Many people in Scotland now benefit from anticipatory care before they die: an after death analysis and interviews with general practitioners

Implementing advance care planning in palliative and end of life care: a scoping review of community nursing perspectives

BACKGROUND

Advance care planninganning (ACP) is a priority within palliative care service provision. Nurses working in the community occupy an opportune role to engage with families and patients in ACP. Carers and family members of palliative patients often find ACP discussions difficult to initiate. However, community nurses caring for palliative patients can encourage these discussions, utilising the rapport and relationships they have already built with patients and families. Despite this potential, implementation barriers and facilitators continue to exist. To date, no research synthesis has captured the challenges community nurses face when implementing ACP, nor the facilitators of community nurse-led ACP. Considering this, the review question of: 'What factors contribute to or hinder ACP discussion for nurses when providing care to palliative patients?' was explored.

METHOD

To capture challenges and facilitators, a global qualitative scoping review was undertaken in June 2023. The Arksey and O'Malley framework for scoping reviews guided the review methodology. Six databases were searched identifying 333 records: CINAHL (16), MEDLINE (45), PUBMED (195), EMBASE (30), BJOCN (15), IJOPN (32). After de-duplication and title and abstract screening, 108 records remained. These were downloaded, hand searched (adding 5 articles) and subject to a full read. 98 were rejected, leaving a selected dataset of 15 articles. Data extracted into a data extraction chart were thematically analysed.

RESULTS

Three key themes were generated: 'Barriers to ACP', 'Facilitators of ACP' and 'Understanding of professional role and duty'. Key barriers were - lack of confidence, competence, role ambiguity and prognostic uncertainty. Key facilitators concerned the pertinence of the patient-practitioner relationship enabling ACP amongst nurses who had both competence and experience in ACP and/or palliative care (e.g., palliative care training). Lastly, nurses understood ACP to be part of their role, however, met challenges understanding the law surrounding this and its application processes.

CONCLUSIONS

This review suggests that community nurses' experience and competence are associated with the effective implementation of ACP with palliative patients. Future research is needed to develop interventions to promote ACP uptake in community settings, enable confidence building for community nurses and support higher standards of palliative care via the implementation of ACP.

Developing and pilot testing a frailty-focused education and communication training workshop

Objective

To describe development and pilot testing of a multi-modal frailty-focused education and communication training workshop for health care clinicians.

Methods

Pilot testing was conducted via two workshops (#1:face-to-face [2019], #2:virtual [2020]). Participants: convenience sample of clinicians and students who volunteered. Workshop #1 included registered nurses working in an acute care and one medical student (N=14); #2: nursing students enrolled in an APRN program. Design: Pre/post observational study. Data analysis: descriptive statistics, paired t-tests and Wilcoxon rank test.

Results

Statistically significant increases in frailty knowledge (#1: p = 0.02, d = 0.44; #2: p = 0.006, d = 0.55) and self-reported competency with older adult interactions (#1: p < 0.001, d = 0.62; #2: p = 0.001, d = 0.63) were reported for both workshops. Post course evaluations of the workshop were positive, with scores ranging from 3.5-3.9 (range: 0-4) for increased understanding of the concept of frailty, communication to support health-related behavior, and best practice empathic communication skills.

Conclusion

The FCOM workshop was successful. Participants gained knowledge and skills for use in working with older adults across the aging continuum from non-frail to frail.

Innovation

Our FCOM training workshop expands prior communication training on shared decision-making with frail individuals to a broader population of all older adults.

Integrating lived experiences of out-of-hours health services for people with palliative and end-of-life care needs with national datasets for people dying in Scotland in 2016: A mixed methods, multi-stage design

BACKGROUND

Unscheduled care is used increasingly during the last year of life by people known to have significant palliative care needs.

AIM

To document the frequency and patterns of use of unscheduled healthcare by people in their last year of life and understand the experiences and perspectives of patients, families and professionals about accessing unscheduled care out-of-hours.

DESIGN

A mixed methods, multi-stage study integrating a retrospective cohort analysis of unscheduled healthcare service use in the last year of life for all people dying in Scotland in 2016 with qualitative data from three regions involving service users, bereaved carers and general practitioners.

SETTING

Three contrasting Scottish Health Board regions and national datasets for the whole of Scotland.

RESULTS

People who died in Scotland in 2016 (n = 56,407) had 472,360 unscheduled contacts with one of five services: telephone advice, primary care, ambulance service, emergency department and emergency hospital admission. These formed 206,841 individual continuous unscheduled care pathways: 65% starting out-of-hours. When accessing healthcare out-of-hours, patients and carers prioritised safety and a timely response. Their choice of which service to contact was informed by perceptions and previous experiences of potential delays and whether the outcome might be hospital admission. Professionals found it difficult to practice palliative care in a crisis unless the patient had previously been identified.

