged ≥65 years who died between 2015 and 2018 and received long-term care (LTC) or home care 6 months before death.

METHODS

Disease trajectories were defined based on EOL functional decline: terminal illness, organ failure, frailty, sudden death, and other. Places of care included LTC, EOL home care, and non-EOL home care. Burdensome transitions were defined as early (≥3 hospitalizations for any reason or ≥2 hospitalizations due to pneumonia, urinary tract infection, sepsis, or dehydration in the last 90 days of life) or late (≥1 hospitalizations for any reason in the last 3 days of life). Multinomial logistic regression tested for effect modification between disease trajectory and places of care on burdensome transitions.

RESULTS

Of 110,776 decedents, 40.7% had organ failure, 37.5% had frailty, and 12.8% had a terminal illness, with the remainder in sudden death or other categories. Most were in LTC (62.5%), and 37.5% received home care, with 6.8% receiving designated EOL home care and 30.7% non-EOL home care. There was a significant interaction (P < .001) between disease trajectory and care settings. Compared with terminal illness, organ failure was associated with increased odds of early transitions across all care settings [odds ratios (ORs) ranging 1.14-1.21]. Frailty was associated with increased odds of early transitions solely for non-EOL home care recipients (OR 1.17, 95% CI 1.06-1.28). Organ failure and frailty were associated with increased odds of late transitions across all settings, with organ failure having greater odds in LTC (organ failure OR 2.29, 95% CI 2.02-2.60, vs frailty OR 1.79, 95% CI 1.58-2.04).

CONCLUSIONS AND IMPLICATIONS

Disparities exist in burdensome transitions, notably for noncancer decedents with organ failure in LTC. Enhancing palliative care may help reduce burdensome transitions and improve patient outcomes.

Veterans' use of inpatient and outpatient palliative care: The national landscape

BACKGROUND

Palliative care improves the quality of life for people with life-limiting conditions, which are common among older adults. Despite the Veterans Health Administration (VA) outpatient palliative care expansion, most research has focused on inpatient palliative care. This study aimed to compare veteran characteristics and hospice use for palliative care users across care settings (inpatient vs. outpatient) and dose (number of palliative care encounters).

METHODS

This national cohort included veterans with any VA palliative care encounters from 2014 through 2017. We used VA and Medicare administrative data (2010-2017) to describe veteran demographics, socioeconomic status, life-limiting conditions, frailty, and palliative care utilization. Specialty palliative care encounters were identified using clinic stop codes (353, 351) and current procedural terminology codes (99241-99245).

RESULTS

Of 120,249 unique veterans with specialty palliative care over 4 years, 67.8% had palliative care only in the inpatient setting (n = 81,523) and 32.2% had at least one palliative care encounter in the outpatient setting (n = 38,726), with or without an inpatient palliative care encounter. Outpatient versus inpatient palliative care users were more likely to have cancer and less likely to have high frailty, but sociodemographic factors including rurality and housing instability were similar. Duration of hospice use was similar between inpatient (median = 37 days; IQR = 11, 112) and outpatient (median = 44 days; IQR = 14, 118) palliative care users, and shorter among those with only one palliative care encounter (median = 18 days; IQR = 5, 64).

CONCLUSIONS

This national evaluation provides novel insights into the care setting and dose of VA specialty palliative care for veterans. Among veterans with palliative care use, one-third received at least some palliative care in the outpatient care setting. Differences between veterans with inpatient and outpatient use motivate the need for further research to understand how care settings and number of palliative care encounters impact outcomes for veterans and older adults.

Nurse-Led Advance Care Planning in Adults in the U.S.- A Scoping Review

BACKGROUND

Advance care planning involves discussing individuals' future medical treatment and care preferences. Nurses, due to their close relationships with patients and families, may be well-positioned to lead these discussions. Exploring the components and characteristics of nurse-led ACP interventions is essential for enhancing their implementation, effectiveness, and sustainability.

OBJECTIVE

This scoping review aimed to explore the characteristics of nurse-led ACP interventions in adult patients, identify the populations and settings where these interventions have been utilized, and the outcomes of these interventions in the U.S.

METHODS

A scoping review was conducted following Arksey and O'Malley's five-stage framework. Using keywords related to nurse-led ACP interventions, a comprehensive search was performed across PubMed, Web of Science, CINAHL, EMBASE, and PsycINFO databases.

RESULTS

Twelve studies met the inclusion criteria. These studies were conducted in varied settings. Registered nurses, oncology nurse navigators, and other specialized nurses primarily delivered nurse-led ACP interventions. The interventions ranged from one to two sessions and utilized various models and resources such as the Five Wishes and Respecting Choices.

CONCLUSIONS

Nurse-led ACP interventions have shown significant positive outcomes, including increased engagement in ACP, improved attitudes towards ADs, higher completion rates of ADs, and enhanced patient-surrogate congruence. These interventions are well-received by patients and can be implemented in diverse settings. However, a general guideline regarding nurse-led ACP interventions is needed to address the specific duration, sessions, and mode of delivery required for their optimal effectiveness.

A palliative care approach for adult non-cancer patients with life-limiting illnesses is cost-saving or cost-neutral: a systematic review of RCTs

BACKGROUND

Patients living with life-limiting illnesses other than cancer constitute the majority of patients in need of palliative care globally, yet most previous systematic reviews of the cost impact of palliative care have not exclusively focused on this population. Reviews that tangentially looked at non-cancer patients found inconclusive evidence. Randomised controlled trials (RCTs) are the gold standard for treatment efficacy, while total health care costs offer a comprehensive measure of resource use. In the sole review of RCTs for non-cancer patients, palliative care reduced hospitalisations and emergency department visits but its effect on total health care costs was not assessed. The aim of this study is to review RCTs to determine the difference in costs between a palliative care approach and usual care in adult non-cancer patients with a life-limiting illness.

METHODS

A systematic review using a narrative synthesis approach. The protocol was registered with PROSPERO prospectively (no. CRD42020191082). Eight databases were searched: Medline, CINAHL, EconLit, EMBASE, TRIP database, NHS Evidence, Cochrane Library, and Web of Science from inception to January 2023. Inclusion criteria were: English or German; randomised controlled trials (RCTs); adult non-cancer patients (> 18 years); palliative care provision; a comparator group of standard or usual care. Quality of studies was assessed using Drummond's checklist for assessing economic evaluations.

RESULTS

Seven RCTs were included and examined the following diseases: neurological (3), heart failure (2), AIDS (1) and mixed (1). The majority (6/7) were home-based interventions. All studies were either cost-saving (3/7) or cost-neutral (4/7); and four had improved outcomes for patients or carers and three no change in outcomes.

CONCLUSIONS

In a non-cancer population, this is the first systematic review of RCTs that has demonstrated a palliative care approach is cost-saving or at least cost-neutral. Cost savings are achieved without worsening outcomes for patients and carers. These findings lend support to calls to increase palliative care provision globally.

