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Prescribing practices, patterns, and potential harms in patients receiving palliative care: A systematic scoping review. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 3:100050. [PMID: 35480601 PMCID: PMC9031741 DOI: 10.1016/j.rcsop.2021.100050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 07/12/2021] [Accepted: 07/20/2021] [Indexed: 01/25/2023] Open
Abstract
Background Patients receiving palliative care often have existing comorbidities necessitating the prescribing of multiple medications. To maximize quality of life in this patient cohort, it is important to tailor prescribing of medication for preventing and treating existing illnesses and those for controlling symptoms, such as pain, according to individual specific needs. Objective(s) To provide an overview of peer-reviewed observational research on prescribing practices, patterns, and potential harms in patients receiving palliative care. Methods A systematic scoping review was conducted using four electronic databases (PubMed, EMBASE, CINAHL, Web of Science). Each database was searched from inception to May 2020. Search terms included ‘palliative care,’ ‘end of life,’ and ‘prescribing.’ Eligible studies had to examine prescribing for adults (≥18 years) receiving palliative care in any setting as a study aim or outcome. Studies focusing on single medication types (e.g., opioids), medication classes (e.g., chemotherapy), or clinical indications (e.g., pain) were excluded. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for scoping reviews, and the findings were described using narrative synthesis. Results Following deduplication, 16,565 unique citations were reviewed, and 56 studies met inclusion criteria. The average number of prescribed medications per patient ranged from 3 to 23. Typically, prescribing changes involved decreases in preventative medications and increases in symptom-specific medications closer to the time of death. Twenty-one studies assessed the appropriateness of prescribing using various tools. The prevalence of patients with ≥1 potentially inappropriate prescription ranged from 15 to 92%. Three studies reported on adverse drug events. Conclusions This scoping review provides a broad overview of existing research and shows that many patients receiving palliative care receive multiple medications closer to the time of death. Future research should focus in greater detail on prescribing appropriateness using tools specifically developed to guide prescribing in palliative care and the potential for harm.
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Bertocchi E, Artioli G, Rabitti E, Bedini G, Di Leo S, Asensio Sierra NM, Braglia L, Costantini M. Quality of cancer end-of-life care: discordance between bereaved relatives and professional proxies. BMJ Support Palliat Care 2020; 12:bmjspcare-2019-002108. [PMID: 32690478 DOI: 10.1136/bmjspcare-2019-002108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 04/07/2020] [Accepted: 06/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Quality of care for patients dying in hospital remains suboptimal. A major problem is the identification of valid sources of information about the views and experiences of dying patients and their relatives. AIM This study aimed to estimate the agreement on quality of end-of-life care from the perspectives of bereaved relatives, physicians and nurses interviewed after the patients' death. DESIGN In this prospective study, we interviewed, after the patient death, the bereaved relatives, the attending physicians and the reference nurses, using the Toolkit After-death Family Interview and the View Of Informal Carers-Evaluation of Services (VOICES). Agreement was assessed using Lin's concordance correlation coefficient, Cohen's kappa, overall concordance correlation coefficient and Fleiss' kappa. SETTING/PARTICIPANTS We enrolled a consecutive series of 40 adult patients who died of cancer between January and December 2016 who had spent at least 48 hours in the medical oncology ward of the Santa Maria Hospital of Reggio Emilia, Italy. RESULTS We interviewed all physicians and nurses, and 26 (65.0%) out of 40 relatives. We found a poor agreement on overall quality of care among the three proxies (+0.21; -0.04 to 0.44), between relatives and nurses (+0.05; -0.39 to +0.47), and between relatives and physicians (+0.25; -0.13 to +0.57). A similar poor agreement was observed for all the other Toolkit and VOICES scales. CONCLUSIONS The agreement was rather poor, confirming previous results in different settings. Information from professional proxies should not be used for assessing the quality of care or for estimating missing information from bereaved relatives.
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Affiliation(s)
- Elisabetta Bertocchi
- Palliative Care Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Giovanna Artioli
- Palliative Care Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Elisa Rabitti
- Psycho-Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Gabriele Bedini
- Casa Madonna dell'Uliveto Hospice, Albinea, Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Silvia Di Leo
- Psycho-Oncology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Nuria Maria Asensio Sierra
- Medicina Oncologica, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Luca Braglia
- Research and Statistics Infrastructure, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| | - Massimo Costantini
- Scientific Directorate, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
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Penders YWH, Bopp M, Zellweger U, Bosshard G. Continuing, Withdrawing, and Withholding Medical Treatment at the End of Life and Associated Characteristics: a Mortality Follow-back Study. J Gen Intern Med 2020; 35:126-132. [PMID: 31654360 PMCID: PMC6957664 DOI: 10.1007/s11606-019-05344-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 04/18/2019] [Accepted: 08/22/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies on forgoing treatment often ignore treatments that are continued until death. OBJECTIVE To investigate how often specific treatments are withdrawn or withheld before death and to describe the associated patient, physician, and care characteristics. DESIGN National mortality follow-back study in Switzerland in 2013/2014 using a standardized survey to collect information on the patient's end of life and demographics on the physician. PARTICIPANTS A random sample of adults who died non-suddenly without an external cause and who had met the physician completing the survey (N = 3051). MAIN MEASURES Any of nine specific treatments was continued until death, withdrawn, or withheld. KEY RESULTS In 2242 cases (84%), at least one treatment was either continued until death or withheld or withdrawn. The most common treatment was artificial hydration, which was continued in 23%, withdrawn in 4%, and withheld in 22% of all cases. The other eight treatments were withdrawn or withheld in 70-94% of applicable cases. The impact of physician characteristics was limited, but artificial hydration, antibiotics, artificial nutrition, and ventilator therapy were more likely to be withheld at home and in nursing homes than in the hospitals. CONCLUSIONS Large differences exist between care settings in whether treatments are continued, withdrawn, or withheld, indicating the different availability of treatment options or different philosophies of care. While certain patient groups are more likely to have treatment withheld rather than attempted, neither patient nor physician characteristics impact the decision to continue or withdraw treatment.