CONCLUSION

Strengthening unscheduled care in the community, together with patient and public information about how to access these services could prevent hospital admissions of low benefit and enhance community support for people living with advanced illness.

Palliative care research promotion in policy and practice: a knowledge exchange process

In palliative care, as in many areas of medicine, there is a considerable amount of research conducted that makes sound recommendations but does not result consistently in improved care. For instance, though palliative care has been shown to benefit all people with a life-threatening illness, its main reach continues to be for those with cancer. Drawing on relational models of research use, we set out to engage policy-makers, educators, clinicians, commissioners and service providers in a knowledge exchange process to identify implications of research for Scottish palliative care priorities. First, we mapped the existing palliative care research evidence in Scotland. We then organised evidence review meetings and a wider stakeholder event where research producers and users came together to coproduce implications of the evidence for policy, education and practice. We used questionnaires and key stakeholder feedback meetings to explore impacts of this process on research uptake and use immediately after the events and over time. In this paper, we reflect on this knowledge exchange process and the broader context in which it was set. We found that participation fostered relationships and led to a rich and enthusiastic exploration of research evidence from multiple perspectives. Potential impacts relating to earlier identification for palliative care, education and need-based commissioning ensued. We make suggestions to guide replication.

Frequency of providing a palliative approach to care in family practice: a chart review and perceptions of healthcare practitioners in Canada

Background

Most patients nearing the end of life can benefit from a palliative approach in primary care. We currently do not know how to measure a palliative approach in family practice. The objective of this study was to describe the provision of a palliative approach and evaluate clinicians’ perceptions of the results.

Methods

We conducted a descriptive study of deceased patients in an interprofessional team family practice. We integrated conceptual models of a palliative approach to create a chart review tool to capture a palliative approach in the last year of life and assessed a global rating of whether a palliative approach was provided. Clinicians completed a questionnaire before learning the results and after, on perceptions of how often they believed a palliative approach was provided by the team.

Results

Among 79 patients (mean age at death 73 years, 54% female) cancer and cardiac diseases were the top conditions responsible for death. One-quarter of patients were assessed as having received a palliative approach. 53% of decedents had a documented discussion about goals of care, 41% had nurse involvement, and 15.2% had a discussion about caregiver well-being. These indicators had the greatest discrimination between a palliative approach or not. Agreement that elements of a palliative approach were provided decreased significantly on the clinician questionnaire from before to after viewing the results.

Conclusions

This study identified measurable indicators of a palliative approach in family practice, that can be used as the basis for quality improvement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01400-4.

Bolstering General Practitioner Palliative Care: A Critical Review of Support Provided by Australian Guidelines for Life-Limiting Chronic Conditions

General practitioners (GPs) are increasingly expected to provide palliative care as ageing populations put pressure on specialist services. Some GPs, however, cite barriers to providing this care including prognostication challenges and lack of confidence. Palliative care content within clinical practice guidelines might serve as an opportunistic source of informational support to GPs. This review analysed palliative care content within Australian guidelines for life-limiting conditions to determine the extent to which it might satisfy GPs’ stated information needs and support them to provide quality end-of-life care. Six databases and guideline repositories were searched (2011–2018). Eligible guidelines were those for a GP audience and explicitly based on an appraisal of all available evidence. Content was mapped against an established palliative care domain framework (PEPSI-COLA) and quality was assessed using AGREE-II. The nine guidelines meeting inclusion criteria were heterogenous in scope and depth of palliative care domain coverage. The ‘communication’ needs domain was best addressed while patient physical and emotional needs were variably covered. Spiritual, out-of-hours, terminal care and aftercare content was scant. Few guidelines addressed areas GPs are known to find challenging or acknowledged useful decision-support tools. A template covering important domains might reduce content variability across guidelines.

Antimicrobial use at the end of life: a scoping review

OBJECTIVE

To examine antibiotic use in patients approaching end of life, in terms of frequency of prescription, aim of treatment, beneficial and adverse effects and contribution to the development of antimicrobial resistance.

DESIGN

Scoping review DATA SOURCES: An information scientist searched Ovid MEDLINE, Ovid EMBASE, The Cochrane library, PubMed Clinical Queries, NHS Evidence, Epistemonikos, SIGN, NICE, Google Scholar from inception to February 2019 for any study design including, but not limited to, randomised clinical trials, prospective interventional or observational studies, retrospective studies and qualitative studies. The search of Ovid MEDLINE was updated on the 10 June 2020.

STUDY SELECTION

Studies reporting antibiotic use in patients approaching end of life in any setting and clinicians' attitudes and behaviour in relation to antibiotic prescribing in this population DATA EXTRACTION: Two reviewers screened studies for eligibility; two reviewers extracted data from included studies. Data were analysed to describe antibiotic prescribing patterns across different patient populations, the benefits and adverse effects (for individual patients and wider society), the rationale for decision making and clinicians behaviours and attitudes to treatment with antibiotics in this patient group.

