Harnessing New and Existing Virtual Platforms to Meet the Demand for Increased Inpatient Palliative Care Services During the COVID-19 Pandemic: A 5 Key Themes Literature Review of the Characteristics and Barriers of These Evolving Technologies

Comparison of physician-delivered models of virtual and home-based in-person care for adults in the last 90 days of life with cancer and terminal noncancer illness during the COVID-19 pandemic

OBJECTIVE

To measure the association between types of serious illness and the use of different physician-delivered care models near the EOL during the COVID-19 pandemic.

DESIGN, SETTING AND PARTICIPANTS

Population-based cohort study using health administrative datasets in Ontario, Canada, for adults aged ≥18 years in their last 90 days of life who died of cancer or terminal noncancer illness and received physician-delivered care models near the end-of-life between March 14, 2020 and January 24, 2022.

EXPOSURE

The type of serious illness (cancer or terminal noncancer illness).

MAIN OUTCOME

Physician-delivered care models for adults in the last 90 days of life (exclusively virtual, exclusively home-based in-person, or mixed).

RESULTS

The study included 75,930 adults (median age 78 years, 49% female, cancer n = 58,894 [78%], noncancer illness n = 17,036 [22%]). A higher proportion of people with cancer (39.3%) received mixed model of care compared to those with noncancer illnesses (chronic organ failure 24.4%, dementia 37.9%, multimorbidity 28%). Compared to people with cancer, people with chronic organ failure (adjusted odds ratio [aOR], 1.61, 95% CI: 1.54 to 1.68) and those with multimorbidity ([aOR], 1.49, 95% CI: 1.39 to 1.59) had a higher odds of receiving virtual care than a mixed model of care. People with dementia had a higher odds of home-based in-person care than a mixed model of care ([aOR], 1.47, 95% CI 1.27, 1.71) and virtual care ([aOR], 1.40, 95% CI 1.20-1.62) compared to people with cancer.

CONCLUSION

A person's type of serious illness was associated with different care models near the end-of-life. This study demonstrates persistent disease-specific differences in care delivery or possibly the tailoring of models of care in the last 90 days of life based on a person's specific care needs.

Psychosocial palliative care: Patients' preferred intervention medium, target domains, and well-being priorities

OBJECTIVES

Although psychological distress in palliative patients has at least an equal or greater impact on the quality of life compared to physical or spiritual distress, there is limited research on contextual factors associated with psychosocial intervention accessibility and relevance. This is the first published study to explore patients' views on psychosocial intervention delivery medium preferences, key biopsychosocial target domains, and well-being priorities during the palliative and end-of-life (EOL) phases.

METHODS

Eighty-one palliative patients from a Specialist Palliative Care Service completed a questionnaire, which collected quantitative and qualitative data on preferred mediums for receiving psychosocial interventions, priority biopsychosocial target domains, and well-being priorities during the palliative and EOL phases.

RESULTS

Results showed that an individual in-person was the most preferred medium for receiving psychosocial interventions. Improving quality of life, distressing emotions, and adjusting to the palliative care context were the 3 most frequently endorsed biopsychosocial target domains. Valued living and comfortable living were the key priority well-being themes for the palliative phase, whereas being surrounded by loved ones and comfortable and dignified dying were the priority well-being themes for the EOL phase.

SIGNIFICANCE OF RESULTS

Findings highlight psychosocial interventions as an essential part of a holistic approach to patient-centered care throughout both the palliative and the EOL phases. Results can inform the refinement of existing and the development of new psychosocial interventions, particularly those that target emotional distress, adjustment, and quality of life. Furthermore, in-person treatment delivery remains essential in an evolving digital world.

Experiences of healthcare professionals, patients and families with video calls to stimulate patient- and family-centred care during hospitalization: A scoping review

AIM

To synthesize the literature on the experiences of patients, families and healthcare professionals with video calls during hospital admission. Second, to investigate facilitators and barriers of implementation of video calls in hospital wards.

DESIGN

Scoping review.

METHODS

PubMed, CINAHL and Google Scholar were searched for relevant publications in the period between 2011 and 2023. Publications were selected if they focused on experiences of patients, families or healthcare professionals with video calls between patients and their families; or between families of hospitalized patients and healthcare professionals. Quantitative and qualitative data were summarized in data charting forms.