Tele-Assisted Home-Based Palliative Care Reduces Health Care Costs for Terminal Cancer Patients: Real-World Evidence From a Regional Hospital in Taiwan

Background: Tele-assisted home-based palliative care (THPC) usually fulfills the desire of terminal patients to pass away at home. The overall costs of such a service deserve evaluation. Objectives: This study aims to determine health care utilization and costs for cancer patients at the end of life, stratified by THPC service. Design: Patients who received THPC were matched 1:1 based on age, gender, year of death, and propensity score with those who did not receive THPC. Setting/Subjects: A total of 773 cancer patients passed away in a regional hospital in Taiwan during the period of 2012-2020, of which 293 received THPC. Measurements: We measured the rates and costs of outpatient clinic visits, emergency department (ED) visits, hospitalizations, and intensive care unit (ICU) admissions during the last week, the last two weeks and the last month before death. In addition, we estimated the driving times and expenses required for transportation from each cancer patient's home to the hospital using Google Maps. National Health Insurance (NHI) reimbursements and out-of-pocket expenses were also calculated. Results: In comparison with patients without THPC, those who received THPC had a 50% lower likelihood of visiting the ED or being hospitalized, a more than 90% reduced chance of ICU admission, but were four times more likely to obtain their medicines from outpatient clinics. THPC patients had similar out-of-pocket expenditures, approximately half of the NHI costs, and lower rates and costs for ambulance transportation to the ED. Conclusions: THPC reduced health care costs for terminal cancer patients in the last week, the last two weeks, and the last month before death, while also increasing the likelihood of patients being able to rest and pass away at home.

Limitations With California Medicaid Data for Palliative and End of Life Care Quality Measures

In 2014 the California legislature passed Senate Bill 1004 (SB 1004) that was designed to expand access to specialty palliative care for individuals served by California's Medicaid (known as Medi-Cal) Managed Care Plans (MCPs). The California Department of Health Care Services (DHCS) operationalized the legislation by developing minimum requirements for palliative care programs that all MCPs must meet or exceed.7 Quality and utilization data specific to California's Medicaid population are needed for stakeholders to identify care deficiencies and disparities, describe the end of life experience and utilization patterns of MCP members, compare these patterns to Medicare beneficiaries or other populations, and set appropriate targets to help monitor progress. We evaluated the feasibility of using Medicaid claims data and encounter data either by partnering with MCPs or by obtaining statewide data from DHCS to measure the quality of palliative care and end of life care. In a concurrent but separate effort, we analyzed administrative data supplied by three MCPs as part of a prospective pilot of standards for home-based palliative care in California, including care delivered to Medicaid beneficiaries under SB 1004. Beyond the practical challenges of allowing time for data access and approvals, both projects revealed several limitations to using administrative data to assess quality of palliative and end of life care for a Medicaid population. We describe these challenges that undermined our confidence in analysis results and propose solutions to measuring the quality of palliative and end of life care for Medicaid patients and suggested next steps.

"Unless someone sees and hears you, how do you know you exist?" Meanings of confidential conversations - a hermeneutic study of the experiences of patients with palliative care needs

BACKGROUND

Patients with palliative care needs live with the reality of limited time due to illness or age, eliciting emotional and existential responses. A failure to address their existential needs can lead to significant suffering. A person-centred approach is paramount to effectively address these needs, emphasising holistic care and effective communication. Although existing communication models focus on predefined frameworks, a need exists to explore more spontaneous and confidential conversations between patients and nurses. Confidential conversations have the potential to build therapeutic relationships and provide vital emotional support, highlighting the need for further research and integration into palliative care practice. This study aims to more deeply understand the meaning of confidential conversations for patients with palliative care needs.

METHODS

In-depth interviews were conducted with 10 patients in the context of specialised palliative care. A hermeneutic analysis was used to gain a deeper understanding of the meanings of the conversations.

RESULTS

The patients had varying experiences and wishes concerning confidential conversations. They strived for self-determination in finding confidants, seeking trust and comfort in their interactions with nurses. Trust was crucial for creating a safe space where patients could express themselves authentically. In shared belonging, confidential conversations with a nurse provided validation and relief from life's challenges. Experiences of feeling unheard or rejected by a nurse could intensify loneliness, prompting individuals to withdraw and remain silent. Regardless of the motives behind their choices, it was crucial that patients felt respect and validation in their decisions. Their autonomy could thus be recognised, and they felt empowered to make decisions based on their unique preferences.

CONCLUSIONS

Patients value trust and understanding, particularly in confidential conversations with nurses, which offer solace, validation and empowerment. However, indifference can increase patients' suffering, fostering self-doubt and reluctance to engage further. To address this, health care can prioritise empathic communication skills, offer ongoing support to nurses, and promote continuity in care through investment in training and resources. Additionally, adopting a person-centred approach in confidential conversations is crucial, considering patients' varying preferences.

Evaluating palliative care case conferences in primary care for patients with advanced non-malignant chronic conditions: a cluster-randomised controlled trial (KOPAL)

BACKGROUND

Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs.

OBJECTIVE

To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC.

METHODS

A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse-patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale.

RESULTS

A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = -0.02, 95%CI: [-0.09, 0.05], P = 0.53) or self-rated health (∆ = -2.48, 95%CI: [-9.95, 4.99], P = 0.51).

CONCLUSIONS

The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.

The impact of outpatient supportive oncology on cancer care cost and utilization

BACKGROUND

Supportive oncology (SO) care reduces symptom severity, admissions, and costs in patients with advanced cancer. This study examines the impact of SO care on utilization and costs.

METHODS

Retrospective analysis of utilization and costs comparing patients enrolled in SO versus three comparison cohorts who did not receive SO. Using claims, the authors estimated differences in health care utilization and cost between the treatment group and comparison cohorts. The treatment group consisting of patients treated for cancer at an National Cancer Institute-designated cancer center who received SO between January 2018 and December 2019 were compared to an asynchronous cohort that received cancer care before January 2018 (n = 60), a contemporaneous cohort with palliative care receiving SO care from other providers in the Southeastern Pennsylvania region during the program period (n = 86), and a contemporaneous cohort without palliative care consisting of patients at other cancer centers who were eligible for but did not receive SO care (n = 393).

RESULTS

At 30, 60, and 90 days post-enrollment into SO, the treatment group had between 27% and 70% fewer inpatient admissions and between 16% and 54% fewer emergency department visits (p < .05) compared to non-SO cohorts. At 90 days following enrollment in SO care, total medical costs were between 4.4% and 24.5% lower for the treatment group across all comparisons (p < .05).

CONCLUSIONS

SO is associated with reduced admissions, emergency department visits, and total costs in advanced cancer patients. Developing innovative reimbursement models could be a cost-effective approach to improve care of patients with advanced cancer.

Inclusion of Social Work in Comprehensive Palliative Care to Address Psychosocial Needs of Advanced Cancer Patients in Vietnam

The need for psychosocial care among patients with serious illnesses and available social work services continues to be great, especially in low- and middle-income countries. To evaluate the specific needs of Vietnamese cancer patients' quality of life (QOL), prevalence and severity of symptoms including depression and anxiety, and caregiver burden were assessed. Data on QOL, mood, caregiver burden, and other parameters were collected through face-to-face and phone- interviews. The QOL assessed by European Quality of Life scale version 5D (EQ5D) was poor but consistent with other studies of cancer patients. Assessed by the Hospital Anxiety and depression Scale (HADS), borderline or severe anxiety and depression were prevalent. Caregiver burden was high for one third of study participants. These results confirm the need among cancer patients for psycho-social support services that currently are rarely available in Vietnam. In light of this need, a comprehensive palliative care (CPC) service, including social work, was created to improve the quality of life (QOL) of Vietnamese cancer patients.