RESULTS

Eighty-eight studies were included. Definition of the end of life is highly variable as is use of antibiotics in patients approaching end of life. Prescribing decisions are influenced by patient age, primary diagnosis, care setting and therapy goals, although patients' preferences are not always documented or adhered to. Urinary and lower respiratory tract infections are the most commonly reported indications with outcomes in terms of symptom control and survival variably reported. Small numbers of studies reported on adverse events and antimicrobial resistance. Clinicians sometimes feel uncomfortable discussing antibiotic treatment at end of life and would benefit from guidelines to direct care.

CONCLUSIONS

Use of antibiotics in patients approaching the end of life is common although there is significant variation in practice. There are a myriad of intertwined biological, ethical, social, medicolegal and clinical issues associated with the topic.

Unscheduled and out-of-hours care for people in their last year of life: a retrospective cohort analysis of national datasets

OBJECTIVES

To analyse patterns of use and costs of unscheduled National Health Service (NHS) services for people in the last year of life.

DESIGN

Retrospective cohort analysis of national datasets with application of standard UK costings.

PARTICIPANTS AND SETTING

All people who died in Scotland in 2016 aged 18 or older (N=56 407).

MAIN OUTCOME MEASURES

Frequency of use of the five unscheduled NHS services in the last 12 months of life by underlying cause of death, patient demographics, Continuous Unscheduled Pathways (CUPs) followed by patients during each care episode, total NHS and per-patient costs.

RESULTS

53 509 patients (94.9%) had at least one contact with an unscheduled care service during their last year of life (472 360 contacts), with 34.2% in the last month of life. By linking patient contacts during each episode of care, we identified 206 841 CUPs, with 133 980 (64.8%) starting out-of-hours. People with cancer were more likely to contact the NHS telephone advice line (63%) (χ² (4)=1004, p<0.001) or primary care out-of-hours (62%) (χ² (4)=1924,p<0.001) and have hospital admissions (88%) (χ² (4)=2644, p<0.001). People with organ failure (79%) contacted the ambulance service most frequently (χ² (4)=584, p<0.001). Demographic factors associated with more unscheduled care were older age, social deprivation, living in own home and dying of cancer. People dying with organ failure formed the largest group in the cohort and had the highest NHS costs as a group. The cost of providing services in the community was estimated at 3.9% of total unscheduled care costs despite handling most out-of-hours calls.

CONCLUSIONS

Over 90% of people used NHS unscheduled care in their last year of life. Different underlying causes of death and demographic factors impacted on initial access and subsequent pathways of care. Managing more unscheduled care episodes in the community has the potential to reduce hospital admissions and overall costs.

Development and testing of a frailty-focused communication (FCOM) aid for older adults

The concept of frailty as it pertains to aging, health and well-being is poorly understood by older adults and the public-at-large. We developed an aging and frailty education tool designed to improve layperson understanding of frailty and promote behavior change to prevent and/or delay frailty. We subsequently tested the education tool among adults who attended education sessions at 16 community sites. Specific aims were to: 1) determine acceptability (likeability, understandability) of content, and 2) assess the likelihood of behavior change after exposure to education tool content. Results: Over 90% of participants "liked" or "loved" the content and found it understandable. Eighty-five percent of participants indicated that the content triggered a desire to "probably" or "definitely" change behavior. The desire to change was particularly motivated by information about aging, frailty and energy production. Eight focus areas for proactive planning were rated as important or extremely important by over 90% of participants.

Information sharing challenges in end-of-life care: a qualitative study of patient, family and professional perspectives on the potential of an Electronic Palliative Care Co-ordination System

OBJECTIVES

To explore current challenges in interdisciplinary management of end-of-life care in the community and the potential of an Electronic Palliative Care Co-ordination System (EPaCCS) to facilitate the delivery of care that meets patient preferences.

DESIGN

Qualitative study using interviews and focus groups.

SETTING

Health and Social Care Services in the North of England.

PARTICIPANTS

71 participants, 62 health and social care professionals, 9 patients and family members.

RESULTS

Four key themes were identified: information sharing challenges; information sharing systems; perceived benefits of an EPaCCS and barriers to use and requirements for an EPaCCS. Challenges in sharing information were a source of frustration for health and social care professionals as well as patients, and were suggested to result in inappropriate hospital admissions. Current systems were perceived by participants to not work well-paper advance care planning (ACP) documentation was often unavailable or inaccessible, meaning it could not be used to inform decision-making at the point of care. Participants acknowledged the benefits of an EPaCCS to facilitate information sharing; however, they also raised concerns about confidentiality, and availability of the increased time and resources required to access and maintain such a system.

