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McLouth LE, Borger T, Hoerger M, Stapleton JL, McFarlin J, Heckman PE, Bursac V, Shearer A, Shelton B, Mullett T, Studts JL, Goebel D, Thind R, Trice L, Schoenberg NE. Clinician perspectives on delivering primary and specialty palliative care in community oncology practices. Support Care Cancer 2024; 32:627. [PMID: 39222247 DOI: 10.1007/s00520-024-08816-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Clinical guidelines recommend early palliative care for patients with advanced lung cancer. In rural and underserved community oncology practices with limited resources, both primary palliative care from an oncologist and specialty palliative care are needed to address patients' palliative care needs. The aim of this study is to describe community oncology clinicians' primary palliative care practices and perspectives on integrating specialty palliative care into routine advanced lung cancer treatment in rural and underserved communities. METHODS Participants were clinicians recruited from 15 predominantly rural community oncology practices in Kentucky. Participants completed a one-time survey regarding their primary palliative care practices and knowledge, barriers, and facilitators to integrating specialty palliative care into advanced-stage lung cancer treatment. RESULTS Forty-seven clinicians (30% oncologists) participated. The majority (72.3%) of clinicians worked in a rural county. Over 70% reported routinely asking patients about symptom and physical function concerns, whereas less than half reported routinely asking about key prognostic concerns. Roughly 30% held at least one palliative care misconception (e.g., palliative care is for only those who are stopping cancer treatment). Clinician-reported barriers to specialty palliative care referrals included fear a referral would send the wrong message to patients (77%) and concern about burdening patients with appointments (53%). Notably, the most common clinician-reported facilitator was a patient asking for a referral (93.6%). CONCLUSION Educational programs and outreach efforts are needed to inform community oncology clinicians about palliative care, empower patients to request referrals, and facilitate patients' palliative care needs assessment, documentation, and standardized referral templates.
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Affiliation(s)
- Laurie E McLouth
- Department of Behavioral Science, University of Kentucky College of Medicine, 760 Press Avenue, 467 Healthy Kentucky Research Building, Lexington, KY, USA.
- Center for Health, Engagement, and Transformation, University of Kentucky, Lexington, KY, USA.
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA.
| | - Tia Borger
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
- Department of Psychiatry, University of Kentucky, Lexington, KY, USA
| | - Michael Hoerger
- Departments of Psychology, Psychiatry, and Medicine, Freeman School of Business and Tulane Cancer Center, Tulane University, New Orleans, USA
- Department of Palliative Medicine and Supportive Care, University Medical Center of New Orleans, New Orleans, USA
| | - Jerod L Stapleton
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
- Department of Health, Behavior and Society, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Jessica McFarlin
- Department of Neurology, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Patrick E Heckman
- Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Vilma Bursac
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Andrew Shearer
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
| | - Brent Shelton
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
- Department of Internal Medicine, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Timothy Mullett
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
- Department of Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Jamie L Studts
- Department of Medicine, University of Colorado School of Medicine, University of Colorado Cancer Center, Aurora, USA
| | - David Goebel
- King's Daughters Health System, Ashland, KY, USA
| | | | | | - Nancy E Schoenberg
- Department of Behavioral Science, University of Kentucky College of Medicine, 760 Press Avenue, 467 Healthy Kentucky Research Building, Lexington, KY, USA
- Center for Health, Engagement, and Transformation, University of Kentucky, Lexington, KY, USA
- Markey Cancer Center, University of Kentucky, Lexington, KY, USA
