Defining patients as palliative: hospital doctors' versus general practitioners' perceptions

Translation and Cross-Cultural Adaptation of the Supportive and Palliative Care Indicators Tool into Japanese: A Preliminary Report

Background:

Methods:

Results:

Conclusion:

Association Between Attending Physicians' Rates of Referral to Palliative Care and Location of Death in Hospitalized Adults With Serious Illness: A Population-based Cohort Study

BACKGROUND

Patients who receive palliative care are less likely to die in hospital.

OBJECTIVE

To measure the association between physician rates of referral to palliative care and location of death in hospitalized adults with serious illness.

RESEARCH DESIGN

Population-based decedent cohort study using linked health administrative data in Ontario, Canada.

SUBJECTS

A total of 7866 physicians paired with 130,862 hospitalized adults in their last year of life who died of serious illness between 2010 and 2016.

EXPOSURE

Physician annual rate of referral to palliative care (high, average, low).

MEASURES

Odds of death in hospital versus home, adjusted for patient characteristics.

RESULTS

There was nearly 4-fold variation in the proportion of patients receiving palliative care during follow-up based on attending physician referral rates: high 42.4% (n=24,433), average 24.7% (n=10,772), low 10.7% (n=6721). Referral to palliative care was also associated with being referred by palliative care specialists and in urban teaching hospitals. The proportion of patients who died in hospital according to physician referral rate were 47.7% (high), 50.1% (average), and 52.8% (low). Hospitalized patients cared for by a physician who referred to palliative care at a high rate had lower risk of dying in hospital than at home compared with patients who were referred by a physician with an average rate of referral [adjusted odds ratio 0.91; 95% confidence interval, 0.86-0.95; number needed to treat=57 (interquartile range 41-92)] and by a physician with a low rate of referral [adjusted odds ratio 0.81; 95% confidence interval, 0.77-0.84; number needed to treat =28 patients (interquartile range 23-44)].

CONCLUSIONS AND RELEVANCE

An attending physicians' rates of referral to palliative care is associated with a lower risk of dying in hospital. Therefore, patients who are cared for by physicians with higher rates of referral to palliative care are less likely to die in hospital and more likely to die at home. Standardizing referral to palliative care may help reduce physician-level variation as a barrier to access.

Comparison of Palliative Care Delivery in the Last Year of Life Between Adults With Terminal Noncancer Illness or Cancer

IMPORTANCE

Palliative care improves health outcomes, but studies of the differences in the delivery of palliative care to patients with different types of serious illness are lacking.

OBJECTIVE

To examine the delivery of palliative care among adults in their last year of life who died of terminal noncancer illness compared with those who died of cancer.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used linked health administrative data of adults who received palliative care in their last year of life and died between January 1, 2010, and December 31, 2017, in Ontario, Canada.

EXPOSURES

Cause of death (chronic organ failure, dementia, or cancer).

MAIN OUTCOMES AND MEASURES

Components of palliative care delivery, including timing and location of initiation, model of care, physician mix, care settings, and location of death.

RESULTS

A total of 145 709 adults received palliative care (median age, 78 years; interquartile range, 67-86 years; 50.7% female); 21 054 died of chronic organ failure (4704 of heart failure, 5715 of chronic obstructive pulmonary disease, 3785 of end-stage kidney disease, 579 of cirrhosis, and 6271 of stroke), 14 033 died of dementia, and 110 622 died of cancer. Palliative care was initiated earlier (>90 days before death) in patients with cancer (32 010 [28.9%]) than in those with organ failure (3349 [15.9%]; absolute difference, 13.0%) or dementia (2148 [15.3%]; absolute difference, 13.6%). A lower proportion of patients with cancer had palliative care initiated in the home (16 088 [14.5%]) compared with patients with chronic organ failure (6904 [32.8%]; absolute difference, -18.3%) or dementia (3922 [27.9%]; absolute difference, -13.4%). Patients with cancer received palliative care across multiple care settings (92 107 [83.3%]) more often than patients with chronic organ failure (12 061 [57.3%]; absolute difference, 26.0%) or dementia (7553 [53.8%]; absolute difference, 29.5%). Palliative care was more often delivered to patients with cancer (80 615 [72.9%]) using a consultative or specialist instead of a generalist model compared with patients with chronic organ failure (9114 [43.3%]; absolute difference, 29.6%) or dementia (5634 [40.1%]; absolute difference, 32.8%). Patients with cancer (42 718 [38.6%]) received shared palliative care more often from general practitioners and physicians with subspecialty training, compared with patients with chronic organ failure (3599 [17.1%]; absolute difference, 21.5%) or dementia (1989 [14.2%]; absolute difference, 24.4%).