CONCLUSIONS

EPaCCS offer a potential solution to information sharing challenges in end-of-life care. However, our findings suggest that there are issues in the initiation and documentation of end-of-life discussions that must be addressed through investment in training in order to ensure that there is sufficient information regarding ACP to populate the system. There is a need for further qualitative research evaluating use of an EPaCCS, which explores benefits and challenges, uptake and reasons for disparities in use to better understand the potential utility and implications of such systems.

The perception of people with cancer of starting a conversation about palliative care: A qualitative interview study

OBJECTIVE

Communication and patient-centred care are important determinants for timely initiation of palliative care. Therefore, we aimed to understand and explain the behaviour "starting a conversation about palliative care with a professional carer" from the perspective of people with incurable cancer.

METHODS

A qualitative study using semi-structured face-to-face interviews with 25 people with incurable cancer: 13 not (yet) receiving palliative care and 12 receiving palliative care; 4 started the conversation themselves. Determinants related to the defined behaviour were matched with concepts in existing behavioural theories.

RESULTS

Both positive and negative stances towards starting a conversation about palliative care with a professional carer were found. Influencing behavioural factors were identified, such as knowledge (e.g. about palliative care), attitude (e.g. association of palliative care with quality of life) and social influence (e.g. relationship with the professional carer). We modelled the determinants into a behavioural model.

CONCLUSION

The behavioural model developed helps to explain why people with incurable cancer do or do not start a conversation about palliative care with their professional carer. By targeting the modifiable determinants of the model, promising interventions can be developed to help patients taken the initiative in communication about palliative care with a professional carer.

A narrative review of facilitating and inhibiting factors in advance care planning initiation in people with dementia

Aim

To identify and assess factors that affect the decisions to initiate advance care planning (ACP) amongst people living with dementia (PwD).

Findings

All articles included for the analysis came from countries that have supportive regulations and guidelines for ACP. ACP initiation amongst PwD is a complex decision that involves several stakeholders who have different knowledge and attitudes of ACP.

Message

More research is required on ACP education, initiation timing given the disease trajectory, and changing family dynamics overtime.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00314-1) contains supplementary material, which is available to authorized users.

Purpose of the review

To identify and assess factors that affect the decisions to initiate advance care planning (ACP) amongst people living with dementia (PwD).

Methods

A narrative review was conducted. A keyword search of Medline, CINAHL PsycINFO, and Web of Sciences databases produced 22,234 articles. Four reviewers independently applying inclusion/exclusion criteria resulted in 39 articles. Discrepancies were settled in discussion.

Results

Twenty-eight primary studies and eleven review articles remained. Narrative analysis generated five categories of facilitating and inhibitory factors: people with dementia, family orientation, healthcare professionals (HCP), systemic and contextual factors, and time factors. Key facilitators of ACP initiation were (i) healthcare settings with supportive policies and guidelines, (ii) family members and HCPs who have a supportive relationship with PwD, and (iii) HCPs who received ACP education. Key inhibitors were: (i) lack of knowledge about the dementia trajectory in stakeholders, (ii) lack of ACP knowledge, and (iii) unclear timing to initiate an ACP.

Conclusion

This review highlighted the main challenges associated with optimal ACP initiation with PwD. To encourage effective ACP initiation with PwD, succinct policies and guidelines for clinical commissioners are needed. ACP also needs to be discussed with family members in an informal, iterative manner. More research is required on initiation timing given the disease trajectory and changing family dynamics.

Electronic supplementary material

The online version of this article (10.1007/s41999-020-00314-1) contains supplementary material, which is available to authorized users.

Electronic care coordination systems for people with advanced progressive illness: a mixed-methods evaluation in Scottish primary care

Background

Electronic care coordination systems, known as the Key Information Summary (KIS) in Scotland, enable the creation of shared electronic records available across healthcare settings. A KIS provides clinicians with essential information to guide decision making for people likely to need emergency or out-of-hours care.

Aim

To estimate the proportion of people with an advanced progressive illness with a KIS by the time of death, to examine when planning information is documented, and suggest improvements for electronic care coordination systems.

Design and setting

This was a mixed-methods study involving 18 diverse general practices in Scotland.

Method

Retrospective review of medical records of patients who died in 2017, and semi-structured interviews with healthcare professionals were conducted.

Results

Data on 1304 decedents were collected. Of those with an advanced progressive illness (79%, n = 1034), 69% (n = 712) had a KIS. These were started a median of 45 weeks before death. People with cancer were most likely to have a KIS (80%, n = 288), and those with organ failure least likely (47%, n = 125). Overall, 68% (n = 482) of KIS included resuscitation status and 55% (n = 390) preferred place of care. People with a KIS were more likely to die in the community compared to those without one (61% versus 30%). Most KIS were considered useful/highly useful. Up-to-date free-text information within the KIS was valued highly.