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Hu X, Jiang C, Fan Q, Shi KS, Parikh RB, Kamal AH, Anderson RT, Yabroff KR, Han X. US Medicare Hospice and Palliative Medicine Physician Workforce and Service Delivery in 2008-2020. J Pain Symptom Manage 2024; 67:e851-e857. [PMID: 38467348 DOI: 10.1016/j.jpainsymman.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 03/13/2024]
Abstract
CONTEXT Despite clinical benefits of early palliative care, little is known about Medicare physician workforce specialized in Hospice and Palliative Medicine (HPM) and their service delivery settings. OBJECTIVES To examine changes in Medicare HPM physician workforce and their service delivery settings in 2008-2020. METHODS Using the Medicare Data on Provider Practice and Specialty from 2008 to 2020, we identified 2375 unique Medicare Fee-For-Service (FFS) physicians (15,565 physician-year observations) with self-reported specialty in "Palliative Care and Hospice". We examined changes in the annual number of HPM physicians, average number of Medicare services overall and by care setting, total number of Medicare FFS beneficiaries, and total Medicare allowed charges billed by the physician. RESULTS The number of Medicare HPM physicians increased 2.32 times from 771 in 2008 to 1790 in 2020. The percent of HPM physicians practicing in metropolitan areas increased from 90% to 96% in 2008-2020. Faster growth was also observed in female physicians (52.4% to 60.1%). Between 2008 and 2020, we observed decreased average annual Medicare FFS beneficiaries (170 to 123), number of FFS services (467 to 335), and Medicare allowed charges billed by the physician ($47,230 to $37,323). The share of palliative care delivered in inpatient settings increased from 47% to 68% in 2008-2020; whereas the share of services delivered in outpatient settings decreased from 37% to 19%. CONCLUSION Despite growth in Medicare HPM physician workforce, access is disproportionately concentrated in metropolitan and inpatient settings. This may limit receipt of early outpatient specialized palliative care, especially in nonmetropolitan areas.
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Affiliation(s)
- Xin Hu
- Department of Public Health Sciences (X. Hu, R.T.A.), University of Virginia School of Medicine, Charlottesville, Virginia 22911, USA.
| | - Changchuan Jiang
- Division of Hematology and Oncology (C.J.), Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas 75390, USA
| | - Qinjin Fan
- Surveillance and Health Equity Science (Q.F., K.S.S., K.R.Y., X. Han), American Cancer Society, Atlanta, Georgia 30303, USA
| | - Kewei Sylvia Shi
- Surveillance and Health Equity Science (Q.F., K.S.S., K.R.Y., X. Han), American Cancer Society, Atlanta, Georgia 30303, USA
| | - Ravi B Parikh
- Perelman School of Medicine (R.B.P.), University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Arif H Kamal
- Patient Support Department (A.H.K.), American Cancer Society, Kennesaw, Georgia 30144, USA
| | - Roger T Anderson
- Department of Public Health Sciences (X. Hu, R.T.A.), University of Virginia School of Medicine, Charlottesville, Virginia 22911, USA
| | - K Robin Yabroff
- Surveillance and Health Equity Science (Q.F., K.S.S., K.R.Y., X. Han), American Cancer Society, Atlanta, Georgia 30303, USA
| | - Xuesong Han
- Surveillance and Health Equity Science (Q.F., K.S.S., K.R.Y., X. Han), American Cancer Society, Atlanta, Georgia 30303, USA
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Sedhom R, Bates-Pappas GE, Feldman J, Elk R, Gupta A, Fisch MJ, Soto-Perez-de-Celis E. Tumor Is Not the Only Target: Ensuring Equitable Person-Centered Supportive Care in the Era of Precision Medicine. Am Soc Clin Oncol Educ Book 2024; 44:e434026. [PMID: 39177644 DOI: 10.1200/edbk_434026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2024]
Abstract
Communication in oncology has always been challenging. The new era of precision oncology creates prognostic uncertainty. Still, person-centered care requires attention to people and their care needs. Living with cancer portends an experience that is life-altering, no matter what the outcome. Supporting patients and families through this unique experience requires careful attention, honed skills, an understanding of process and balance measures of innovation, and recognizing that supportive care is a foundational element of cancer medicine, rather than an either-or approach, an and-with approach that emphasizes the regular integration of palliative care (PC), geriatric oncology, and skilled communication.