Are Surprise Questions and Probabilistic Questions by Nurses Useful in Home Palliative Care? A Prospective Study

Background: Surprise questions (SQs) are used as screening tools in palliative care. Probabilistic questions (PQs) are more accurate than temporal predictions. However, no study has examined the usefulness of SQs and PQs assessed by nurses. Objectives: To examine the accuracy of nurses' SQ and PQ assessments in patients with advanced cancer receiving home palliative care. Design: A prospective single-center cohort study. Setting/Subjects: Adult patients with advanced cancer who received palliative care at home in South Korea between 2019 and 2020. Measurements: Palliative care specialized nurses were asked the SQ, "Would you be surprised if the patient died in a specific timeframe?" and PQ, "What is the probability that this patient will be alive (0 to 100%) within a specific timeframe?" at the 1-, 2-, 4-, and 6-week timeframes at enrollment. We calculated the sensitivities and specificities of the SQs and PQs. Results: 81 patients were recruited with 47 days of median survival. The sensitivity, specificity, and overall accuracy (OA) of the 1-week SQ were 50.0, 93.2, and 88.9%, respectively. The accuracies for the 1-week PQ were 12.5, 100.0, and 91.3%, respectively. The 6-week SQ showed sensitivity, specificity, and OA of 84.6, 42.9, and 62.9%, respectively; the accuracies for the 6-week PQ were 59.0, 66.7, and 63.0%, respectively.Conclusion: The SQ and PQ showed acceptable accuracy in home palliative care patients. Interestingly, PQ showed higher specificity than SQ at all timeframes. The SQ and PQ assessed by nurses may be useful in providing additional prognostic information for home palliative care.

Strategies to Improve Perioperative Palliative Care Integration for Seriously Ill Veterans

CONTEXT

Seriously ill patients are at higher risk for adverse surgical outcomes. Palliative care (PC) interventions for seriously ill surgical patients are associated with improved quality of patient care and patient-centered outcomes, yet, they are underutilized perioperatively.

OBJECTIVES

To identify strategies for improving perioperative PC integration for seriously ill Veterans from the perspectives of PC providers and surgeons.

METHODS

We conducted semistructured, in-depth individual and group interviews with Veteran Health Administration PC team members and surgeons between July 2020 and April 2021. Participants were purposively sampled from high- and low-collaboration sites based on the proportion of received perioperative palliative consults. We performed a team-based thematic analysis with dual coding (inter-rater reliability above 0.8).

RESULTS

Interviews with 20 interdisciplinary PC providers and 13 surgeons at geographically distributed Veteran Affairs sites converged on four strategies for improving palliative care integration and goals of care conversations in the perioperative period: 1) develop and maintain collaborative, trusting relationships between palliative care providers and surgeons; 2) establish risk assessment processes to identify patients who may benefit from a PC consult; 3) involve both PC providers and surgeons at the appropriate time in the perioperative workflow; 4) provide sufficient resources to allow for an interdisciplinary sharing of care.

CONCLUSION

The study demonstrates that individual, programmatic, and organizational efforts could facilitate interservice collaboration between PC clinicians and surgeons.

Nurse practitioner and physician end-of-life home visits and end-of-life outcomes

OBJECTIVES

Physicians and nurse practitioners (NPs) play critical roles in supporting palliative and end-of-life care in the community. We examined healthcare outcomes among patients who received home visits from physicians and NPs in the 90 days before death.

METHODS

We conducted a retrospective cohort study using linked data of adult home care users in Ontario, Canada, who died between 1 January 2018 and 31 December 2019. Healthcare outcomes included medications for pain and symptom management, emergency department (ED) visits, hospitalisations and a community-based death. We compared the characteristics of and outcomes in decedents who received a home visit from an NP, physician and both to those who did not receive a home visit.

RESULTS

Half (56.9%) of adult decedents in Ontario did not receive a home visit from a provider in the last 90 days of life; 34.5% received at least one visit from a physician, 3.8% from an NP and 4.9% from both. Compared with those without any visits, having at least one home visit reduced the odds of hospitalisation and ED visits, and increased the odds of receiving medications for pain and symptom management and achieving a community-based death. Observed effects were larger in patients who received at least one visit from both.

CONCLUSIONS

Beyond home care, receiving home visits from primary care providers near the end of life may be associated with better outcomes that are aligned with patients' preferences-emphasising the importance of NPs and physicians' role in supporting people near the end of life.

Palliative care: economic challenges for researchers

The economic challenges for researchers in palliative care is an emerging and challenging topic. Knowing where, how and how much is spent is fundamental for palliative care (PC) provision to be increasingly efficient and with lower costs. To accomplish this, there are three important factors to consider: early access to PC; specialised PC using standardised procedures and informal and home-based PC. Beyond costs, ethical aspects should always be present when this care is being provided in its different forms, locations and contexts. For those who want to study the economic challenges in PC, they need to comprehend the complexity of them, since they will always come from a careful articulation between ethics, the person´s needs, the cost of the care and who these costs are charged to.

Systematic Review of Models of Effective Community Specialist Palliative Care Services for Evidence of Improved Patient-Related Outcomes, Equity, Integration, and Health Service Utilization

Background: The benefits of palliative care programs are well documented. However, the effectiveness of specialist palliative care services is not well established. The previous lack of consensus on criteria for defining and characterizing models of care has restrained direct comparison between these models and limited the evidence base to inform policy makers. A rapid review for studies published up to 2012 was unable to find an effective model. Aim: To identify effective models of community specialist palliative care services. Design: A mixed-method synthesis design reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Prospero: CRD42020151840. Data sources: Medline, PubMed, EMBASE, CINAHL and the Cochrane Database of Systematic Reviews were searched in September 2019 for primary research and review articles from 2012 to 2019. Supplementary search was conducted on Google in 2020 for policy documents to identify additional relevant studies. Results: The search yielded 2255 articles; 36 articles satisfied the eligibility criteria and 6 additional articles were identified from other sources. Eight systematic reviews and 34 primary studies were identified: observational studies (n = 24), randomized controlled trials (n = 5), and qualitative studies (n = 5). Community specialist palliative care was found to improve symptom burden/quality of life and to reduce secondary service utilization across cancer and noncancer diagnoses. Much of this evidence relates to face-to-face care in home-based settings with both round-the-clock and episodic care. There were few studies addressing pediatric populations or minority groups. Findings from qualitative studies revealed that care coordination, provision of practical help, after-hours support, and medical crisis management were some of the factors contributing to patients' and caregivers' positive experience. Conclusion: Strong evidence exists for community specialist palliative care to improve quality of life and reducing secondary service utilization. Future research should focus on equity outcomes and the interface between generalist and specialist care.

Tools for guiding interventions to address patient-perceived multidimensional unmet healthcare needs in palliative care: systematic literature review

CONTEXT

The unmet needs of patients with advanced disease are indicative of the patient centredness of healthcare. By tracking unmet needs in clinical practice, palliative interventions are aligned with patient priorities, and clinicians receive support in intervention delivery decisions for patients with overlapping, complex needs.

OBJECTIVE

Identify tools used in everyday clinical practice for the purpose of identifying and addressing unmet healthcare needs for patients with advanced disease.

METHODS

We conducted PubMed and Cumulative Index of Nursing and Allied Health Literature searches to include studies published between 1 January 2008 and 21 April 2020. Three concepts were used in constructing a search statement: (1) patient need, (2) validated instrument and (3) clinical practice. 2313 citations were reviewed according to predefined eligibility, exclusion and inclusion criteria. Data were collected from 17 tools in order to understand how instruments assess unmet need, who is involved in tool completion, the psychometric validation conducted, the tool's relationship to delivering defined palliative interventions, and the number of palliative care domains covered.