RESULTS

Forty-three studies were included. Patients and families were satisfied with video calls as it facilitated daily communication. Family members felt more engaged and felt they could provide support to their loved ones during admission. Healthcare professionals experienced video calls as an effective way to communicate when in-person visits were not allowed. However, they felt that video calls were emotionally difficult as it was hard to provide support at distance and to use communication skills effectively. Assigning local champions and training of healthcare professionals were identified as facilitators for implementation. Technical issues and increased workload were mentioned as main barriers.

CONCLUSION

Patients, families and healthcare professionals consider video calls as a good alternative when in-person visits are not allowed. Healthcare professionals experience more hesitation towards video calls during admission, as it increases perceived workload. In addition, they are uncertain whether video calls are as effective as in-person conservations.

IMPLICATIONS FOR THE CLINICAL PRACTICE

When implementing video calls in hospital wards, policymakers and healthcare professionals should select strategies that address the positive aspects of family involvement at distance and the use of digital communication skills.

PATIENT CONTRIBUTION

No patient or public contribution.

Clinician Perspectives on Virtual Specialty Palliative Care for Patients With Advanced Illnesses

Background: Patients with serious illnesses have unmet symptom and psychosocial needs. Specialty palliative care could address many of these needs; however, access varies by geography and health system. Virtual visits and automated referrals could increase access and lead to improved quality of life, health outcomes, and patient-centered care for patients with serious illness. Objectives: We sought to understand referring clinician perspectives on barriers and facilitators to utilizing virtual tools to increase upstream access to palliative care. Design: Participants in this multisite qualitative study included practicing clinicians who commonly place palliative care referrals across multiple specialties, including hematology/oncology, family medicine, cardiology, and geriatrics. All interviews were transcribed and subsequently coded and analyzed by trained research coordinators using Atlas.ti software. Settings/Subjects: This study included 23 clinicians (21 physicians, 2 nonphysicians) across 5 specialties, 4 practice settings, and 7 states in the United States. Results: Respondents felt that community-based specialty palliative services including symptom management, advance care planning, physical therapy, and mental health counseling would benefit their patients. However, they had mixed feelings about automated referrals, with some clinicians feeling hesitant about not being alerted to such referrals. Many respondents were supportive of virtual palliative care, particularly for those who may have difficulty accessing physician offices, but most respondents felt that such care should only be provided after an initial in-person consultation where clinicians can meet face-to-face with patients. Conclusion: Clinicians believe that automated referrals and virtual palliative care could increase access to the benefits of specialty palliative care. However, virtual palliative care models should give attention to iterative communication with primary clinicians and the perceived need for an initial in-person visit.

Using inpatient telehealth for family engagement: A mixed methods study of perceptions from patients, families, and care team providers

Background

The Inpatient Telehealth Program permits family to remotely communicate with the patient and care team through secure, live video. We aimed to assess the implementation of this program for family engagement from the perspectives of patients, families, and providers.

Methods

We used a convergent mixed methods design. The quantitative component was a cross-sectional analysis of surveys assessing patient, family, and provider experience. The qualitative component used thematic analysis of patient, family, and provider interviews plus survey free text responses. We performed memo-writing and coding. We developed hypotheses about relationships among categories and identified analytic themes. We used data transformation and narrative discussion to report the integrated findings.

Results

Surveys from 214 individuals (33 patients, 145 family, 36 providers) were evaluated. Mean (standard deviation) experience ratings (1-poor, 5-best) were 4.0 (1.5) for patients, 4.6 (0.8) for family, and 4.0 (1.4) for providers. We received 134 free text responses and conducted 21 interviews. Three themes emerged: (1) inpatient telehealth enhanced patient and family experience through strengthened relationships and increased support; (2) inpatient telehealth enhanced patient care through improved information sharing and engagement; (3) low awareness of the program limited adoption. Quantitative and qualitative data aligned in that participants perceived inpatient telehealth to be valuable; however, surveys revealed that patients and providers have relatively lower satisfaction with the program.