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Affiliation(s)
- Ramy Sedhom
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Penn Medicine, Philadelphia, PA
| | - Gleneara E Bates-Pappas
- Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, New York, NY
| | | | - Ronit Elk
- Center for Palliative and Supportive Care, University of Alabama at Birmingham, Birmingham, AL
- Division of Geriatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Arjun Gupta
- Division of Hematology, Oncology, and Transplantation, University of Minnesota, Minneapolis
| | | | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
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Boulanger MC, Krasne MD, Gough EK, Myers S, Browner IS, Feliciano JL. Outpatient Embedded Palliative Care for Patients with Advanced Thoracic Malignancy: A Retrospective Cohort Study. Curr Oncol 2024; 31:1389-1399. [PMID: 38534938 PMCID: PMC10968799 DOI: 10.3390/curroncol31030105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 02/27/2024] [Accepted: 02/27/2024] [Indexed: 05/26/2024] Open
Abstract
Although cancer care is often contextualized in terms of survival, there are other important cancer care outcomes, such as quality of life and cost of care. The ASCO Value Framework assesses the value of cancer therapies not only in terms of survival but also with consideration of quality of life and financial cost. Early palliative care for patients with advanced cancer is associated with improved quality of life, mood, symptoms, and overall survival for patients, as well as cost savings. While palliative care has been shown to have numerous benefits, the impact of real-world implementation of outpatient embedded palliative care on value-based metrics is not fully understood. We sought to describe the association between outpatient embedded palliative care in a multidisciplinary thoracic oncology clinic and inpatient value-based metrics. We performed a retrospective cohort study of 215 patients being treated for advanced thoracic malignancies with non-curative intent. We evaluated the association between outpatient embedded palliative care and inpatient clinical outcomes including emergency room visits, hospitalizations, intensive care unit admissions, hospital charges, as well as hospital quality metrics including 30-day readmissions, admissions within 30 days of death, inpatient mortality, and inpatient hospital charges. Outpatient embedded palliative care was associated with lower hospital charges per day (USD 3807 vs. USD 4695, p = 0.024). Furthermore, patients who received outpatient embedded palliative care had lower hospital admissions within 30 days of death (O.R. 0.45; 95% CI 0.29, 0.68; p < 0.001) and a lower inpatient mortality rate (IRR 0.67; 95% CI 0.48, 0.95; p = 0.024). Our study further supports that outpatient palliative care is a high-value intervention and alternative models of palliative care, including one embedded into a multidisciplinary thoracic oncology clinic, is associated with improved value-based metrics.
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Affiliation(s)
- Mary C. Boulanger
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
- Department of Medical Oncology, Dana-Farber Cancer Institute/Massachusetts General Brigham, Boston, MA 02114, USA
| | - Margaret D. Krasne
- Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Ethan K. Gough
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Samantha Myers
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
| | - Ilene S. Browner
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
- Department of Internal Medicine, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Josephine L. Feliciano
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD 21287, USA
- Johns Hopkins Bayview, 301 Lord Mason Drive, Baltimore, MD 21224, USA
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Johnston EE, Rosenberg AR. Palliative Care in Adolescents and Young Adults With Cancer. J Clin Oncol 2024; 42:755-763. [PMID: 37862672 DOI: 10.1200/jco.23.00709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 04/27/2023] [Accepted: 08/25/2023] [Indexed: 10/22/2023] Open
Abstract
Palliative care (PC) aims to improve quality of life (QOL) for patients with serious illness and their families by recognizing and alleviating the physical, emotional, social, existential, and spiritual suffering of patients and their communities. Because adolescents and young adults (AYAs, age 15-39 years) with cancer commonly report distress across all these domains and because that distress translates to their QOL during and after their cancers, PC is particularly relevant for this population. Here, we review the evidence for PC among AYAs with cancer, including its rationale, gaps, opportunities, and implications for care delivery. For example, nearly 90% of AYAs with cancer report distressing symptoms during their treatment, those who survive report ongoing unmet psychosocial and physical health needs, and those who die from their cancers are highly likely to receive medically intense care that is discordant with their goals and values. AYA communication and decision making can be challenging because of ethical and developmental considerations regarding the patient's autonomy and competing priorities of patients and caregivers. PC interventions (including primary PC delivered by oncologists, routine PC subspecialty care, symptom tracking, advance care planning, and psychosocial programs promoting AYA resilience) are all associated with improved patient-centered outcomes. However, PC is inconsistently integrated into AYA oncology care, and access to PC programs is not equitable; marginalized groups continue to experience poorer outcomes. Ongoing and future research and clinical initiatives must continue to bridge these gaps. Improving the QOL of AYAs with cancer is a shared goal of the larger clinical oncology community, and including PC in AYA cancer care delivery can help attain that goal.