RESULTS

The majority of the 17 tools assessed unmet healthcare needs and had been validated. However, most did not link directly to clinical intervention, nor did they facilitate interaction between clinicians and patients to ensure a patient-reported view of unmet needs. Half of the tools reviewed covered ≤3 dimensions of palliative care. Of the 17 tools evaluated, 4 were compared in depth, but all were determined to be insufficient for the specific clinical applications sought in this research.

CONCLUSION

A new, validated tool is needed to track unmet healthcare needs and guide interventions for patients with advanced disease.

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

Nursing interventions in palliative care in the intensive care unit: A systematic review

CONTEXT

Patients in palliative care are found in different places where care is provided, including the intensive care environment with important role of the nursing staff.

OBJECTIVE

The aim of this systematic review was to answer the following question: which nursing interventions are aimed to the palliative care patients who are in the intensive care unit (ICU).

DATA SOURCES

US National Library of Medicine (PUBMED), Virtual Health Library (BVS), SciELO, The Cochrane Library (Cochrane) and Lilacs databases were used.

DATA EXTRACTION

After applying inclusion and exclusion criteria in accordance with the PRISMA method, a total of 36 entries published between 2010 and 2020 were used.

DATA ANALYSIS

The records extracted were analyzed from a qualitative approach, so no statistical analysis was carried out.

RESULTS

The findings demonstrated that the interventions that focus on promoting the patient's autonomy and respect their needs on ICU involves effective communication, promoting shared decision with patient and family, individualize care for each patient including the family on the daily care and decisions, maintaining basic nursing care as hygiene and comfort and encouraging self-care, as well as the involvement of nursing palliative care specialists the care is important. Other interventions included promoting a continuing education program for the nursing staff and other professionals involved in caring for patients in palliative care at ICU.

CONCLUSION

This review highlighted the need for specific nursing interventions aimed at palliative care patients at ICU to promote patient autonomy and the focus on patient needs, always sharing decisions with the patient and family. However, it showed that there is a need for the continuous training of the nursing staff because factors such as the nurses' lack of technical-scientific knowledge and, concomitantly, the absence of a standardized and specific intervention model linked to a bureaucratic system, make it difficult to carry out a specialized care for this type of patient.

Enhancing Care of Older Adults Through Standardizing Palliative Care Education

Nursing skill in caring for persons with serious chronic illness is increasingly in demand as the proportion of older adults in the United States increases. There is robust evidence that palliative care education among health care providers influences the reduction of death anxiety and avoidance behavior, while positively impacting self-efficacy and comfort, when caring for persons with serious illness or those nearing death. The international recognition of access to palliative care as a universal human right drives the need for education to adequately prepare nurses who have not been properly prepared for this work. The development of national competencies in palliative care education for nurses is an important step in synthesizing and disseminating available evidence in support of palliative care nursing education. These recently published competencies can lead to policy innovations at local, state, and national levels. Identifying competencies that lead to more clearly defined curricula will ultimately improve standardizing education and improve nursing practice in caring for older adults with serious chronic illness and their families. [Journal of Gerontological Nursing, 49(6), 6-12.].

Palliative Care Interventions Effects on Psychological Distress: A Systematic Review & Meta-Analysis

BACKGROUND

Managing psychological distress is an objective of palliative care. No meta-analysis has evaluated whether palliative care reduces psychological distress.

OBJECTIVES

Examine the effects of palliative care on depression, anxiety, and general psychological distress for adults with life-limiting illnesses and their caregivers.

DESIGN

We searched PubMed, PsycInfo, Embase, and CINAHL for randomized clinical trials (RCTs) of palliative care interventions. RCTs were included if they enrolled adults with life-limiting illnesses or their caregivers, reported data on psychological distress at 3 months after study intake, and if authors had described the intervention as "palliative care."

RESULTS

We identified 38 RCTs meeting our inclusion criteria. Many (14/38) included studies excluded participants with common mental health conditions. There were no statistically significant improvements in patient or caregiver anxiety (patient SMD: -0.008, P = 0.96; caregiver SMD: -0.21, P = 0.79), depression (patient SMD: -0.13, P = 0.25; caregiver SMD -0.27, P = 0.08), or psychological distress (patient SMD: 0.26, P = 0.59; caregiver SMD: 0.04, P = 0.78).

CONCLUSIONS

Psychological distress is not likely to be reduced in the context of a typical palliative care intervention. The systemic exclusion of patients with common mental health conditions in more than 1/3 of the studies raises ethical questions about the goals of palliative care RCTS and could perpetuate inequalities.

Differences in family caregiver experiences and expectations of end-of-life heart failure care across providers and settings: a systematic literature review

Heart failure impacts patients' quality of life and life expectancy and significantly affects the daily behaviours and feelings of family caregivers. At the end-of-life, the burden for family caregivers depends on their emotional and sentimental involvement, as well as social costs.

OBJECTIVES

The aim of this work is to determine whether and how family caregivers' experiences and expectations vary in relation to the places of care and teams involved in heart failure management.

METHODS

A systematic literature review was conducted, by screening manuscripts dealing with the experience of Family Care Givers' (FCGs) of patients with Advanced Heart failure. Methods and results were reported following the PRISMA rules. Papers were searched through three databases (PubMed, Scopus and Web of Science). Seven topics were used to synthetize results by reporting qualitative information and quantitative evidence about the experience of FCGs in places of care and with care teams.

RESULTS

Thirty-one papers, dealing with the experience of 814 FCGs, were selected for this systematic review. Most manuscripts came from the USA (N = 14) and European countries (N = 13) and were based on qualitative methods. The most common care setting and provider profile combination at the end of life was home care (N = 22) and multiprofessional teams (N = 27). Family caregivers experienced "psychological issues" (48.4%), impact of patients' condition on their life (38,7%) and "worries for the future" (22.6%). Usually, when family caregivers were unprepared for the future, the care setting was the home, and there was a lack of palliative physicians on the team.

DISCUSSION

At the end-of-life, the major needs of chronic patients and their relatives are not health related. And, as we observed, non-health needs can be satisfied by improving some key components of the care management process that could be related to care team and setting of care. Our findings can support the design of new policies and strategies.

"It's Not Us Versus Them": Building Cross-Disciplinary Relationships in the Perioperative Period

CONTEXT

Palliative care (PC) interventions improve quality outcomes for surgical patients, yet they are underutilized in the perioperative period. Developing cross-disciplinary provider relationships increases PC consults. However, the attributes of collaborative relationships and how they evolve are unclear.

OBJECTIVES

To identify perceptions of PC providers and surgeons on how collaborative cross-disciplinary relationships are built and maintained in the perioperative period.

METHODS

This cross-sectional multiphase qualitative study included 23 semistructured interviews with 10 PC teams (20 providers) and 13 surgeons at geographically distributed Veteran Health Administration (VHA) sites. An analytic approach relied on team-based thematic analysis with a dual review (Krippendorf α above 0.8).

RESULTS

Respondents defined successful collaborative work relationships between PC and surgeons as having the following features: 1) mutual trust; 2) mutual respect; 3) perceived usefulness; 4) shared clinical objectives; 5) effective communication; and 6) organizational enablers. In addition, the analysis elucidated a framework of six strategies for developing collaborative relationships between PC and surgical teams in the perioperative period: 1) being present, available, and responsive; 2) understanding roles; 3) establishing communication; 4) recognizing an intermediary and connecting role of supporting team members; 5) working as a team; and 6) building on previous experiences.

CONCLUSION

The study informs future interventions to improve the quality of care for seriously ill patients by better-involving PC in the perioperative period. Future work will extend this approach to incorporate the perspectives of patients on their providers' collaboration and how it impacts patient-related outcomes at the intersection of PC and surgery.