Conclusion

In Scotland, most people with an advanced progressive illness have an electronic care coordination record by the time of death. This is an achievement. To improve further, better informal carer information, regular updating, and a focus on generating a KIS for people with organ failure is warranted.

Advance care planning for patients with cancer in the palliative phase in Dutch general practices

BACKGROUND

Advance care planning (ACP) is a crucial element of palliative care. It improves the quality of end-of-life care and reduces aggressive and needless life-prolonging medical interventions. However, little is known about its application in daily practice. This study aims to examine the application of ACP for patients with cancer in general practice.

METHODS

We performed a retrospective cohort study in 11 general practices in the Netherlands. Electronic patient records (EPRs) of deceased patients with colorectal or lung cancer were analysed. Data on ACP documentation, correspondence between medical specialist and GP, and health care use in the last year of life were extracted.

RESULTS

Records of 163 deceased patients were analysed. In 74% of the records, one or more ACP items were registered. GPs especially documented patients' preferences for euthanasia (58%), palliative sedation (46%) and preferred place of death (26%). Per patient, GPs received on average six letters from medical specialists. These letters mainly contained information regarding medical treatment and rarely ACP items. In the last year of life, patients contacted the GP over 30 times, and 51% visited the emergency department at least once, of whom 54% in the last month.

CONCLUSIONS

Registration of ACP items in GPs' EPRs appeared to be limited. ACP elements were rarely subject of communication between primary and secondary care, which may impact the continuity of patient care during the last year of life. More emphasis on registration of ACP items and better exchange of information regarding patients' preferences are needed.

Identifying patients at risk of futile resuscitation: palliative care indicators in out-of-hospital cardiac arrest

OBJECTIVES

Patients with indicators for palliative care, such as those with advanced life-limiting conditions, are at risk of futile cardiopulmonary resuscitation (CPR) if they suffer out-of-hospital cardiac arrest (OHCA). Patients at risk of futile CPR could benefit from anticipatory care planning (ACP); however, the proportion of OHCA patients with indicators for palliative care is unknown. This study quantifies the extent of palliative care indicators and risk of CPR futility in OHCA patients.

METHODS

A retrospective medical record review was performed on all OHCA patients presenting to an emergency department (ED) in Edinburgh, Scotland in 2015. The risk of CPR futility was stratified using the Supportive and Palliative Care Indicators Tool. Patients with 0-2 indicators had a 'low risk' of futile CPR; 3-4 indicators had an 'intermediate risk'; 5+ indicators had a 'high risk'.

RESULTS

Of the 283 OHCA patients, 12.4% (35) had a high risk of futile CPR, while 16.3% (46) had an intermediate risk and 71.4% (202) had a low risk. 84.0% (68) of intermediate-to-high risk patients were pronounced dead in the ED or ED step-down ward; only 2.5% (2) of these patients survived to discharge.

CONCLUSIONS

Up to 30% of OHCA patients are being subjected to advanced resuscitation despite having at least three indicators for palliative care. More than 80% of patients with an intermediate-to-high risk of CPR futility are dying soon after conveyance to hospital, suggesting that ACP can benefit some OHCA patients. This study recommends optimising emergency treatment planning to help reduce inappropriate CPR attempts.

Using the Term "Palliative Care": International Survey of How Palliative Care Researchers and Academics Perceive the Term "Palliative Care"

Background: The term "palliative care" (PC) has often been found to have a negative connotation leading some to suggest rebranding and some services to change their name. Perceptions of the PC community about the term remain largely unexplored. Objective: To explore how PC researchers/academics perceive the term is the objective of this study. Design: This is a cross-sectional survey of attendees to the 10th World Research Congress of the EAPC. The questionnaire covered areas of academic activity, including the use of the term. We analyzed data through descriptive and nonparametric statistics and open responses through content analysis. Participants: Academics and researchers in PC were the participants in this study. Results: Of 318 respondents, the majority were women (65%), physicians (48%), and had a postgraduate degree (90%). For 40%, the term hindered the positioning of PC, 28% worried about using the term, and 55% did not discuss these difficulties. We found significant differences between responses and several demographics (e.g., younger age and higher likelihood of worrying about the term). Through open responses, we identified that the term is widely in use, and that its limitations are seen as a cultural by-product, and not as something that a name change would solve. Conclusions: Senior PC academics, researchers, and clinicians have an onus to ensure that colleagues with limited PC experience have the opportunity to discuss and explore the impact of the term on the practice of research. Regarding the term itself, the community's views are conclusive: although using the term will remain a difficult task, the field's identity is in the name.

How do physicians and nurses in family practice describe their care for patients with progressive life-limiting illness? A qualitative study of a 'palliative approach'

AIM

To explore how a palliative approach to care is operationalized in primary care, through the description of clinical practices used by primary care clinicians to identify and care for patients with progressive life-limiting illness (PLLI).