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Affiliation(s)
- Emily E Johnston
- Institute for Cancer Outcomes and Survivorship, University of Alabama at Birmingham, Birmingham, AL
- Pediatric Hematology/Oncology, University of Alabama at Birmingham, Birmingham, AL
| | - Abby R Rosenberg
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA
- Department of Pediatrics, Boston Children's Hospital, Boston, MA
- Department of Pediatrics, Harvard Medical School, Boston, MA
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Galiano A, Feltrin A, Pambuku A, Lo Mauro L, De Toni C, Murgioni S, Soldà C, Maruzzo M, Bergamo F, Brunello A, Zagonel V. What do cancer patients experience of the simultaneous care clinic? Results of a cross-sectional study on patient care satisfaction. Cancer Med 2024; 13:e7000. [PMID: 38400662 PMCID: PMC10891442 DOI: 10.1002/cam4.7000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/28/2024] [Accepted: 01/31/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Veneto Institute of Oncology has activated a simultaneous care outpatient clinic (SCOC) in which cancer patients with advanced-stage cancer are evaluated by oncologist and palliative care specialists. This cross-sectional study investigated patients' perceptions of the quality of this service. MATERIALS AND METHODS An ad-hoc self-administered questionnaire, developed by SCOC team, was used to assess the satisfaction of patients admitted at SCOC consultation. The questionnaire, in addition to the socio-demographic questions, contains eight questions with the Likert scale: time dedicated, feel listened to, feel understood, feel free to speak openly and to express doubts and concerns, feeling about information and indication received, level of empathy of health care and quality of the relationship, level of professional/quality of performance and utility of consultation, and one open-ended question. The questionnaire has been proposed to all 174 consecutively admitted patients at SCOC. RESULTS One hundred and sixty-two patients filled in the questionnaire: 66.7% were male, median age was 71 years, 88.3% had metastatic disease. The time dedicated to SCOC consultation was judged more than adequate (55%) or adequate (35%) by 90% of subjects. Patients completely satisfied about being listened to were 92.5%, with 80.9% being completely satisfied with understanding of their issues and 92% with the freedom to speak and express doubts. Usefulness of the SCOC was rated as excellent by 40% and good by 54.4% of patients. No statistically significant differences were observed in the responses to the questions by gender, age (< or ≥70 years old) and type of tumor. CONCLUSION Our study shows high levels of satisfactions after SCOC consultation in advanced cancer subjects. Patients' feedback confirmed that SCOC model was effective in helping them during their treatment journey and decision at the end of life. This study encouraged us to enhance our practice of SCOC consultation. IMPLICATIONS FOR PRACTICE A joint evaluation of patients living with cancer by oncologist and palliative care team (SCOC-embedded model), has shown to enhance patients' experience/satisfaction with care-such as listening, understanding, receiving information, symptom control, and decision about future, independently of age, gender, and kind of tumor.
