Barriers for Adult Patients to Access Palliative Care in Hospitals: A Mixed Methods Systematic Review

BACKGROUND

Access to palliative care services is variable, and many inpatients do not receive palliative care. An overview of potential barriers could facilitate the development of strategies to overcome factors that impede access for patients with palliative care needs.

AIM

To review the current evidence on barriers that impair, delay, or prohibit access to palliative care for adult hospital inpatients.

DESIGN

A mixed methods systematic review was conducted using an integrated convergent approach and thematic synthesis (PROSPERO ID: CRD42021279477).

DATA SOURCES

The Cochrane Library, MEDLINE, CINAHL, and PsycINFO were searched from 10/2003 to 12/2020. Studies with evidence of barriers for inpatients to access existing palliative care services were eligible and reviewed.

RESULTS

After an initial screening of 3,359 records and 555 full-texts, 79 studies were included. Thematic synthesis yielded 149 access-related phenomena in 6 main categories: 1) Sociodemographic characteristics, 2) Health-related characteristics, 3) Individual beliefs and attitudes, 4) Interindividual cooperation and support, 5) Availability and allocation of resources, and 6) Emotional and prognostic challenges. While evidence was inconclusive for most socio-demographic factors, the following barriers emerged: having a noncancer condition or a low symptom burden, the focus on cure in hospitals, nonacceptance of terminal prognosis, negative perceptions of palliative care, misleading communication and conflicting care preferences, lack of resources, poor coordination, insufficient expertise, and clinicians' emotional discomfort and difficult prognostication.

CONCLUSION

Hospital inpatients face multiple barriers to accessing palliative care. Strategies to address these barriers need to take into account their multidimensionality and long-standing persistence.

Late to Palliate? Inpatient Palliative Care Consultation at an Academic Veterans Affairs Hospital

INTRODUCTION

Despite robust evidence describing the benefits of palliative care consultation (PCC), this service is underutilized. Hospital admission provides an important opportunity to obtain PCC.

METHODS

We evaluated all inpatients who received PCC at a Veterans Affairs academic hospital from January 1, 2019 to December 31, 2019. Logistic regression was used to determine factors associated with early versus late PCC, with early defined as >30 days from consult to death and late defined as ≤30 days.

RESULTS

The median time from PCC to death was 37 days. The majority of PCCs were early (58.4%). Of all patients receiving inpatient PCC, 13.2% died that admission. Cardiac (odds ratio = 0.3, 95% CI = 0.11-0.73) and neurological (odds ratio = 0.21, 95% CI = 0.05-0.70) diagnoses were more likely to receive early PCC compared to malignancy. Of the late PCCs receiving first-time consults, 58.9% had at least one admission during the last year.

CONCLUSIONS

Many patients are introduced to palliative care services within a month of death. These patients were often admitted during the prior year, presenting a missed opportunity to involve inpatient PCC earlier.

Screening tools to identify patients with unmet palliative care needs in the emergency department: A systematic review

OBJECTIVES

This systematic review identified and assessed psychometric properties of the available screening tools to identify patients with unmet palliative care (PC) needs in the emergency department (ED).

METHODS

A comprehensive search of electronic databases and the gray literature was conducted. Two independent reviewers completed study screening and inclusion, data extraction, and quality assessment. A descriptive summary of the results was reported using median of medians and interquartile ranges (IQRs).

RESULTS

A total of 35 studies were included, involving the assessment of 14 unique screening tools. The most commonly used screening tool was the surprise question (SQ; n = 12 studies), followed by the Palliative Care and Rapid Emergency Screening (P-CaRES) tool (n = 8), and the screening for palliative and end-of-life care needs in the emergency department (SPEED) instrument (n = 4). Twelve of the included studies reported on the psychometric properties of the screening tools, of which eight of these studies assessed the performance of the SQ to predict patient mortality. Overall, the median sensitivity (63%, IQR 38%-78%) and specificity (75%, IQR 57%-84%) of the SQ to predict mortality at 1 or 12 months was moderate. While the median positive predictive value of the SQ was low (32%, IQR 16%-40%), the median negative predictive value was high (91%, IQR 88%-95%). Across the studies, the proportion of patients identified as having unmet PC based on the criteria of the screening tools ranged from 5% to 83%.

CONCLUSIONS

This review identified 14 unique screening tools used to identify adult patients with unmet PC needs in the ED. One screening tool, the SQ, was found to have moderate sensitivity and specificity to accurately predict future patient mortality. Additional research is needed to better understand the clinical value of this and the other available tools prior to their widespread implementation.