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Affiliation(s)
- Yolanda W H Penders
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Matthias Bopp
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland.
| | - Ueli Zellweger
- Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Georg Bosshard
- Clinic for Geriatric Medicine, Zurich University Hospital, and Center on Aging and Mobility, University of Zurich and City Hospital Waid, Zurich, Switzerland
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Elmstedt S, Mogensen H, Hallmans DE, Tavelin B, Lundström S, Lindskog M. Cancer patients hospitalised in the last week of life risk insufficient care quality - a population-based study from the Swedish Register of Palliative Care. Acta Oncol 2019; 58:432-438. [PMID: 30633611 DOI: 10.1080/0284186x.2018.1556802] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND One-quarter of all cancer deaths in Sweden occur in hospitals. If the place of death affects the quality of end-of-life (EOL) is largely unknown. METHODS This population-based, retrospective study included all adults cancer deaths reported to the Swedish Register of Palliative Care in 2011-2013 (N = 41,729). Hospital deaths were compared to deaths occurring in general or specialised palliative care, or in nursing homes with respect to care quality indicators in the last week of life. Odds ratios (OR) with 95% confidence intervals (CI) were calculated with specialised palliative home care as reference. RESULTS Preferred place of death was unknown for 63% of hospitalised patients and consistent with the actual place of death in 25% compared to 97% in palliative home care. Hospitalised patients were less likely to be informed when death was imminent (OR: 0.3; CI: 0.28-0.33) as were their families (OR: 0.51; CI: 0.46-0.57). Validated screening tools were less often used in hospitals for assessment of pain (OR: 0.32; CI: 0.30-0.34) or other symptoms (OR: 0.31; CI: 0.28-0.34) despite similar levels of EOL symptoms. Prescriptions of as needed drugs against anxiety (OR: 0.27; CI: 0.24-0.30), nausea (OR: 0.19; CI: 0.17-0.21), or pulmonary secretions (OR: 0.29; CI: 0.26-0.32) were less prevalent in hospitals. Bereavement support was offered after 57% of hospital deaths compared to 87-97% in palliative care units and 72% in nursing homes. CONCLUSIONS Dying in hospital was associated with inferior end-of-life care quality among cancer patients in Sweden.
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Affiliation(s)
- Sixten Elmstedt
- Department of Immunology Genetics and Pathology, Section of clinical and experimental oncology, Uppsala University, Uppsala, Sweden
| | - Hanna Mogensen
- Unit of Epidemiology, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Dan-Erik Hallmans
- Department of Immunology Genetics and Pathology, Section of clinical and experimental oncology, Uppsala University, Uppsala, Sweden
| | - Björn Tavelin
- Department of Radiation Sciences, Umeå University, Umeå, Sweden
| | - Staffan Lundström
- Stockholms Sjukhem Foundation and Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Lindskog
- Department of Immunology Genetics and Pathology, Section of clinical and experimental oncology, Uppsala University, Uppsala, Sweden
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Massa I, Balzi W, Altini M, Bertè R, Bosco M, Cassinelli D, Vignola V, Cavanna L, Foca F, Dall'Agata M, Nanni O, Rossi R, Maltoni M. The challenge of sustainability in healthcare systems: frequency and cost of diagnostic procedures in end-of-life cancer patients. Support Care Cancer 2018; 26:2201-2208. [PMID: 29387995 PMCID: PMC5982433 DOI: 10.1007/s00520-018-4067-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 01/22/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Literature data on the overuse and misuse of diagnostic procedures leading to end-of-life aggressiveness are scarce due to the limited amount of estimated economic waste. This study investigated the potential overuse of diagnostic procedures in a population of end-of-life patients. METHODS This is a retrospective study on consecutive advanced patients admitted into two Italian hospices. Frequency and relative costs of X-ray imaging, CT scans, MRI, and interventional procedures prescribed in the 3 months before admission were collected in patient electronic charts and/or in administrative databases. We conducted a deeper analysis of 83 cancer patients with a diagnosis of at least 1 year before admission to compare the number of examinations performed at two distant time periods. RESULTS Out of 541 patients, 463 (85.6%) had at least one radiological exam in the 3 months before last admission. The mean radiological exam number was 3.9 ± 3.2 with a relative mean cost of 278.60 ± 270.20 € per patient with a statistically significant (p < 0.001) rise near death. In the 86-patient group, a higher number of procedures was performed in the last 3 months of life than in the first quarter of the year preceding last admission (38.43 ± 28.62 vs. 27.95 ± 23.21, p < 0.001) with a consequent increase in cost. CONCLUSIONS Patients nearing death are subjected to a high level of "diagnostic aggressiveness." Further studies on the integration of palliative care into the healthcare pathway could impact the appropriateness of interventions, quality of care, and, ultimately, estimated costs.