CONCLUSIONS AND RELEVANCE

In this cohort study, there were substantial patient- and practitioner-level differences in the delivery of palliative care across distinct types of serious illness. These patient- and practitioner-level differences have important implications for the organization and scaled implementation of palliative care programs, including enhancement of practitioner education and training and improvements in equitable access to care across all settings.

Similar levels of symptoms and problems were found among patients referred to specialized palliative care by general practitioners and hospital physicians: A nationwide register-based study of 31,139 cancer patients

BACKGROUND

Previous studies suggest that the symptomatology threshold (i.e. the level and types of symptoms) for a referral to specialized palliative care might differ for doctors in different parts of the healthcare system; however, it has not yet been investigated.

AIM

To investigate if the number and level of symptoms/problems differed for patients referred from the primary and secondary healthcare sectors (i.e. general practitioner versus hospital physician).

SETTING/PARTICIPANTS

Adult cancer patients registered in the Danish Palliative Care Database who reported their symptoms/problems at admittance to specialized palliative care between 2010 and 2017 were included. Ordinal logistic regression analyses were performed with each symptom/problem as outcome to study the association between referral sector and symptoms/problems, controlled for the effect of gender, age, cancer diagnosis and the specialized palliative care service referred to.

RESULTS

The study included 31,139 patients. The average age was 69 years and 49% were women. Clinically neglectable associations were found between referral sector and pain, appetite loss, fatigue, number of symptoms/problems, number of severe symptoms/problems (odds ratios between 1.05 and 1.20, all p < 0.05) and physical functioning (odds ratio = 0.81 (inpatient care) and 1.32 (outpatient), both p < 0.05). The remaining six outcomes were not significantly associated with referral sector.

CONCLUSION

Differences across healthcare sectors in, for example, competences and patient population did not seem to result in different symptomatology thresholds for referring patients to palliative care since only small, and probably not clinically relevant, differences in symptomatology was found across referral sectors.

Venous thromboembolism in palliative care patients: what do we know?

Despite a breadth of data on the management of cancer-associated thrombosis, all the studies informing clinical guidelines excluded patients receiving palliative care. Patients with advanced cancer have a higher rate of recurrent venous thromboembolism (VTE) and bleeding, making them one of the most challenging populations to treat. The dearth of population-specific research leaves clinicians with few options but to extrapolate data from clinical trials conducted on a healthier population. Recent observational studies have challenged the utility of doing this, suggesting the natural history of VTE in the advanced cancer patient may differ to our first beliefs and that a less aggressive approach to anticoagulation is warranted particularly near the end of life. This paper highlights what we know so far.

Rethinking End-of-Life Care and Palliative Care: Learning From the Illness Trajectories and Lived Experiences of Terminally Ill Patients and Their Family Carers

Lynn conceptualized end-of-life (EoL) care for patients with advanced chronic-progressive illnesses as a combination of life-preserving/palliative care, the palliative aspect gradually becoming the main focus as death approaches. We checked this concept by exploring the advanced-terminal illness trajectories of 50 patients. Strategies heralding active therapy exhaustion were the catalyst for a participant's awareness of terminality, but were not a decisive factor in the divergent EoL care pathways we detected. The terms life-preserving and palliative do not adequately capture EoL care pathways due to their conceptual ambiguity. Conversely, the concept of EoL care encompassing three palliative care modalities ( life-prolonging palliative therapy, restorative palliative care, and symptom-oriented [only] palliative care), each harboring a different blend of life-preserving and symptom-comforting aspects, proved adequate. These modalities could run serially, oscillatorily, or parallelly, explaining the divergent EoL care pathways. We suggest an adjustment of the model of Lynn and reconsider the traditional palliative care concept.

A framework for complexity in palliative care: A qualitative study with patients, family carers and professionals

Background:

Palliative care patients are often described as complex but evidence on complexity is limited. We need to understand complexity, including at individual patient-level, to define specialist palliative care, characterise palliative care populations and meaningfully compare interventions/outcomes.