The high-risk hip fracture patient and the palliative care consult : A retrospective study to investigate risks of complications and the utility of a palliative care consult in hip fracture patients undergoing surgical fixation

We evaluated the utility of a palliative care consult (PCC) in high-risk hip fracture patients. The main result was that a PCC reflects certain risk factors for post-surgical complications and is associated with a delay to surgery in the high-risk patient population that it served.

PURPOSE

The objective of this study was to identify risks of complications in surgically managed hip fractures and determine the utility of a PCC in this population, particularly regarding time to the operating room (OR).

METHODS

Retrospective cohort at a Level I academic trauma center.

RESULTS

Four hundred sixty-two patients were treated surgically for hip fracture. Decreased pre-injury ambulatory status (OR 2.18, 95% CI 1.13-4.20, p = .02), time to OR > 48 h (OR 4.76, 95% CI 1.43-15.87, p = .011), and obtaining a pre-operative PCC (OR 3.03, 95% CI 1.34-6.85, p = .008) were independent risk factors for post-surgical complications. Multivariate risk factors for obtaining a PCC included older age (OR 1.1, CI 1.0-1.1, p = .007), pre-injury ambulatory status (OR 2.2, CI 1.3-3.9, p = .005), renal failure (OR 3.1, CI 1.1-9.0, p = 0.032), and higher ASA category (OR 2.6, CI 1.2-5.5, p = .014). A delay of more than 48 h was associated with being male ( OR 4.6, CI 1.4-15.0, p = .013) or having obtained a PCC (OR 5.5, CI 1.4-22.7, p = .017).

CONCLUSIONS

Obtaining a PCC can reflect risks of complications and mortality. It is a valuable resource for use in high-risk patients who are inherently at risk for delays to surgery and should be used judiciously.

Palliative Care in Heart Failure: An Integrative Review of Nurse Practice

Introduction: Because it is a chronic disease of progressive evolution, heart failure requires nursing attitudes and practices that are articulated with palliative care, implemented in an interdisciplinary team along with patients and their families. Objective: Identifying nurses' attitudes and practices in palliative care in cardiology. Method: Integrative literature review. The searches were carried out in the following bases: Google Scholar, Virtual Health Library, LILACS, SciELO, Embase, MEDLINE, CINAHL, and Scopus; through the terms Palliative Care AND Cardiology AND Nursing. Results: We identified 1298 studies published in the last five years, 14 of which have been selected for the scope of this review. Nurse attitudes and practices were characterized as: approach to symptom control; promotion of comfort and well-being; integrality of care and family orientation; effective communication among patients, family members and nursing team; timely evaluation for palliative care. Most of the studies included in this review have evidence level 2C (n = 7) and 2B (n = 4). Therefore, the results can be interpreted as reliable. Conclusions: This study makes important contributions to the practice of nurses in palliative care for heart failure. Based on the evidence collected, nurses can develop actions with the nursing team and with the interdisciplinary team related to direct patient and family care, as well as professional training. However, the field lacks studies showing the practices and actions implemented by the nursing team.

COVID-19 and the current state of palliative care in the United States

Palliative care is becoming increasingly pertinent to be strengthened across health systems around the world, and the United States is not an exception. The emergence of the COVID-19 pandemic has disrupted provision and access to palliative care among patients with serious and complex illnesses, critically ill persons, and their families in the United States. Prior to the emergence of the pandemic, the United States faced a number of challenges ranging from racial discrimination, a stressed medical workforce, a lack of passable reimbursement for palliative care, and legal barriers, among others. Unfortunately, these issues have gotten worse amid the pandemic. This further revealed the need to invest more in innovative strategies that will ensure the provision of palliative care services during public health emergencies. In this article, we comment on the current state of palliative care in the United States.

Rural community-based nurses' self-reported knowledge and skills in the provision of psychosocial care to palliative and end-of-life clients and carers

OBJECTIVE

This study examined rural community-based nurses' self-reported knowledge and skills in the provision of psychosocial care to rural residing palliative and end-of-life clients and carers. We further sought to determine correlates of knowledge gaps to inform workforce education and planning.

METHOD

Nurses from a rural area of Victoria, Australia, were invited to complete an electronic questionnaire rating their knowledge against 6 national palliative care standards and 10 screening and assessment tools. A 5-point scale of (1) No experience to (5) Can teach others was used to rate knowledge. Results were classified into three categories: practice gaps, areas of consolidation, and strengths. Descriptive and logistical regression was used to analyze data.

RESULTS

A total of 122 of 165 nurses (response rate = 74%) completed the survey. Of these nurses, 87% were Registered Nurses, 43% had ≥10 years' experience in palliative care, and 40% had palliative care training. The majority of practices across the standards and screening and assessment tools were rated as knowledge strengths (N = 55/67, 82%). Gaps and areas of consolidation were in the use of client and carer assessment tools, the care of specific populations such as children, supporting carers with appropriate referrals, resources, and grief, and facilitating the processes of reporting a death to the coroner. Lack of formal training and lower years of experience were found to be associated with practice gaps.

SIGNIFICANCE OF RESULTS

Our study found rural nurses were confident in their knowledge and skills in the majority of psychosocial care. As generalist nurses make up the majority of the rural nursing workforce, further research should be undertaken on what educational strategies are needed to support and upskill rural community-based nurses to undertake formal training in palliative care.

A meta-analysis of nursing students' knowledge and attitudes about end-of-life care

OBJECTIVES

To synthesize nursing students' knowledge and attitudes about end-of-life care and to identify strategic directions for optimizing end-of-life care education.

DESIGN

A meta-analysis of observational studies.

DATA SOURCES

PubMed, Web of Science, EMBASE, CINAHL, PsycINFO, MEDLINE, CNKI, and WANFANG 8 electronic databases in English and Chinese were systematically searched from inception until 10 April 2022.

REVIEW METHODS

Two reviewers independently screened literature and extracted data using structured tables. The Agency for Healthcare Research and Quality (AHRQ) was used to appraise the methodological quality of included studies. The study outcomes were synthesized using a meta-analysis.

RESULTS

26 cross-sectional studies of medium or high quality from 13 countries met the eligibility criteria, involving 9749 nursing students. In our review, nursing students demonstrated insufficient knowledge about end-of-life care, with a pooled mean score of 7.50 (95 % CI: 6.55-8.45); of these, knowledge about philosophy and principles, psychosocial and spiritual care, and pain and symptom management were all deficient, with pooled mean scores of 1.49 (95 % CI: 0.78-2.21), 1.00 (95 % CI: 0.35-1.65), and 3.44 (95 % CI: 2.25-4.63), respectively. Conversely, nursing students showed positive attitudes toward end-of-life care, with a pooled mean score of 102.97 (95 % CI: 99.43-106.51). The subgroup analysis revealed that male nursing students had lower pooled mean scores for end-of-life care knowledge and attitudes.

CONCLUSION

There is a mismatch between nursing students' knowledge and attitudes about end-of-life care, they have a positive attitude but lack the necessary knowledge. Male nursing students seem to have a greater deficit of knowledge and a relatively conservative attitude toward end-of-life care. These findings may provide a significant reference for nursing educators to adjust educational strategies promptly.

A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings

Background

Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.

Aim

To define and understand determinants of  non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.

Design

Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.

Data sources

Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.

Results

Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences.

Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’.

Conclusion

A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.

Trial registration

PROSPERO Protocol CRD42021214137.