Comparison of the Management and Short-Term Outcomes between Patients with Advanced Cancer and Other End-of-Life Conditions Presenting to Two Canadian Emergency Departments

Background: An increasing number of patients with end-of-life (EOL) conditions, particularly those with advanced cancer, are presenting to the emergency department (ED). Objectives: To assess the characteristics, management and short-term outcomes of ED patients with advanced cancer compared to patients with other EOL conditions. Methodology/Design: A secondary analysis of a prospective cohort study. Setting/Participants: Volunteer emergency physicians in two Canadian EDs identified presentations for advanced cancer and other EOL conditions with the aid of a modified screening tool March-August 2018. Results: Among the 663 presentations by patients with EOL conditions, 272 (41%) presented with advanced cancer. The majority of presentations for advanced cancer (81%) or other EOL conditions (77%) were by patients with unmet palliative care (PC) needs. Patients with advanced cancer were significantly less likely to have active goals of care (GOC) documented on their charts (53% vs. 75%; p < 0.001). While no significant differences were found between the groups, the majority of presentations involved imaging, investigations, consultations, and hospitalization. Presentations for advanced cancer were more likely to receive a postdischarge referral (38% vs. 23%; p < 0.001). Referrals to PC consultations or postdischarge referrals were infrequent. Regression analysis found that patients with advanced cancer were associated with shorter length of stay (LOS). Conclusions: The majority of presentations for advanced cancer or other EOL conditions involved significant resource use. Patients with cancer experienced shorter LOS; however, had less documentation of GOC and gaps in referrals to PC services were identified. Interventions should be explored to promote early GOC discussions and PC referrals in this patient group.

The Influence of Palliative Care in Hospital Length of Stay and the Timing of Consultation

BACKGROUND

Inpatient palliative care may reduce length-of-stay, costs, mortality, and prevent readmissions. Timing of consultation may influence outcomes. The aim of this study was to explore the timing of consultation and its influences patient outcomes.

METHOD

This retrospective study of hospital consultations between July 1, 2019 and December 31, 2019 compared patients seen within 72 hours of admission with those seen after 72 hours. Outcomes length of stay and mortality. Chi-square analyses for categorical variables and independent t-tests for continuous normally distributed variables were done. For nonparametrically distributed outcome variables, Wilcoxon rank sum test was used. For mortality, a time-to-event analysis was used. 30-day readmissions were assessed using the Fine-Gray sub-distribution hazard model. Multiple regression models were used, controlling for other variables.

RESULTS

696 patients were seen, 424 within 72 hours of admission. The average age was 73 and 50.6% were female. Consultation within 72 hours was not associated with a shorter stay for cancer but was for patients with non-cancer illnesses. Inpatient mortality and 30-days mortality were reduced but there was a higher 30-day readmission rate.

DISCUSSION

Palliative consultations within 72 hours of admission was associated with lower hospital stays and inpatient mortality but increased the risk of readmission. Benefits were largely observed in patients followed in continuity.

CONCLUSION

Early inpatient palliative care consultation was associated with reduced hospital mortality, 30-day mortality and length of stay particularly if patients were seen by palliative care prior to hospitalization.

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.

An Assessment of the Management of Patients with Advanced End-Stage Illness in the Emergency Department: An Observational Cohort Study

Background: Presentations to the emergency department (ED) by patients with end-of-life (EOL) conditions for their acute care needs are common. Objectives: The objective of this study was to identify and describe the ED management across presentations to the ED for EOL conditions. Design: Prospective observational cohort study. Settings/Subjects: Emergency physicians in two Canadian ED's were asked to identify presentations by adult patients with EOL conditions using a modified screening tool. Measurements: Patient characteristics and ED management for each presentation were collected through chart review by trained research assistants. Descriptive analyses were conducted as appropriate and bivariate comparisons of dichotomous and continuous variables were completed using χ² tests and using t test or Wilcoxon rank-sum test, respectively. Results: Physicians identified 663 ED presentations for EOL conditions, with advanced cancer (41%), dementia (23%), and chronic obstructive pulmonary disease (16%) being the most common EOL conditions. The majority of presentations involved consultations (77%), hospitalization (65%), and numerous investigations (97%), including blood work (97%) and imaging (92%). The majority of patients with EOL conditions had a history of ED visits (68%). Using a modified screening tool, 78% of presentations involved patients with unmet palliative care needs, but only 1% of presentations involved a palliative consultation or admission to a palliative care unit. Conclusion: Presentations to the ED for EOL conditions involve significant ED resources; however, only a handful of patients are referred to palliative services. Patients with EOL conditions are appropriate targets for palliative services and community support outside the ED.