Aim:

To explore palliative care stakeholders’ views on what makes a patient more or less complex and insights on capturing complexity at patient-level.

Design:

In-depth qualitative interviews, analysed using Framework analysis.

Participants/setting:

Semi-structured interviews across six UK centres with patients, family, professionals, managers and senior leads, purposively sampled by experience, background, location and setting (hospital, hospice and community).

Results:

65 participants provided an understanding of complexity, which extended far beyond the commonly used physical, psychological, social and spiritual domains. Complexity included how patients interact with family/professionals, how services’ respond to needs and societal perspectives on care. ‘Pre-existing’, ‘cumulative’ and ‘invisible’ complexity are further important dimensions to delivering effective palliative and end-of-life care. The dynamic nature of illness and needs over time was also profoundly influential. Adapting Bronfenbrenner’s Ecological Systems Theory, we categorised findings into the microsystem (person, needs and characteristics), chronosystem (dynamic influences of time), mesosystem (interactions with family/health professionals), exosystem (palliative care services/systems) and macrosystem (societal influences). Stakeholders found it acceptable to capture complexity at the patient-level, with perceived benefits for improving palliative care resource allocation.

Conclusion:

Our conceptual framework encompasses additional elements beyond physical, psychological, social and spiritual domains and advances systematic understanding of complexity within the context of palliative care. This framework helps capture patient-level complexity and target resource provision in specialist palliative care.

Use of non-pharmacological interventions for comforting patients in palliative care: a scoping review

BACKGROUND

Palliative care aims to provide the maximum possible comfort to people with advanced and incurable diseases. The use of non-pharmacological interventions to promote comfort in palliative care settings has been increasing.However, information on implemented and evaluated interventions, their characteristics, contexts of application, and population is scattered in the literature, hampering the formulation of accurate questions on the effectiveness of those interventions and, consequently, the development of a systematic review.

OBJECTIVE

The objective of this scoping review is to examine and map the non-pharmacological interventions implemented and evaluated to provide comfort in palliative care.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

This scoping review considered all studies that focused on patients with advanced and incurable diseases, aged 18 years or older, assisted by palliative care teams.

CONCEPT

This scoping review considered all studies that addressed non-pharmacological interventions implemented and evaluated to provide comfort for patients with advanced and incurable diseases.It considered non-pharmacological interventions implemented to provide not only comfort but also well-being, and relief of pain, suffering, anxiety, depression, stress and fatigue which are comfort-related concepts.

CONTEXT

This scoping review considered all non-pharmacological interventions implemented and evaluated in the context of palliative care. This included home care, hospices or palliative care units (PCUs).

TYPES OF SOURCES

This scoping review considered quantitative and qualitative studies, and systematic reviews.

SEARCH STRATEGY

A three-step search strategy was undertaken: 1) an initial limited search of CINAHL and MEDLINE; 2) an extensive search using all identified keywords and index terms across all included databases; and 3) a hand search of the reference lists of included articles.This review was limited to studies published in English, Spanish and Portuguese in any year.

EXTRACTION OF RESULTS

A data extraction instrument was developed. Two reviewers extracted data independently. Any disagreements that arose between the reviewers were resolved through discussion, or with a third reviewer. When necessary, primary authors were contacted for further information/clarification of data.

PRESENTATION OF RESULTS

Eighteen studies were included covering 10 non-pharmacological interventions implemented and evaluated to provide comfort. The interventions included one to 14 sessions. The interventions lasted between five and 60 minutes. Most of the interventions were implemented in PCUs and hospice settings. Ten of the 18 interventions were implemented and evaluated exclusively in cancer patients.

CONCLUSIONS

Ten non-pharmacological interventions were identified, of which the most common were music therapy and massage therapy. Their characteristics differed significantly across interventions and even in the same intervention. They were mostly implemented in palliative care units and hospices, and in patients with a cancer diagnosis. These data raise questions for future primary studies and systematic reviews.

IMPLICATIONS FOR RESEARCH

Future research should focus on the implementation of interventions not only with cancer patients but also with non-cancer patients and patients receiving palliative care at home. Systematic reviews on the effect of massage therapy and music therapy should be conducted.