End-of-life cancer patients' total pain: the necessity to supplement pharmacology with psycho-socio-spiritual treatments

Aim: To analyze pain considering its different bio-psycho-social-spiritual manifestations and to assess the effectiveness of the analgesic treatments in end-of-life cancer patients. Materials & methods: The study was cross-sectional. A total of 376 end-of-life cancer inpatients participated in the research. Their socio-demographic and clinical data were collected and, during the first psychological consultancy, they filled in a set of validated rating scales assessing pain, anxiety, depression and quality of life. Results: The results show that physical pain was well managed for almost all patients. Nevertheless, the majority showed clinically significant levels of psychological distress. Conclusion: Treating pain means caring for all its possible manifestations including psychological symptoms and reduced wellbeing. Thus, integrating pharmacological treatment with psycho-socio-spiritual interventions, in other words, psychological, social and spiritual support, could be effective and desirable.

Attitudes and Beliefs of End-of-Life Care Among Blackfeet Indians

Disparity in hospice use threatens optimal quality of life during the final stage of life while American Indians/Alaska Natives may not be aware of hospice benefits. Our established Blackfeet members and Montana State University collaborative team conducted a modified Duke End-of-Life Care Survey (8 sections with 60 questions) to assess a baseline end-of-life values, beliefs, and attitudes of Blackfeet individuals. In this manuscript, we present the results of 3 sections with 28 questions: Preference of Care; Beliefs About Dying, Truth Telling, and Advance Care Planning; and Hospice Care by examining overall and generational differences. Most participants (n = 92) chose quality of life over quantity of life with using various devices if they had an incurable disease (54-82%), would want to know if they were dying (92%) or had cancer (89%), but had not thought or talked about their preference of end-of-life care (30% and 35% respectively). The results portray understandable cultural context as well as generational differences with personal variability. While an affirmative shift towards hospice was emerging, dissemination of accurate hospice information would benefit people in the partner community. In conclusion, an individual-centered approach-understanding individual need first-may be the most appropriate and effective strategy to promote hospice information and its use.

Knowledge and associated factors towards palliative care among nurses in Ethiopia: A systematic review and meta-analysis

Palliative care is a holistic care that emphasises on relieving pain and other symptoms of a critical illness, irrespective of age, diagnosis, or stage of illness. It improves the quality of life of the individual. Since nurses spend the longest time with patients, they are the heart of the palliative care team who deliver high standards of care. This study was intended to assess the pooled prevalence of knowledge and associated factors towards palliative care among nurses in Ethiopia. During this study, a comprehensive search was performed by using different databases. A funnel plot and Egger’s test were used to evaluate a publication bias. I² statistic was used to check the heterogeneity between the studies. The subgroup analysis was also conducted for this study. A total of 11 studies with 3330 study participants were included in this systematic review and meta-analysis. The systematic review and meta-analysis showed that the pooled prevalence of knowledge towards palliative care among nurses in Ethiopia was 42.31% (95% confidence interval = [32.41, 52.21]). Educational status (adjusted odds ratio = 2.69, 95% confidence interval = [1.11, 4.25]), experience of caring for a dying patient (adjusted odds ratio = 3.15, 95% confidence interval = [1.17, 5.13]), and training on palliative care (adjusted odds ratio = 2.53, 95% confidence interval = [1.42, 3.64]) were factors significantly associated with the knowledge of nurses towards palliative care. This study indicated that the pooled prevalence of knowledge towards palliative care among nurses in Ethiopia was low. Educational status, experience of caring for a dying patient, and training on palliative care were factors significantly associated with the knowledge of nurses towards palliative care. Thus, training on palliative care and education is suggested for nurses to improve their knowledge towards palliative care.

Systematic review registration: PROSPERO CRD42021247590

Validation of the Nurse Spiritual Care Therapeutics Scale in Portuguese palliative care settings: a methodological study

BACKGROUND

Spirituality is a critical dimension in palliative care, but difficulties have been described in literature concerning the effective implementation and measuring of spiritual care.

AIM

To translate, adapt and validate the Nurse Spiritual Care Therapeutics Scale (NSCTS) in Portuguese palliative care settings.

METHODS

A methodological study was conducted. A final version of the questionnaire included the scale and was submitted to full psychometric testing using nurses working in Portuguese palliative care settings.

FINDINGS

A total of 88 nurses participated. The average age of the sample was 36.1 ± 8.93 years (range 23-60 years), and 92.0% were women. A Cronbach alpha value of 0.88; Kaiser-Meyer-Olkin measure of sampling adequacy 0.80; and Bartlett's Test of Sphericity were adequate. An exploratory factor analysis was conducted using principal axis factoring with an oblimin rotation that resulted in a three-factors solution.

CONCLUSION

The European Portuguese NSCTS questionnaire is a valid and reliable tool to assess the frequency of nurses' activities concerning spirituality in palliative care.

Cross Country Comparison of Expert Assessments of the Quality of Death and Dying 2021

CONTEXT

Few efforts have attempted to quantify how well countries deliver end-of-life (EOL) care.

OBJECTIVES

To score, grade, and rank countries (and Hong Kong and Taiwan) on the quality of EOL care based on assessments from country experts using a novel preference-based scoring algorithm.

METHODS

We fielded a survey to country experts around the world, asking them to assess the performance of their country on 13 key indicators of EOL care. Results were combined with preference weights from caregiver-proxies of recently deceased patients to generate a preference-weighted summary score. The scores were then converted to grades (from A-F) and a ranking was created for all included countries.

RESULTS

The final sample included responses from 181 experts representing 81 countries with 2 or more experts reporting. The 6 countries who received the highest assessment scores and a grade of A were United Kingdom, Ireland, Taiwan, Australia, Republic of Korea, and Costa Rica. Only Costa Rica (upper middle) is not a high income country. Not until Uganda (ranked 31st) does a low-income country appear on the ranking. Based on the assessment scores, twenty-one countries received a failing grade, with only two - Czech Republic (66th), and Portugal (75th) - being high income countries.

CONCLUSION

This study provides an example of how a preference-based scoring algorithm and input from key stakeholders can be used to assess EOL health system performance. Results highlight the large disparities in assessments of the quality of EOL care across countries, and especially between the highest income countries and others.

Developing a meta-understanding of 'human aspects' of providing palliative care

Objectives:

Our intention was to develop a meta-understanding of the ‘human aspects’ of providing palliative care. Integral to developing this meta-understanding was recognising the individuality of people, their varied involvements, situations, understandings, and responses, and the difficulty in stepping back to get a whole view of this while being in the midst of providing palliative care. We intended for this meta-understanding to inform reflections and sense-making conversations related to people’s changing situations and diverse needs.

Methods:

Using collaborative inquiry, this qualitative research was undertaken ‘with’ clinicians rather than ‘on’ them. Our team (n = 7) was composed of palliative care clinicians and researchers from a co-located rural health service and university. We explored our personal perceptions and experiences through a series of 12 meetings over 8 months. In addition, through five focus groups, we acccessed perceptions and experiences of 13 purposively sampled participants with a range of roles as carers and/or healthcare providers. Data were dialogically and iteratively interpreted.

Findings:

Our meta-understanding of ‘human aspects’ of providing palliative care, represented diagrammatically in a model, is composed of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING. ATTRIBUTES OF HUMANITY are death’s inevitability, suffering’s variability, compassion’s dynamic nature, and hope’s precariousness. ACTIONS OF CARING include recognising and responding, aligning expectations, valuing relationships, and using resources wisely. The meta-understanding is a framework to keep multiple complex concepts ‘in view’ as they interrelate with each other.