Conclusion

Inpatient telehealth for family engagement was perceived to improve family-centeredness of care. Future work is needed to overcome implementation challenges and to increase awareness of this resource among patients and families.

Disparities in Palliative Care Among Critically Ill Patients With and Without COVID-19 at the End of Life: A Population-Based Analysis

Background

The surge in critical illness and associated mortality brought by the coronavirus virus disease 2019 (COVID-19) pandemic, coupled with staff shortages and restrictions of family visitation, may have adversely affected delivery of palliative measures, including at the end of life of affected patients. However, the population-level patterns of palliative care (PC) utilization among septic critically ill patients with and without COVID-19 during end-of-life hospitalizations are unknown.

Methods

A statewide dataset was used to identify patients aged ≥ 18 years with intensive care unit (ICU) admission and a diagnosis of sepsis in Texas, who died during hospital stay during April 1 to December 31, 2020. COVID-19 was defined by the International Classification of Diseases, 10th Revision (ICD-10) code U07.1, and PC was identified by ICD-10 code Z51.5. Multivariable logistic models were fitted to estimate the association of COVID-19 with use of PC among ICU admissions. A similar approach was used for sensitivity analyses of strata with previously reported lower and higher than reference use of PC.

Results

There were 20,244 patients with sepsis admitted to ICU during terminal hospitalization, and 9,206 (45.5%) had COVID-19. The frequency of PC among patients with and without COVID-19 was 32.0% vs. 37.1%, respectively. On adjusted analysis, the odds of PC use remained lower among patients with COVID-19 (adjusted odds ratio (aOR): 0.84, 95% confidence interval (CI): 0.78 - 0.90), with similar findings on sensitivity analyses.

Conclusions

PC was markedly less common among critically ill septic patients with COVID-19 during terminal hospitalization, compared to those without COVID-19. Further studies are needed to determine the factors underlying these findings in order to reduce disparities in use of PC.

What are the digitally enabled psychosocial interventions delivered by trained practitioners being offered to adults with life-shortening illnesses and palliative care needs and their informal and professional caregivers? A scoping review

OBJECTIVES

Computer-mediated and telephone communication connecting professionals and patients (eHealth) is well established. Yet there is little information about psychosocial interventions delivered by trained practitioners for a palliative care population. The aim is to describe digitally enabled psychosocial interventions offered to adults with life-shortening or terminal illnesses and carers/families receiving palliative care, and how these are delivered and evaluated.

METHODS

Using Joanna Briggs Institute scoping review methodology, 4 databases (MEDLINE, CINAHL, PsycINFO, and Academic Search Ultimate) were searched (January 2011-April 2021). Inclusion criteria: (a) any design reporting and (b) psychosocial interventions delivered digitally by palliative care health and social care practitioners to (c) adults with life-shortening illnesses.

RESULTS

Included papers (n=16) were from Europe ((n=8), Asia (n=2), and the USA (n=6). Research designs encompassed pre- and post-studies, randomized control trials, feasibility, and pilot studies. Tools evaluated psychological, somatic, functional, and psychosocial outcomes. Underpinning approaches included cognitive behavioral therapy, Erikson's life review, coping skills training, psychoeducation, problem-solving therapy, counseling, emotional support and advice, and art therapy. Delivery tools used were telephones, text messages and emails, websites, videos, workbooks, and compact discs. Practitioners included counselors, psychotherapists, psychologists, art therapists, social workers, registered nurses, and trainees. Patients had Alzheimer's disease and related dementias, advanced cancers, chronic obstructive pulmonary disease, and heart failure.

SIGNIFICANCE OF RESULTS

COVID-19 has accelerated the usages of digitally enabled psychosocial interventions. Evidence indicates a growing interest in hybrid, novel, synchronous, and asynchronous digital psychosocial interventions for adults with life-shortening illnesses and their caregivers receiving palliative care.

Strategies for Virtual Bereavement Care

ABSTRACT

The contagiousness of some illnesses (e.g., COVID-19) limits the ways in which families can interact with their dying loved ones who have been admitted to the hospital, especially in the intensive care unit. As a result, nurses have developed culturally relevant strategies for virtual bereavement care for patients and families predeath, perideath, and postdeath. Specific ways nurses can support, communicate, and facilitate meaningful rituals when patients die in isolation are provided in this article.