Are general practitioners getting the information they need from hospitals to manage their lung cancer patients? A qualitative exploration

The delivery of cancer services is primarily hospital-based; however, General Practitioners (GPs) have a key role to play within the context of a multidisciplinary model of care. In order to fulfill their role in cancer care GPs must receive complete and timely information from appropriate members of the hospital team. The aim of this study was to investigate perceptions of the quality, format and timeliness of the patient information GPs receive from a multidisciplinary hospital-based lung cancer team, and elicit how communication between the team and the GP could be improved. Data were collected using semi-structured interviews with a representative sample (n=22) of members of the hospital team and a sample of GPs (n=8). A grounded theory approach was used to categorise the data. Most communications with GPs were from medical officers; however, GPs desired information from all health professional groups in the hospital-based lung cancer team. Most GPs were dissatisfied with the timing of communication. A multidisciplinary discharge summary was suggested as a means of providing both clinical and social information from the team to the GP. Further developments in electronic health records could improve access to patient information by GPs. Results from this study illustrate the need for GPs to receive information from all members of the multidisciplinary hospital team so that they may fulfill their diverse role in supporting patients through all phases of the cancer journey.

Palliative care for patients with chronic obstructive pulmonary disease: current perspectives

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory illness with a myriad of disabling symptoms and a decline in the functional parameters that affect the quality of life. The mortality and morbidity associated with severe COPD is high and the patients are mostly housebound and in need of continuous care and support. The uncertain nature of its prognosis makes the commencement of palliative care and discussion of end-of-life issues difficult even in the advanced stage of the disease. This is often compounded by inadequate communication and counseling with patients and their relatives. The areas that may improve the quality of care include the management of dyspnea, oxygen therapy, nutritional support, antianxiety, and antidepressant treatment, and advance care planning. Hence, it is necessary to pursue a holistic care approach for palliative care services along with disease-specific medical management in all such patients to improve the quality of life in end-stage COPD.

A Comparison of Cancer and Noncancer Patients Who Receive Palliative Care Consultation Services

This study aimed to compare multiaspect characteristics in cancer and noncancer patients who received palliative care. Totally, 226 patients with cancer and 115 noncancer patients received palliative care consultation service in Taiwan from September 2007 through December 2009 were retrospectively analyzed. Noncancer patients were older (81 vs 67 years, P < .001), more likely to be enrolled from an intensive care unit (51% vs 5%, P < .001), and waited longer to be referred for admission to a palliative care (8 vs 3 days, P < .001) than patients with cancer. Cancer and noncancer patients presented as polysymptomatics in both physical and psychosocial symptoms at the end of life. Such physical and psychosocial characteristics should be taken into account in providing appropriate end-of-life care in the same way as it is for the patients with cancer.

Early identification of and proactive palliative care for patients in general practice, incentive and methods of a randomized controlled trial

Background

According to the Word Health Organization, patients who can benefit from palliative care should be identified earlier to enable proactive palliative care. Up to now, this is not common practice and has hardly been addressed in scientific literature. Still, palliative care is limited to the terminal phase and restricted to patients with cancer. Therefore, we trained general practitioners (GPs) in identifying palliative patients in an earlier phase of their disease trajectory and in delivering structured proactive palliative care. The aim of our study is to determine if this training, in combination with consulting an expert in palliative care regarding each palliative patient's tailored care plan, can improve different aspects of the quality of the remaining life of patients with severe chronic diseases such as chronic obstructive pulmonary disease, congestive heart failure and cancer.

Methods/Design

A two-armed randomized controlled trial was performed. As outcome variables we studied: place of death, number of hospital admissions and number of GP out of hours contacts.

Discussion

We expect that this study will increase the number of identified palliative care patients and improve different aspects of quality of palliative care. This is of importance to improve palliative care for patients with COPD, CHF and cancer and their informal caregivers, and to empower the GP. The study protocol is described and possible strengths and weaknesses and possible consequences have been outlined.

Trial Registration

The Netherlands National Trial Register: NTR2815

Defining priorities in prognostication research: results of a consensus workshop

PURPOSE

To establish consensus among palliative care researchers on the priorities for prognostication research.

METHODS

A nominal group technique was employed involving palliative care researchers attending a workshop within a scientific meeting on prognostication. Participants worked in small facilitated groups to generate future research questions which were amalgamated and rated according to importance.