BACKGROUND

Increasing numbers of people are living with PLLI but are often not recognized as needing a palliative approach to care. To meet growing needs, generalists such as family physicians will need to adopt a palliative approach to care in their own setting. Practical descriptions of a palliative approach in non-specialist settings have been lacking.

METHODS

We conducted a qualitative descriptive study design using in-depth semi-structured interviews with 11 key informant participants (6 physicians, 3 nurse practitioners, 1 registered nurse, and 1 registered practical nurse) known to be providing comprehensive care to patients with PLLI in family practices in Ontario, Canada. We asked about their approach to identifying patients with PLLI and the strategies used in their care. We employed content analysis to develop themes.

FINDINGS

Participants identified patients by functional decline, change in needs, increased acuity, and the specifics of a condition/diagnosis. Care strategies included concretizing commitment to care, eliciting goals of care, shifting care to the home, broadening team members including leveraging the support of family and community resources, and shifting to a 'proactive' approach involving increased follow-up, flexibility, and intensity.

CONCLUSION

Primary care providers articulated strategies for identifying and providing care to patients with PLLI that illuminate an upstream approach tailored to their setting.

Primary palliative care research: opportunities and challenges

INTRODUCTION

Primary care has a central role in palliative and end of life care: 45.6% of deaths in England and Wales occur under the care of primary care teams at home or in care homes. The Community Care Pathways at the End of Life (CAPE) study investigated primary care provided for patients in the final 6 months of life. This paper highlights the opportunities and challenges associated with primary palliative care research in the UK, describing the methodological, ethical, logistical and gatekeeping challenges encountered in the CAPE study and how these were addressed.

THE STUDY METHODS

Using a mixed-methods approach, quantitative data were extracted from the general practitioner (GP) and district nurse (DN) records of 400 recently deceased patients in 20 GP practices in the East of England. Focus groups were conducted with some GPs and DNs, and individual interviews held with bereaved carers and other GPs and DNs.

THE CHALLENGES ADDRESSED

Considerable difficulties were encountered with ethical permissions, with GP, DN and bereaved carer recruitment and both quantitative and qualitative data collection. These were overcome with flexibility of approach, perseverance of the research team and strong user group support. This enabled completion of the study which generated a unique primary palliative care data set.

Early initiation of palliative care is associated with reduced late-life acute-hospital use: A population-based retrospective cohort study

BACKGROUND:

Early palliative care can reduce end-of-life acute-care use, but findings are mainly limited to cancer populations receiving hospital interventions. Few studies describe how early versus late palliative care affects end-of-life service utilization.

AIM:

To investigate the association between early versus late palliative care (hospital/community-based) and acute-care use and other publicly funded services in the 2 weeks before death.

DESIGN:

Retrospective population-based cohort study using linked administrative healthcare data.

SETTING/PARTICIPANTS:

Decedents (cancer, frailty, and organ failure) between 1 April 2010 and 31 December 2012 in Ontario, Canada. Initiation time before death (days): early (⩾60) and late (⩾15 and <60). ‘Acute-care settings’ included acute-hospital admissions with (‘palliative-acute-care’) and without palliative involvement (‘non-palliative-acute-care’).

RESULTS:

We identified 230,921 decedents. Of them, 27% were early palliative care recipients and 13% were late; 45% of early recipients had a community-based initiation and 74% of late recipients had a hospital-based initiation. Compared to late recipients, fewer early recipients used palliative-acute care (42% vs 65%) with less days (mean days: 9.6 vs 12.0). Late recipients were more likely to use acute-care settings; this was further modified by disease: comparing late to early recipients, cancer decedents were nearly two times more likely to spend >1 week in acute-care settings (odds ratio = 1.84, 95% confidence interval: 1.83–1.85), frailty decedents were three times more likely (odds ratio = 3.04, 95% confidence interval: 3.01–3.07), and organ failure decedents were four times more likely (odds ratio = 4.04, 95% confidence interval: 4.02–4.06).

CONCLUSION:

Early palliative care was associated with improved end-of-life outcomes. Late initiations were associated with greater acute-care use, with the largest influence on organ failure and frailty decedents, suggesting potential opportunities for improvement.

Frailty trajectories to identify end of life: a longitudinal population-based study

BACKGROUND

Timely recognition of the end of life allows patients to discuss preferences and make advance plans, and clinicians to introduce appropriate care. We examined changes in frailty over 1 year, with the aim of identifying trajectories that could indicate where an individual is at increased risk of all-cause mortality and may require palliative care.

METHODS

Electronic health records from 13,149 adults (cases) age 75 and over who died during a 1-year period (1 January 2015 to 1 January 2016) were age, sex and general practice matched to 13,149 individuals with no record of death over the same period (controls). Monthly frailty scores were obtained for 1 year prior to death for cases, and from 1 January 2015 to 1 January 2016 for controls using the electronic frailty index (eFI; a cumulative deficit measure of frailty, available in most English primary care electronic health records, and ranging in value from 0 to 1). Latent growth mixture models were used to investigate longitudinal patterns of change and associated impact on mortality. Cases were reweighted to the population level for tests of diagnostic accuracy.