Exploring the Barriers and Facilitators Experienced by Palliative Health Care Providers Working with Patients Experiencing Homelessness during the COVID-19 Pandemic

Background

Patients experiencing homelessness not only have higher rates of medical complexity, comorbidity, and mortality, but also face barriers to accessing palliative care services. In structurally vulnerable populations with palliative care needs, these barriers are compounded, creating significant challenges for both patients and providers that have important health equity implications.

Objective

The aim is to explore the experiences of palliative care providers working with patients experiencing homelessness during the COVID-19 pandemic and understand the barriers they faced in providing care, as well as facilitators that aided in the success of their teams.

Methods

Seven health care providers from two Canadian palliative outreach teams involved in delivering palliative care services to patients experiencing homelessness during the COVID-19 pandemic participated in audio-recorded and transcribed videoconferencing interviews. Analysis was completed using generic descriptive thematic analysis.

Results

Five key themes were identified: (1) factors negatively impacting patient health, (2) use of technology, (3) care provider emotions, (4) care provider education and advocacy, and (5) outreach team factors.

Conclusion

Identified barriers during the pandemic included worsening of existing patient vulnerabilities, as well as challenges incorporating technology into care. Providers faced increased emotional burden, with a rise in workload, stress, fear, and grief. However, several facilitators allowed teams to provide high-quality care to this vulnerable population, including team support, interprofessional collaboration, and advocacy and education initiatives. The outreach model also proved to be a highly flexible, resilient, and adaptable model for providing care during the COVID-19 pandemic.

"Never waste a good crisis": A qualitative study of the impact of COVID-19 on palliative care in seven hospitals using the Dynamic Sustainability Framework

BACKGROUND

The COVID-19 pandemic led to rapid adaptations among palliative care services, but it is unclear how these adaptations vary in relation to their unique organizational contexts.

AIM

Understand how the pandemic impacted the implementation of new and existing palliative care programs in diverse hospital systems using the Dynamic Sustainability Framework.

DESIGN

Twelve in-depth interviews with 15 key informants representing palliative care programs from seven hospital systems between April and June 2020.

SETTING

Public, not-for-profit private, community, and academic teaching hospitals in the San Francisco Bay Area with existing palliative care programs that were expanding services to new clinical areas (e.g. new outpatient clinic or community-based care).

RESULTS

Six themes characterized how palliative care programs were impacted and adapted during the early stages of the COVID-19 pandemic: palliative care involvement in preparing for surge, increased emphasis on advance care planning, advocating for visitors for dying patients, providing emotional support to clinicians, adopting virtual approaches to care, and gaps in chaplaincy support. There was variation in how new and existing programs were able to adapt to early pandemic stresses; systems with new outpatient programs struggled to utilize their programs effectively during the crisis onset.

CONCLUSIONS

The fit between palliative care programs and practice setting was critical to program resiliency during the early stages of the pandemic. Reconceptualizing the Dynamic Sustainability Framework to reflect a bidirectional relationship between ecological system, practice setting, and intervention levels might better guide implementers and researchers in understanding how ecological/macro changes can influence interventions on the ground.

Impact of the coronavirus disease 2019 pandemic on delivery of and models for supportive and palliative care for oncology patients

PURPOSE OF REVIEW

Supportive and palliative care services have been an important component of the overall COVID-19 pandemic response. However, significant changes in the provision and models of care were needed in order to optimize the care delivered to vulnerable cancer patients. This review discusses the evolution of palliative and supportive care service in response to the pandemic, and highlights remaining challenges.

RECENT FINDINGS

Direct competition for resources, as well as widespread implementation of safety measures resulted in major shifts in the mode of assessment and communication with cancer patients by supportive care teams. Telemedicine/virtual consultation and follow-up visits became an integral strategy, with high uptake and satisfaction amongst patients, families and providers. However, inequities in access to the required technologies were sometimes exposed. Hospice/palliative care unit (PCU) bed occupancy declined markedly because of restrictive visitation policies. Collection of patient-reported outcome (PRO) data was suspended in many cancer centers, with resulting under-recognition of anxiety and depression in ambulatory patients. As in many other areas, disparities in delivery of supportive and palliative care were magnified by the pandemic.