RESULTS

Twenty-five meeting delegates took part in the workshop including 10 palliative care physicians and four nurses, one dietician, and 10 academic researchers, all of whom had experience and/or interest in prognosis research. A total of 40 research questions were generated and after prioritization ratings, the top five questions were: (1) How valid are prognostic tools? (=2) Can we use prognostic criteria as entry criteria for research? (=2) How do we judge the impact of a prognostic score in clinical practice? (4) What is the best way of presenting survival data to patients? (5) What is the most user-friendly validated tool?

CONCLUSIONS

Although a wide range of research questions relating to prognostication were identified, the strongest priority to emerge from the consensus data concerned the validity of prognostic tools. Further research to validate existing tools is essential to ensure their clinical value.

What Information Do General Practitioners Need to Care for Patients with Lung Cancer? A Survey of General Practitioners Perceptions

General practitioners (GPs) are an integral part of the multidisciplinary team that care for patients with lung cancer. It is essential that patient information including results of tests, management plans, treatment, and follow-up arrangements are communicated between hospital-based carers and the community-based GR. The aim of this study was to explore GPs' views about the information they need from hospital-based health professionals in the management of their patients with lung cancer. This exploration is undertaken within the context of a multidisciplinary model of care, a relatively new concept in service delivery for cancer patients. Data were collected using a questionnaire that was distributed to the population of 433 GPs from one Australian regional Division of General Practice. Questions related to from whom, what, when and how GPs would like to receive information from the multidisciplinary hospital-based lung cancer team. GPs reported that they wanted information from all members of the multidisciplinary hospital-based lung cancer team, not just physicians. The key triggers for communication included: any change in the patient's condition; following initial outpatient visit; at admission and discharge; and following treatment milestones. Both medical and social information were seen as important to GPs and there was strong support to receive information electronically. This study illustrates the desire by GPs to receive information from all members of the hospital-based lung cancer team if it is relevant to the ongoing care of their patient. Technology-enabled solutions, such as an electronic multidisciplinary discharge summary, the electronic health record and the person-controlled electronic health record, offer strategies to improve both timeliness and access to information.

Quality of life measures (EORTC QLQ-C30 and SF-36) as predictors of survival in palliative colorectal and lung cancer patients

OBJECTIVE

Self-reported health-related quality of life (HRQoL) is an important predictor of survival alongside clinical variables and physicians' prediction. This study assessed whether better prediction is achieved using generic (SF-36) HRQoL measures or cancer-specific (EORTC QLQ-C30) measures that include symptoms.

METHOD

Fifty-four lung and 46 colorectal patients comprised the sample. Ninety-four died before study conclusion. EORTC QLQ-C30 and SF-36 scores and demographic and clinical information were collected at baseline. Follow-up was 5 years. Deaths were flagged by the Office of National Statistics. Cox regression survival analyses were conducted. Surviving cases were censored in the analysis.

RESULTS

Univariate analyses showed that survival was significantly associated with better EORTC QLQ-C30 physical functioning, role functioning, and global health and less dyspnea and appetite loss. For the SF-36, survival was significantly associated with better emotional role functioning, general health, energy/vitality, and social functioning. The SF-36 summary score for mental health was significantly related to better survival, whereas the SF-36 summary score for physical health was not. In the multivariate analysis, only the SF-36 mental health summary score remained an independent, significant predictor, mainly due to considerable intercorrelations between HRQoL scales. However, models combining the SF-36 mental health summary score with diagnosis explained a similar amount of variance (12%-13%) as models combining diagnosis with single scale SF-36 Energy/Vitality or EORTC QLQ-C30 Appetite Loss.

SIGNIFICANCE OF RESULTS

HRQoL contributes significantly to prediction of survival. Generic measures are at least as useful as disease-specific measures including symptoms. Intercorrelations between HRQoL variables and between HRQoL and clinical variables makes it difficult to identify prime predictors. We need to identify variables that are as independent of each other as possible to maximize predictive power and produce more consistent results.

Heart failure and palliative care: implications in practice

The number of people with heart failure is continually rising. Despite continued medical advances that may prolong life, there is no cure. While typical heart failure trajectories include the risk of sudden death, heart failure is typically characterized by periods of stability interrupted by acute exacerbations. The unpredictable nature of this disease and the inability to predict its terminal phase has resulted in few services beyond medical management being offered. Yet, this population has documented unmet needs that extend beyond routine medical care. Palliative care has been proposed as a strategy to meet these needs, however, these services are rarely offered. Although palliative care should be implemented early in the disease process, in practice it is tied to end-of-life care. The purpose of this study was to uncover whether the conceptualization of palliative care for heart failure as end-of-life care may inhibit the provision of these services. The meaning of palliative care in heart failure was explored from three perspectives: scientific literature, health care providers, and spousal caregivers of patients with heart failure. There is confusion in the literature and by the health care community about the meaning of the term palliative care and what the provision of these services entails. Palliative care was equated to end-of-life care, and as a result, health care providers may be reluctant to discuss palliative care with heart failure patients early in the disease trajectory. Most family caregivers have not heard of the term and all would be receptive to an offer of palliative care at some point during the disease trajectory.