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Affiliation(s)
- Antonella Galiano
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | | | - Ardi Pambuku
- Pain Therapy and Palliative Care UnitVeneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Leda Lo Mauro
- Clinical Nutrition Unit, Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Chiara De Toni
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Sabina Murgioni
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Caterina Soldà
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Marco Maruzzo
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Francesca Bergamo
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Antonella Brunello
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
| | - Vittorina Zagonel
- Department of Oncology, Oncology Unit 1Veneto Institute of Oncology IOV‐IRCCSPaduaItaly
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Hjorth NE, Hufthammer KO, Sigurdardottir K, Tripodoro VA, Goldraij G, Kvikstad A, Haugen DF. Hospital care for the dying patient with cancer: does an advance care planning invitation influence bereaved relatives' experiences? A two country survey. BMJ Support Palliat Care 2024; 13:e1038-e1047. [PMID: 34848559 PMCID: PMC10850660 DOI: 10.1136/bmjspcare-2021-003116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Advance care planning (ACP) is not systematically performed in Argentina or Norway. We used the post-bereavement survey of the ERANet-LAC International Care Of the Dying Evaluation (CODE) project (2017-2020) to examine the proportion of relatives who were offered an ACP conversation, the proportion of those not offered it who would have wanted it and whether the outcomes differed between those offered a conversation and those not. METHODS Relatives after cancer deaths in hospitals answered the CODE questionnaire 6-8 weeks post bereavement, by post (Norway) or interview (Argentina). Two additional questions asked if the relative and patient had been invited to a conversation about wishes for the patient's remaining lifetime, and, if not invited, whether they would have wanted such a conversation. The data were analysed using mixed-effects ordinal regression models. RESULTS 276 participants (Argentina 98 and Norway 178) responded (56% spouses, 31% children, 68% women, age 18-80+). Fifty-six per cent had been invited, and they had significantly more positive perceptions about care and support than those not invited. Sixty-eight per cent of the participants not invited would have wanted an invitation, and they had less favourable perceptions about the care, especially concerning emotional and spiritual support. CONCLUSIONS Relatives who had been invited to a conversation about wishes for the patient's remaining lifetime had more positive perceptions about patient care and support for the relatives in the patient's final days of life. A majority of the relatives who had not been invited to an ACP conversation would have wanted it.
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Affiliation(s)
- Nina Elisabeth Hjorth
- Faculty of Medicine, Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
- Specialist Palliative Care Team, Department of Anaesthesia and Surgical Services, Haukeland University Hospital, Bergen, Norway
| | | | - Katrin Sigurdardottir
- Specialist Palliative Care Team, Department of Anaesthesia and Surgical Services, Haukeland University Hospital, Bergen, Norway
- Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
| | - Vilma Adriana Tripodoro
- Pallium Latinoamérica, Buenos Aires, Argentina
- Instituto de Investigaciones Medicas Alfredo Lanari, University of Buenos Aires, Buenos Aires, Argentina
| | - Gabriel Goldraij
- Internal Medicine/Palliative Care Program, Hospital Privado Universitario de Córdoba, Córdoba, Argentina
| | - Anne Kvikstad
- Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Palliative Medicine Unit, Cancer Clinic, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Dagny Faksvåg Haugen
- Faculty of Medicine, Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
- Regional Centre of Excellence for Palliative Care, Western Norway, Haukeland University Hospital, Bergen, Norway
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Han HJ, Pilgrim CR, Buss MK. Integrating palliative care into the evolving landscape of oncology. Curr Probl Cancer 2023; 47:101013. [PMID: 37714795 DOI: 10.1016/j.currproblcancer.2023.101013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/10/2023] [Indexed: 09/17/2023]
Abstract
Patients with cancer have many palliative care needs. Robust evidence supports the early integration of palliative care into the care of patients with advanced cancer. International organizations, such as the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), have recommended early, longitudinal integration of palliative care into oncology care throughout the cancer trajectory. In this review, we pose a series of clinical questions related to the current state of early palliative care integration into oncology. We review the evidence to address each of these questions and highlight areas for further investigation. As cancer care continues to evolve, incorporating new treatment modalities and improving patient outcomes, we reflect on how to apply the existing evidence supporting early palliative care-oncology integration into this ever-changing therapeutic landscape and how specialty palliative care might adapt to meet the evolving needs of patients, caregivers, and the multidisciplinary oncology team.