SUMMARY

Virtual care platforms have been widely adopted and will continue to be used to include a wider circle of family/friends and care providers in the provision of palliative and supportive care. To facilitate equitable delivery of supportive care within a pandemic, further research and resources are needed to train and support generalists and palliative care providers. Strategies to successfully collect PROs from all patients in a virtual manner must be developed and implemented.

Comparative end-of-life communication and support in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada

OBJECTIVE

To compare end-of-life in-person family presence, patient-family communication and healthcare team-family communication encounters in hospitalised decedents before and during the COVID-19 pandemic.

DESIGN

In a regional multicentre retrospective cohort study, electronic health record data were abstracted for a prepandemic group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one COVID-19 free (COVID-ve) and one with COVID-19 infection (COVID+ve). Pre-COVID and COVID-ve groups were matched 2:1 (age, sex and care service) with the COVID+ve group.

SETTING

One quaternary and two tertiary adult, acute care hospitals in Ottawa, Canada.

PARTICIPANTS

Decedents (n=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170).

MAIN OUTCOME MEASURES

End-of-life (last 48 hours) in-person family presence and virtual (video) patient-family communication, and end-of-life (last 5 days) virtual team-family communication encounter occurrences were examined using logistic regression with ORs and 95% CIs. End-of-life (last 5 days) rates of in-person and telephone team-family communication encounters were examined using mixed-effects negative binomial models with incidence rate ratios (IRRs) and 95% CIs.

RESULTS

End-of-life in-person family presence decreased progressively across pre-COVID (90.6%), COVID-ve (79.4%) and COVID+ve (47.1%) groups: adjusted ORs=0.38 (0.2-0.73) and 0.09 (0.04-0.17) for COVID-ve and COVID+ve groups, respectively. COVID-ve and COVID+ve groups had reduced in-person but increased telephone team-family communication encounters: IRRs=0.76 (0.64-0.9) and 0.61 (0.47-0.79) for in-person, and IRRs=2.6 (2.1-3.3) and 4.8 (3.7-6.1) for telephone communications, respectively. Virtual team-family communication encounters occurred in 17/85 (20%) and 10/170 (5.9%) of the COVID+ve and COVID-ve groups, respectively: adjusted OR=3.68 (1.51-8.95).

CONCLUSIONS

In hospitalised COVID-19 pandemic wave 1 decedents, in-person family presence and in-person team-family communication encounters decreased at end of life, particularly in the COVID+ve group; virtual modalities were adopted for communication, and telephone use increased in team-family communication encounters. The implications of these communication changes for the patient, family and healthcare team warrant further study.

[Strategies, guidelines and recommendations for coping with the COVID-19 pandemic in palliative and hospice care facilities. Results of a scoping review]

BACKGROUND

Palliative and hospice care facilities face different challenges emerging from the COVID-19 pandemic. In particular, this results from the high age and pre-existing diseases of patients as well as the physically close contact between staff and patients.

OBJECTIVE

The aim of this study was to identify existing strategies, guidelines and recommendations in Germany and other countries with respect to addressing the challenges of the COVID-19 pandemic in palliative and hospice care.

MATERIAL AND METHODS

The databases PubMed, CINAHL, Web of Science and PsycInfo were searched as part of a scoping review. Additionally, Google Search and Google Scholar were used to identify "grey literature". All German and English language articles related to inpatient palliative and hospice care were included which were published between January 2020 and August 2021.

RESULTS

A total of 51 publications were included in the analysis. The identified measures can be clustered into 10 different categories: infection control measures, structural measures, visiting regulations, communication structures, education and training, psychosocial support measures, specific considerations for people with dementia, advance care planning, farewell and measures after death.

CONCLUSION

With respect to addressing the COVID-19 pandemic, the primary focus is on measures to enable communication between patients, staff and relatives, psychosocial support measures, structural measures and recommendations for training and education of all stakeholders. Measures for the palliative care of people with dementia in times of a pandemic as well as the farewell and grief management of bereaved families received less attention.