RESULTS

Three distinct frailty trajectories were identified. Rapidly rising frailty (initial increase of 0.022 eFI per month before slowing from a baseline eFI of 0.21) was associated with a 180% increase in mortality (OR 2.84, 95% CI 2.34-3.45) for 2.2% of the sample. Moderately increasing frailty (eFI increase of 0.007 per month, with baseline of 0.26) was associated with a 65% increase in mortality (OR 1.65, 95% CI 1.54-1.76) for 21.2% of the sample. The largest (76.6%) class was stable frailty (eFI increase of 0.001 from a baseline of 0.26). When cases were reweighted to population level, rapidly rising frailty had 99.1% specificity and 3.2% sensitivity (positive predictive value 19.8%, negative predictive value 93.3%) for predicting individual risk of mortality.

CONCLUSIONS

People aged over 75 with frailty who are at highest risk of death have a distinctive frailty trajectory in the last 12 months of life, with a rapid initial rise from a low baseline, followed by a plateau. Routine measurement of frailty can be useful to support clinicians to identify people with frailty who are potential candidates for palliative care, and allow time for intervention.

Stakeholders' views on identifying patients in primary care at risk of dying: a qualitative descriptive study using focus groups and interviews

BACKGROUND

Strategies have been developed for use in primary care to identify patients at risk of declining health and dying, yet little is known about the perceptions of doing so or the broader implications and impacts.

AIM

To explore the acceptability and implications of using a primary care-based electronic medical record algorithm to help providers identify patients in their practice at risk of declining health and dying.

DESIGN AND SETTING

Qualitative descriptive study in Ontario and Nova Scotia, Canada.

METHOD

Six focus groups were conducted, supplemented by one-on-one interviews, with 29 healthcare providers, managers, and policymakers in primary care, palliative care, and geriatric care. Participants were purposively sampled to achieve maximal variation. Data were analysed using a constant comparative approach.

RESULTS

Six themes were prevalent across the dataset: early identification is aligned with the values, aims, and positioning of primary care; providers have concerns about what to do after identification; how we communicate about the end of life requires change; early identification and subsequent conversations require an integrated team approach; for patients, early identification will have implications beyond medical care; and a public health approach is needed to optimise early identification and its impact.

CONCLUSION

Stakeholders were much more concerned with how primary care providers would navigate the post-identification period than with early identification itself. Implications of early identification include the need for a team-based approach to identification and to engage broader communities to ensure people live and die well post-identification.

Death within 1 year among emergency medical admissions to Scottish hospitals: incident cohort study

BACKGROUND

It is increasingly recognised that large numbers of hospital inpatients have entered the last year of their lives.

AIM

To establish the likelihood of death within 12 months of admission to hospital; to examine the influence on survival of a cancer diagnosis made within the previous 5 years; to assess whether previous emergency admissions influenced mortality; and to compare mortality with that of the wider Scottish population.

DESIGN

Incident cohort study.

SETTING

22 hospitals in Scotland.

PARTICIPANTS

This study used routinely collected data from 10 477 inpatients admitted as an emergency to medicine in 22 Scottish hospitals between 18 and 31 March 2015. These data were linked to national death records and the Scottish Cancer Registry.

PRIMARY OUTCOME MEASURES

1 year cohort mortality compared with that of the general Scottish population. Patient factors correlating with higher risk of mortality were identified using Cox regression.

RESULTS

There were 2346 (22.4%) deaths in the year following the census admission. Six hundred and ten patients died during that admission (5.8% of all admissions and 26% of all deaths) while 1736 died after the census admission (74% of all deaths). Malignant neoplasms (33.8%), circulatory diseases (22.5%) and respiratory disease (17.9%) accounted for almost three-quarters of all deaths. Mortality rose steeply with age and was five times higher at 1 year for patients aged 85 years and over compared with those who were under 60 years of age (41.9%vs7.9%) (p<0.001). Patients with cancer had a higher mortality rate than patients without a cancer diagnosis (55.6%vs16.6%) (p<0.001). Mortality was higher among patients with one or more emergency medical admissions in the previous year (30.1% v 15.1%) (p<0.001). Age/sex-standardised mortality was 110.4 (95% CI 104.4 to 116.5) for the cohort and 11.7 (95% CI 11.6 to 11.8) for the Scottish population, a 9.4-fold increase in risk.

CONCLUSION

These data may help identify groups of patients admitted to hospital as medical emergencies who are at greatest risk of dying not only during admission but also in the following 12 months.