Significance of findings:

Our meta-understanding, highlighting ‘human aspects’ of providing palliative care, has scope to embrace complexity, uncertainty, and the interrelatedness of people in the midst of resourcing, requiring, and engaging in palliative care. Questions are posed for this purpose. The non-linear diagrammatic representation of ATTRIBUTES OF HUMANITY and ACTIONS OF CARING facilitates multiple ways of engaging and revisiting palliative care situations or navigating changes within and across them.

Experience of African American Surrogate Decision Makers of Patients With Dementia

Dementia cases are expected to grow for African Americans and surrogate decision makers (SDMs) will have a significant role at the end of life (EOL). This qualitative exploratory case study used Cognitive Task Analysis and an integrated conceptual framework to understand the EOL decision experience of African American SDMs for patients with advanced dementia. Using a holistic multiple-case design, 8 African American SDMs were interviewed about their experiences with the decision-making process, including role acceptance, role enactment, and emotional outcomes of decision making. Thirteen themes germane to understanding the EOL decision experience of African American SDMs were identified. Findings suggest African American SDMs often lack sufficient knowledge of disease prognosis and intervention options to make informed treatment choices at EOL. In particular, African Americans extend the caregiver role to SDM for patients with dementia at EOL without being fully aware of the role and decision-making responsibilities. Surrogates lacked a general understanding of EOL options resulting in underutilization of hospice and palliative care and subsequent regret, and few interventions exist to improve the uptake of EOL care services. There is a need to develop culturally appropriate role preparation, education, and decision support to improve EOL treatment decisions and emotional adjustment of surrogates of patients with advanced dementia, which should be rendered early and throughout the illness trajectory.

Does a Hospital Palliative Care Team Have the Potential to Reduce the Cost of a Terminal Hospitalization? A Retrospective Case-Control Study in a Czech Tertiary University Hospital

Background:

More than 50% of patients worldwide die in hospitals and end-of-life care is costly. We aimed to explore whether support from the palliative team can influence end-of-life costs.

Methods:

This was a descriptive retrospective case–control study conducted at a Czech tertiary hospital. We explored the difference in daily hospital costs between patients who died with and without the support of the hospital palliative care team from January 2019 to April 2020. Big data from registries of routine visits were used for case–control matching. As secondary outcomes, we compared the groups over the duration of the terminal hospitalization, intensive care unit (ICU) days, intravenous antibiotics, magnetic resonance imaging/computed tomography scans, oncological treatment in the last month of life, and documentation of the dying phase. Standard descriptive statistics were used to describe the data, and differences between the case and control groups were tested using Fisher's exact test for categorical variables and the Mann–Whitney U test for numerical data.

Results:

In total, 213 dyads were identified. The average daily costs were three times lower in the palliative group (4392.4 CZK per day = 171.3 EUR) than in the nonpalliative group (13992.8 CZK per day = 545.8 EUR), and the difference was probably associated with the shorter time spent in the ICU (16% vs. 33% of hospital days).

Conclusions:

We showed that the integration of the palliative care team in the dying phase can be cost saving. These data could support the implementation of hospital palliative care in developing countries.

A Systematized Approach to Advancing the Quality of Community-Based Palliative Care

Despite growing recognition of the importance of community-based palliative care, optimizing the use of services continues to be a challenge. Until recently, key barriers were reimbursement and limited access. As services have become increasingly available, engagement of patients and their caregivers has emerged as a major obstacle. The Palliative Activation System^TM (PAS) is a comprehensive, quality improvement methodology designed to promote enhanced engagement of seriously ill adults and their caregivers in optimizing the use of community-based palliative care services and accelerate clinicians' progress in meeting patients' and caregivers' care goals. This paper describes the design of the PAS. Experts in patient engagement and the development and evaluation of palliative care programs advised organizational leaders in the development of this methodology. The "Patient and Family Engagement" framework proposed by Carman and colleagues (2013) guided this work. The framework informed the selection of three core concepts-care alignment, illness trajectory, and social determinants of health-as foundational to the goals of the PAS. Additionally, this framework guided the selection of measures that will be used to assess progress in achieving enhanced engagement. This background work, coupled with findings from interviews with patients and caregivers who are current recipients of palliative care services, resulted in the implementation and ongoing testing of strategies targeting clinicians and organizational leaders and designed to enhance engagement. Lessons learned from the design phase of the PAS will advance the efforts of other organizations committed to increasing patient and caregiver engagement and enhancing attainment of their goals.

Survivorship for Individuals Living with Advanced and Metastatic Cancers: National Cancer Institute Meeting Report

An important and often overlooked subpopulation of cancer survivors is individuals who are diagnosed with or progress to advanced or metastatic cancer. Living longer with advanced or metastatic cancer often comes with a cost of burdensome physical and psychosocial symptoms and complex care needs, however research is limited on this population. Thus, in May 2021, the National Cancer Institute convened subject matter experts, researchers, clinicians, survivors, and advocates a for a 2-day virtual meeting. The purpose of this report is to provide a summary of the evidence gaps identified by subject matter experts and attendees and key opportunities identified by NCI in five research areas: epidemiology and surveillance, symptom management, psychosocial research, healthcare delivery, and health behaviors. Identified gaps and opportunities include the need to develop new strategies to estimate the number of individuals living with advanced and metastatic cancers, understand and address emerging symptom trajectories, improve prognostic understanding and communication between providers, patients, and caregivers, develop and test models of comprehensive survivorship care tailored to these populations, and assess patient and provider preferences for health behavior discussions throughout the survivorship trajectory. To best address the needs of individuals living with advanced and metastatic cancer and to deliver comprehensive evidence-based quality care, research is urgently needed to fill evidence gaps, and it is essential to incorporate the survivor perspective. Developing such an evidence base is critical to inform policy and practice.

Predictors of At-Home Death for Cancer Patients in Rural Clinics in Japan

BACKGROUND

The prediction of at-home deaths has become an important topic in rural areas of Japan with an advanced aging society. However, there are no well-established predictors to explain how these factors influence intention. This study aims to investigate the possible predictors of at-home death for cancer patients in rural clinics in Japan.

METHODS

This is a nationwide cross-sectional survey. A self-administered questionnaire was sent to 493 rural clinics in Japan. The main outcome was the realization of at-home deaths for cancer patients.

RESULTS

Among the 264 clinics (54%) that responded to the survey, there were 194 clinics with the realization of at-home death. The use of a clinical pathway (adjusted odds ratio 4.19; 95% confidence interval 1.57-11.19) and the provision of organized palliative care (adjusted odds ratio 19.16; 95% confidence interval 7.56-48.52) were associated with the prediction of at-home death, irrespective of island geography or the number of doctors and nurses.

CONCLUSIONS

Having a clinical pathway and systematizing palliative care could be important to determine the possibility of at-home deaths for cancer patients in rural clinics in Japan.

A scoping review of nurse-led advance care planning

BACKGROUND

Advance care planning (ACP) supports persons at any age or health status to determine their values, goals, and preferences regarding future medical care. The American Nurses Association endorses nurses to facilitate ACP to promote patient- and family-centered care.

PURPOSE

This project reviewed and synthesized literature on nurse-led ACP training models.

METHODS

A scoping review used the Arksey and O'Malley Framework to identify: (a) ACP training model type, (b) nurse-led ACP recipients, (c) ACP in special populations, (d) ACP outcomes.

FINDINGS

Of 33 articles reviewed, 19 included 11 established models; however, the primary finding was lack of a clearly identified evidence-based nurse-led ACP training model.