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Affiliation(s)
- Ilaria Massa
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy.
| | - William Balzi
- Healthcare Administration, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Mattia Altini
- Healthcare Administration, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Raffaella Bertè
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Monica Bosco
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Davide Cassinelli
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Valentina Vignola
- Palliative Care Unit, Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Luigi Cavanna
- Department of Oncology and Hematology, Guglielmo da Saliceto Hospital, Via Taverna 49, 29100, Piacenza, Italy
| | - Flavia Foca
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Monia Dall'Agata
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Oriana Nanni
- Unit of Biostatistics and Clinical Trials, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Romina Rossi
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy
| | - Marco Maltoni
- Palliative Care Unit, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Via P. Maroncelli 40, 47014, Meldola, Italy.,Palliative Care Unit, Valerio Grassi Hospice, Forlimpopoli Hospital, Via Duca D'Aosta 33, 47034, Forlimpopoli, Italy
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Radiological exams on end-stage oncologic patients before hospice admission. Radiol Med 2017; 122:793-797. [PMID: 28540565 DOI: 10.1007/s11547-017-0776-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate frequency, type, and cost of diagnostic and interventional radiological exams performed on end-stage oncologic patients in the 90 days before Hospice admission. MATERIALS AND METHODS Data of patients admitted to Hospice from January 2012 through June 2013 (18 months) were cross-checked with data from the digital archive of the Radiology Department. Frequency and type of exams performed before admission were analyzed across three 1-month periods, namely M-3, M-2, M-1, corresponding to 90-61, 60-31 and 30-1 days before admission. The Regional Range of Fees was used to determine the costs. RESULTS A total of 389 patients were admitted to Hospice. Before admission, 335 patients (86%) underwent 1543 radiological exams: 919 X-rays, 555 CTs, 39 MRs, and 30 interventional procedures. The cost of these services was € 106,988 (€ 19,918 for X-rays, € 73,956 for CTs, € 9502 for MRs, and € 3612 for interventional procedures). Across the pre-Hospice periods, the proportions of examined patients increased as admission approached: 36% in M-3, 43% in M-2 (P = .038), 65% in M-1 (P < .001). The mean number of exams increased significantly, too (P < .001). CONCLUSIONS A substantial number of end-stage oncologic patients underwent radiological exams in the 90 days before Hospice admission, and these numbers grew as Hospice access approached. In the end-of-life span, diagnostic excesses should be avoided.
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Age differences in the last week of life in advanced cancer patients followed at home. Support Care Cancer 2015; 24:1889-95. [PMID: 26471279 DOI: 10.1007/s00520-015-2988-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/09/2015] [Indexed: 10/22/2022]
Abstract
A retrospective analysis of a consecutive sample of patients admitted to a home care program was performed. Data were recorded in the last week through a backward analysis from the day before death as follows: 1 week before dying (-1W), 3 days before death (-3D), and the day before dying (-1D). Data to be collected included the Edmonton Symptom Assessment System (ESAS), background pain intensity, the prevalence of breakthrough pain, the use of opioids in the last week, and the need for palliative sedation, with indications, duration, and drugs used. Patients were distributed according to the following age ranges: adults (<65 years, A) and aged (≥65 years, O). Of the latter group, three subgroups were assessed: old (65-74 years, O1), very old (75-84 years, O2), and the oldest (≥85 years, O3). Four hundred eleven patients were assessed. At -W1, no statistical differences in intensity of ESAS items ≥4 among the age subgroups were found. For ESAS values at -1W, -3D, and -1D, no statistical differences were found unless for anorexia at -1W (p = 0.000) (more likely), depression at -3D (p = 0.000) (less likely), depression (p = 0.000), and dyspnea (p = 0.01) (less likely) at -1D in the oldest group (O3). No differences in pain intensity among the groups were found (p = 0.54). Opioid doses increased in time and were significantly lower in older patients (p = 0.000). The subcutaneous route was more frequently used at -3D and -1D in older patients. No differences in opioid switching were found among the groups (p = 0.56). Adult patients required more often palliative sedation (p = 0.003). Older patients have problems relatively similar to adult patients in the last week of life, unless for some symptoms. Older patients had also a lower opioid consumption, a more frequent use of the subcutaneous route, and a lower need for palliative sedation.
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