Computer screening for palliative care needs in primary care: a mixed-methods study

BACKGROUND

Though the majority of people could benefit from palliative care before they die, most do not receive this approach, especially those with multimorbidity and frailty. GPs find it difficult to identify such patients.

AIM

To refine and evaluate the utility of a computer application (AnticiPal) to help primary care teams screen their registered patients for people who could benefit from palliative care.

DESIGN AND SETTING

A mixed-methods study of eight GP practices in Scotland, conducted in 2016-2017.

METHOD

After a search development cycle the authors adopted a mixed-methods approach, combining analysis of the number of people identified by the search with qualitative observations of the computer search as used by primary care teams, and interviews with professionals and patients.

RESULTS

The search identified 0.8% of 62 708 registered patients. A total of 27 multidisciplinary meetings were observed, and eight GPs and 10 patients were interviewed. GPs thought the search identified many unrecognised patients with advanced multimorbidity and frailty, but were concerned about workload implications of assessment and care planning. Patients and carers endorsed the value of proactive identification of people with advanced illness.

CONCLUSION

GP practices can use computer searching to generate lists of patients for review and care planning. The challenges of starting a conversation about the future remain. However, most patients regard key components of palliative care (proactive planning, including sharing information with urgent care services) as important. Screening for people with deteriorating health at risk from unplanned care is a current focus for quality improvement and should not be limited by labelling it solely as 'palliative care'.

Palliative and end-of-life care research in Scotland 2006-2015: a systematic scoping review

Background

The Scottish Government set out its 5-year vision to improve palliative care in its Strategic Framework for Action 2016–2021. This includes a commitment to strengthening research and evidence based knowledge exchange across Scotland. A comprehensive scoping review of Scottish palliative care research was considered an important first step. The aim of the review was to quantify and map palliative care research in Scotland over the ten-year period preceding the new strategy (2006–15).

Methods

A systematic scoping review was undertaken. Palliative care research involving at least one co-author from a Scottish institution was eligible for inclusion. Five databases were searched with relevant MeSH terms and keywords; additional papers authored by members of the Scottish Palliative and End of Life Care Research Forum were added.

Results

In total, 1919 papers were screened, 496 underwent full text review and 308 were retained in the final set. 73% were descriptive studies and 10% were interventions or feasibility studies. The top three areas of research focus were services and settings; experiences and/or needs; and physical symptoms. 58 papers were concerned with palliative care for people with conditions other than cancer – nearly one fifth of all papers published. Few studies focused on ehealth, health economics, out-of-hours and public health. Nearly half of all papers described unfunded research or did not acknowledge a funder (46%).

Conclusions

There was a steady increase in Scottish palliative care research during the decade under review. Research output was strong compared with that reported in an earlier Scottish review (1990–2005) and a similar review of Irish palliative care research (2002–2012). A large amount of descriptive evidence exists on living and dying with chronic progressive illness in Scotland; intervention studies now need to be prioritised. Areas highlighted for future research include palliative interventions for people with non-malignant illness and multi-morbidity; physical and psychological symptom assessment and management; interventions to support carers; and bereavement support. Knowledge exchange activities are required to disseminate research findings to research users and a follow-up review to examine future research progress is recommended.

Electronic supplementary material

The online version of this article (10.1186/s12904-017-0266-0) contains supplementary material, which is available to authorized users.

Improving access to the KIS in secondary care

BackgroundEffective communication of anticipatory care planning (ACP) discussions between patients and general practitioners across different healthcare settings is vital. In Scotland, the Key Information Summary (KIS) is a new piece of software that allows clinical data for selected patients to be shared electronically across the wider National Health Service from the primary care record. This can include details of ACP discussions and decisions. The KIS is now routinely accessible in secondary care and is available through the hospital electronic record in two formats (abbreviated and full versions).

AimThe primary aim of this project was to significantly improve clinician access to the full KIS record within secondary care.

MethodsFour Plan Do Study Act (PDSA) cycles were undertaken in total to improve access to the full KIS between October 2014 and March 2016 in the Medical Admissions Unit of a Scottish hospital.

ResultsBaseline data showed poor awareness and use of available KIS information by clinicians for patients admitted to hospital. Most were unaware the KIS was available and only 19% had seen the KIS for their patient. Where a KIS existed for a patient, clinicians felt the information contained within it was useful in 75% of cases, and one in every five KIS could alter clinical management. Data collection following the first 3 PDSA cycles revealed a significant increase in access to the full KIS after 5 months (from 4% to 45%). However 1 year on after after a fourth PDSA cycle to implement sustainable interventions this level of access was not maintained.

ConclusionsReasons for these results are discussed, as well as limitations to certain interventions. Access to the full KIS at the point of hospital admission can be significantly improved using a quality improvement approach. Improved access to this information may influence the clinical management of selected patients. However sustainable, system-wide strategies are needed to maintain these changes in the longer term.