DISCUSSION

Nurses are integral team members, well positioned to be a bridge of communication between patients and care providers. This is a call to action for nurse leaders, researchers, educators to collaborate to identify and implement an evidence-based, effective nurse-led ACP training model.

Hospice and palliative care clinicians' perceptions of posttraumatic stress disorder at end-of-life in military veterans

At the end of life, individuals may re-engage with earlier life trauma as they reflect on life experiences and confront their mortality. As such, posttraumatic stress disorder (PTSD) symptoms at the end of life may worsen the quality of death experience. This is a concern for military veterans, who tend to have more trauma exposures and higher rates of PTSD, and particularly for veterans receiving care in rural areas where access to PTSD specialty services is limited. To better understand this issue, we conducted 10 focus groups with clinicians serving veterans in rural communities across five U.S. states. The aims of this project were to evaluate: (1) do hospice and palliative care providers/staff observe PTSD symptoms in veterans at the end of life? (2) if so, how are symptoms similar to and different from existing DSM-5 criteria for PTSD? We used qualitative content analysis with mixed deductive and inductive approaches to code 151 anonymized statements. Analyses found descriptions of PTSD symptoms aligned broadly with existing diagnostic nomenclature, but descriptions revealed specific presentations relevant to the end of life setting such as resistance to care, agitation, restlessness, and effects of delirium. In addition, some veterans expressed pride in service and openness to discussing military experiences. Further, clinicians noted that PTSD symptoms were relevant to family dynamics. Future research should further characterize these symptom differences through direct patient assessment and develop resources to improve quality of death experience for veterans with PTSD symptoms.

Palliative Care Consultation Services on Terminally Ill Cancer Patients and Non-Cancer Patients: Trend Analysis from a 9-Year-Long Observational Study in Taiwan

Early integration of palliative care for terminally ill cancer and non-cancer patients improves quality of life. However, there are sparse data on results of palliative care consultation services (PCCS) between cancer and non-cancer patients. In this 9-year observational study, data were collected from the Hospice-Palliative Clinical Database (HPCD) of Taichung Veterans General Hospital (TCVGH). Terminally ill cancer and non-cancer patients who received PCCS during 2011 to 2019 were enrolled. Trend analysis was performed to evaluate differences in outcomes of PCCS, including duration of PCCS, the awareness of disease of patients and families before and after PCCS, status of PCCS termination, and DNR declaration before and after PCCS among cancer and non-cancer patients throughout study period. In total, 5223 cancer patients and 536 non-cancer patients received PCCS from 2011 to 2019. The number of people who received PCCS increased stably over the decade, both for cancer and non-cancer patients. The average duration of PCCS for cancer and non-cancer patients was 21.4 days and 18.4 days, respectively. Compared with non-cancer patients, cancer patients had longer duration of PCCS, less DNR declaration (82% vs. 98%, respectively), and more transfers to the palliative care unit (17% vs. 11%, respectively), or for palliative home care (12% vs.8%, respectively). Determinants of late referral to PCCS includes age (OR 0.992, 95% CI 0.987–0.996), DNR declaration after PCCS (OR 1.967, 95% CI 1.574–2.458), patients’ awareness after PCCS (OR 0.754, 95% CI 0.635–0.895), and status of PCCS termination. This 9-year observational study showed that the trend of PCCS among cancer and non-cancer patients had changed over the duration of the study, and early integration of PCCS to all patients is essential for both cancer and non-cancer patients.

Acupuncture for palliative cancer pain management: systematic review

BACKGROUND

Pain is one of the most common and problematic symptoms encountered by patients with cancer. Due to the multifactorial aetiology, pain management of these patients frequently requires multidisciplinary interventions including conventional support and specialty palliative care. Acupuncture has been identified as a possible adjunctive therapy for symptom management in cancer pain, and there is currently no systematic review focused solely on the evidence of acupuncture on cancer pain in palliative care.

OBJECTIVE

To critically analyse currently available publications regarding the use of acupuncture for pain management among patients with cancer in palliative care settings.

METHODS

Multiple academic databases were searched from inception to 29 October 2020. Randomised controlled trials involving acupuncture in palliative care for treatment of cancer-related pain were synthesised. Data were extracted by two independent reviewers, and methodological quality of each included study was assessed using the Oxford Centre for Evidence-Based Medicine (OCEBM) 2011 Levels of Evidence.

RESULTS

Five studies (n=189) were included in this systematic review. Results indicated a favourable effect of acupuncture on pain relief in palliative care for patients with cancer. According to OCEBM 2011 Levels of Evidence, they were level 2 in one case (20%), level 3 in two cases (40%) and level 4 in the remaining (40%). Low-level evidence adversely affects the reliability of findings.

CONCLUSIONS

Acupuncture may be an effective and safe treatment associated with pain reduction in the palliative care of patients with cancer. Further high-quality, adequately powered studies are needed in the future.

Implementing Primary Palliative Care in Post-acute nursing home care: Protocol for an embedded pilot pragmatic trial

INTRODUCTION

Older adults with serious illness frequently receive post-acute rehabilitative care in nursing homes (NH) under the Part A Medicare Skilled Nursing Facility (SNF) Benefit. Treatment is commonly focused on disease-modifying therapies with minimal consideration for goals of care, symptom relief, and other elements of palliative care.

INTERVENTION

The evidence-based Primary Palliative Care in Post-Acute Care (PPC-PAC) intervention for older adults is delivered by nurse practitioners (NP). PPC-PAC NPs assess and manage symptoms, conduct goals of care discussions and assist with decision making; they communicate findings with NH staff and providers. Implementation of PPC-PAC includes online and face-to-face training of NPs, ongoing facilitation, and a template embedded in the NH electronic health record to document PPC-PAC.

OBJECTIVES

The objectives of this pilot pragmatic clinical trial are to assess the feasibility, acceptability, and preliminary effectiveness of the PPC-PAC intervention and its implementation for 80 seriously ill older adults newly admitted to a NH for post-acute care.

METHODS

Design is a two-arm nonequivalent group multi-site pilot pragmatic clinical trial. The unit of assignment is at the NP and unit of analysis is NH patients. Recruitment occurs at NHs in Pennsylvania, New Jersey, Delaware, and Maryland. Effectiveness (patient quality of life) data are collected at two times points-baseline and 14-21 days.

CONCLUSION

This will be the first study to evaluate the implementation of an evidence-based primary palliative care intervention specifically designed for older adults with serious illness who are receiving post-acute NH care.

Family caregivers' experiences of end-of-life care in the acute hospital setting. A qualitative study

BACKGROUND

Acute hospital settings are generally not considered adequate places for end-of-life care, but terminally ill patients will continue to die in acute medical wards in the unforeseeable future.

AIM

The aim of this study was to investigate family caregivers' experiences of end-of-life care in an acute community hospital in Iceland.

METHODS

Fifteen in-depth qualitative semi-structured interviews were conducted with participants who had been primary caregivers. The transcribed interviews were analysed using thematic content analysis.

FINDINGS

Findings indicated that the acute hospital setting is not a suitable environment for end-of-life care. Effective communication and management of symptoms characterised by warmth and security give a sense of resilience. Three main themes emerged: (1) Environmental influences on quality of care; (2) Communication in end-of-life care; (3) The dying process. Each of the themes encompassed a variety of subthemes.

CONCLUSIONS

Findings suggest that effective communication is the cornerstone of quality of care in the acute hospital environment and essential for establishing a sense of security. The severity of symptoms can deeply affect family caregivers' well-being. Acknowledging and appreciating the meaning of respect and dignity at the end-of-life from family caregivers' perspective is vital.