Paediatricians' perceptions on referrals to paediatric palliative care

Children have traditionally been referred to palliative care when curative treatments were exhausted. Recently, experts have suggested that children could benefit from palliative care early in their courses of illness. Using survey data from 303 paediatricians in Florida and California, this study assesses if paediatricians would refer children to palliative care early in their course of illness. Results showed that more years in practice were associated with decreased odds of referring children to palliative care. Academic practice setting and more Medicaid patients were associated with greater odds of referral prior to the end of life. Hispanic paediatricians, those with more experience and those who practice in a hospital setting were associated with decreased odds of referral prior to the end of life. Results suggest that health planners who wish to implement or refine integrated paediatric palliative care programs should consider outreach strategies targeted at paediatricians with specific characteristics.

A patient and carer survey in a community clinical nurse specialist service

The community clinical nurse specialist (CNS) team provides specialist palliative care to clients with cancer and non-malignant, life-limiting diseases in clients' homes, community hospitals, and residential and nursing homes. CNSs are based in health centres, community hospitals (geographically spread around the county) or at the local hospice. There has been no systematic review of patient and carer levels of satisfaction since the conception of the CNS service in 1984. Accredited as a nursing development unit (Flint and Wright, 2001) by Leeds University, the team has been encouraged to obtain service users' views. National guidelines in the UK (National Institute for Health and Clinical Excellence (NICE), 2004) also recommend that systems be put in place to enable clients to make their voices heard in a variety of ways. The principle aim was to identify the level of patient and carer satisfaction and to highlight aspects of care that warranted alteration or improvement. The CNS team were also keen to identify the aspects of their role most helpful to patients and carers, enabling CNSs to spend their time in a way that is most beneficial to clients.

Perceptions and utilization of palliative care services in acute care hospitals

OBJECTIVE

To understand perceptions of palliative care in acute care hospitals and identify barriers to earlier use of palliative care in the illness trajectory.

METHODS

In Pennsylvania hospitals, we completed semistructured interviews with 131 providers involved in decision making or discharge planning. We used qualitative methods to analyze transcripts.

RESULTS

Most interviewees characterized palliative care as end-of-life or hospice care that is initiated after the decision to limit curative treatment is made. Few recognized the role of palliative care in managing symptoms and addressing psychosocial needs of patients with chronic illnesses other than cancer. Interviewees viewed earlier and broader palliative care consultations less in terms of clinical benefits than in terms of cost savings accrued from shorter terminal hospitalizations. In general, they thought nurses were most likely to facilitate these consultations, surgeons were most likely to resist them, and intensive care specialists were most likely to view palliative care as within their own scope of practice. Suggestions for broadening palliative care utilization included providing education and training, improving financial reimbursement and sustainability for palliative care, and fostering a hospital culture that turns to high-intensity care only if it meets individual needs and goals of chronically ill patients.

CONCLUSIONS

In acute care hospitals, palliative care is primarily perceived as a means to limit life-sustaining treatment or allow death. Moving consultation earlier in the hospitalization of "dying" patients is a greater preoccupation than increasing palliative service use earlier in the illness trajectory. Any move short of far upstream will require palliative care specialists to market benefits to patients and referring providers in ways that emphasize compatibility with parallel treatment plans and do not threaten provider autonomy.

Hospital doctors' attitudes towards palliative care in Germany

Experts from different areas strongly criticize the current level of palliative care in Germany, both inpatient and home care services. Apart from the experts' opinions, little is known in this context about the perspectives of hospital doctors working in different disciplines, such as surgery, internal medicine, gynaecology or anaesthesia. These doctors presumably treat many incurably ill patients with palliative care needs, but they usually have very little experience in palliative medicine. Their attitudes are particularly important because they are affected by the criticism and by future improvement strategies. To study their viewpoints, questionnaire surveys in five hospitals in the federal state of Brandenburg were performed, with 203 (69%) physicians participating. The results showed that the level of palliative care in hospitals was graded better than in the home care setting. Main needs for improvement were seen in the psychosocial support services and in the co-operation with outpatient services. In [corrected] the hospital physicians' view, palliative nursing care was of a higher standard than medical aspects [corrected] of care [corrected] The physicians showed great interest in improving their knowledge of [corrected] palliative care and in new specialist palliative care services. The conclusions were that three main strategies for improvement should be embarked on: (1) the establishment of integrated care systems to overcome financial and structural barriers between in- and outpatient care; (2) the establishment of further specialist palliative care services (eg, hospital-based palliative care teams); and (3) better education in palliative medicine.

The influence of patient and carer age in access to palliative care services

BACKGROUND

Older patients are less likely to receive palliative care than younger patients. As patient and primary carer age correlate positively, patterns may be due to carer rather than patient age, and reflect better ability to obtain support among younger carers.

OBJECTIVE

To investigate how both patient and carer age relate to palliative care use, controlling for relevant variables.

DESIGN

Comparison of patients who received community Macmillan nurse specialist advice, Marie Curie nursing or inpatient hospice care with patients who did not, using univariate analysis and multivariate logistic regression. Patient and carer data were collected through electronic service record linkage and carer post-bereavement interviews.

SAMPLE

patients referred to a hospice at home service whose primary carer could be interviewed (n = 123).

RESULTS

Whilst a cancer diagnosis was an important determinant of access for all services considered, logistic regression shows that carer age, but not patient age, and hospice at home access predicted Marie Curie nursing use. Both patient and carer age predicted use of Macmillan nurse advice. Age of the patient, but not carer age, predicted admission to inpatient hospice, alongside requiring care for over a month (all P < 0.05).

CONCLUSIONS

Carer age may be as important a predictor of palliative home care use as patient age. We need to investigate whether younger carers have greater support needs or show greater effectiveness in obtaining help and to assess whether older carers need more assistance in recruitment of support.

Barriers to effective communication across the primary/secondary interface: examples from the ovarian cancer patient journey (a qualitative study)

Effective communication across the primary/secondary interface is vital for the planning and delivery of appropriate patient care throughout the cancer patient journey. This study describes GPs' views of the communication issues across the primary/secondary interface in relation to ovarian cancer patients using qualitative interviews with purposively sampled general practitioners (GPs) and an audit of hospital medical records of 30 deceased ovarian cancer patients. Issues raised by the GPs related to the content and format of communications, but of most concern was the tardiness. The time lag between dictation and typing letters ranged from 0 to 27 days, with a delay of up to 8 days for signing before transit through various mail systems to the GP. Three stages in the patient journey were characterized by particular issues: (1) in the pre-diagnostic and diagnostic stage was a need for prompt information regarding the results of tests and diagnoses, and clearer guidance on the use of tests and fast-track referrals; (2) in the active treatment phase, when GPs could lose touch with their patients, they needed effective communication in order to provide moral support and crisis management; and (3) when oncology withdrew and the focus of care switched back to the community for the terminal phase, GPs needed information to enable them to pick up the baton of care. There is a need to develop and evaluate interventions aimed at improving the content and speed of communications between secondary and primary care. Such interventions are likely to be complex and might include the greater use of telephone or fax for more selected communications, a review of secretarial support, the use of email, the development of GP designed proformas, the feasibility of patient/carer letter delivery options, nurse-led communication, universal electronic patient records, or a revisiting of the patient-held record.

Defining the patient population: one of the problems for palliative care research

There is a lack of clear definition and clear inclusion criteria in palliative care research. The aim of this study was to describe consequences of three inclusion criteria in the build up of different study populations, studied in terms of size, number of doctor-patient contacts and demographic characteristics. General practitioners received a questionnaire for all patients who died during the second Dutch National Survey of General Practice (n=2194), to determine whether (1) patients received non-curative treatment; (2) patients received palliative care; and (3) death was expected (total response rate =73%). The criterion 'death was expected' included most patients (62%) followed by 'palliative care' (46%) and 'noncurative treatment' (39%). Similarity between the definition-based populations was fair to moderate. More 'palliative care' and 'death was expected' in patients who had cancer than 'non-curative treatment' patients. The conclusions show substantial differences in populations according to the different inclusion criteria used to select them. Future research in palliative care should acknowledge the limitations of using certain inclusion criteria and explore potential bias.

Defining Cancer Patients As Being in the Terminal Phase: Who Receives a Formal Diagnosis, and What Are the Effects?

Purpose

Physicians either do not define cancer patients as being terminal, or their prognostic estimates tend to be optimistic. This might affect patients' appropriate and timely referral to specialist palliative care services or can lead to unintended acute hospitalization.

Patients and Methods

We used the Danish Cancer Register and four administrative registers to perform a retrospective cohort study in 3,445 patients who died as a result of cancer. We used the Danish “terminal declaration” issued by a physician as a proxy for a formal terminal diagnosis (prognosis of death within 6 months). The terminal declaration gives right to economic benefits and increased care for the dying. We investigated patient-related factors of receiving an explicit terminal diagnosis by logistic regression and then analyzed the effects of such a diagnosis on admission rate per week and place of death.

Results

Thirty-four percent of patients received a formal terminal diagnosis. Age of ≥ 70 years (odds ratio [OR], 0.44; 95% CI, 0.34 to 0.56; P < .001), women (OR, 0.81; 95% CI, 0.69 to 0.96; P = .02), hematologic cancer (OR, 0.20; 95% CI, 0.09 to 0.41; P < .001), and a less than 1-month survival time (OR, 0.10; 95% CI, 0.07 to 0.15; P < .001) were associated with a lesser likelihood of receiving a formal terminal diagnosis. Explicit terminal diagnosis was associated with lower admission rate and an adjusted OR of hospital death of 0.25 (95% CI, 0.21 to 0.29).

Conclusion

Women and the elderly were less likely to receive a formal terminal diagnosis. The formal terminal diagnosis reduced hospital admissions and increased the possibilities of dying at home.

Management of colorectal cancers

The management of colorectal cancers, published in a recent issue of Effective Health Care, is reviewed.

Systematic review of the problems and issues of accessing specialist palliative care by patients, carers and health and social care professionals

OBJECTIVES

To determine the problems and issues of accessing specialist palliative care by patients, informal carers and health and social care professionals involved in their care in primary and secondary care settings.

DATA SOURCES

Eleven electronic databases (medical, health-related and social science) were searched from the beginning of 1997 to October 2003. Palliative Medicine (January 1997-October 2003) was also hand-searched.

STUDY SELECTION

Systematic search for studies, reports and policy papers written in English.

DATA EXTRACTION

Included papers were data-extracted and the quality of each included study was assessed using 10 questions on a 40-point scale.

RESULTS

The search resulted in 9921 hits. Two hundred and seven papers were directly concerned with symptoms or issues of access, referral or barriers and obstacles to receiving palliative care. Only 40 (19%) papers met the inclusion criteria. Several barriers to access and referral to palliative care were identified including lack of knowledge and education amongst health and social care professionals, and a lack of standardized referral criteria. Some groups of people failed to receive timely referrals e.g., those from minority ethnic communities, older people and patients with nonmalignant conditions as well as people that are socially excluded e.g., homeless people.

CONCLUSIONS

There is a need to improve education and knowledge about specialist palliative care and hospice care amongst health and social care professionals, patients and carers. Standardized referral criteria need to be developed. Further work is also needed to assess the needs of those not currently accessing palliative care services.

Access and referral to specialist palliative care: patients’ and professionals’ experiences

The aim of this study was to explore the reasons why patients and families are referred to specialist palliative care. Semi-structured interviews were undertaken with patients and professionals from primary care and specialist palliative care services in the north of England. A content analysis of the transcripts was undertaken, key issues were identified and common themes grouped. Twelve professionals working in specialist palliative care, three GPs, six community nurses and thirteen patients were interviewed (n = 34). Five key themes are reported: reasons why patients are referred to specialist palliative care; reasons why patients are not referred to specialist palliative care; timeliness of referrals; continuity of care; and use of referral criteria. It was found that the professionals in primary care would like more training and education about how to refer patients to specialist palliative care and how to deal with issues of death and dying. The patients were generally satisfied with the service but wanted to be able to be supported at home in their final days. Further training and education may improve the knowledge of professionals who refer patients to specialist palliative care. There are currently no standardized criteria in the UK to determine when a referral should be triggered. The development of a set of standardized referral criteria may be useful in aiding a referral decision.