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Affiliation(s)
- Harry J Han
- Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA.
| | - Carol R Pilgrim
- Division of Palliative Care, Tufts Medical Center, Boston, MA
| | - Mary K Buss
- Division of Palliative Care, Tufts Medical Center, Boston, MA
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9
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Zimmermann C, Buss MK, Rabow MW, Hannon B, Hui D. Should Outpatient Palliative Care Clinics in Cancer Centers be Stand Alone or Embedded? J Pain Symptom Manage 2023; 65:e165-e170. [PMID: 36437178 DOI: 10.1016/j.jpainsymman.2022.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Abstract
Outpatient palliative care facilitates timely symptom management, psychosocial care and care planning. A growing number of cancer centers have either stand-alone or embedded outpatient palliative care clinics. In this "Controversies in Palliative Care" article, three groups of thought leaders independently answer this question. Specifically, each group provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. One group advocates for stand-alone clinics, another for embedded, and the third group tries to find a balance. In the absence of evidence that directly compares the two models, factors such as cancer center size, palliative care team composition, clinic space availability, and financial considerations may drive the decision-making process at each institution. Stand-alone clinics may be more appropriate for larger academic cancer centers or palliative care programs with a more comprehensive interdisciplinary team, while embedded clinics may be more suited for smaller palliative care programs or community oncology programs to stimulate referrals. As outpatient clinic models continue to evolve, investigators need to document the referral and patient outcomes to inform practice.
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Affiliation(s)
- Camilla Zimmermann
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mary K Buss
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael W Rabow
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Breffni Hannon
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - David Hui
- Department of Supportive Care (C.Z., B.H.), Princess Margaret Cancer Centre, Toronto, Ontario, Canada; Division of Palliative Care, Department of Medicine (C.Z., B.H.), University Health Network, Toronto, Ontario, Canada; Division of Palliative Medicine, Department of Medicine (C.Z., B.H.), University of Toronto, Toronto, Ontario, Canada; Dalla Lana School of Public Health (C.Z.), University of Toronto, Toronto, Ontario, Canada; Division of Palliative Care (M.K.B.), Tufts Medical Center, Boston, Massachusetts, USA; Division of Palliative Medicine, Department of Medicine (M.W.R.), University of California San Francisco, San Francisco, California, USA; Department of Palliative Care (D.H.), Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.
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Pini S, Bekker HL, Bennett M, Ziegler L. A Structured Intervention to Support Early Palliative Care Conversations for Oncology Patients - A Qualitative Feasibility Study. Clin Oncol (R Coll Radiol) 2022; 34:e515-e522. [PMID: 35659476 DOI: 10.1016/j.clon.2022.05.012] [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: 02/17/2022] [Revised: 04/11/2022] [Accepted: 05/16/2022] [Indexed: 01/31/2023]
Abstract
AIMS For patients with advanced cancer, early access to palliative care can have numerous psychosocial and disease management benefits. However, it can be difficult for clinicians to initiate these initial conversations about palliative care. The aim of the present study was to beta test an intervention to facilitate timely conversations about palliative care between patients and clinicians. MATERIALS AND METHODS The study reported forms one stage of a complex intervention development study following Medical Research Council guidance for developing complex interventions. Feasibility was explored from patient and clinician perspectives in an oncology outpatient setting. RESULTS Sixteen patients and 18 clinicians participated. Three phases of the intervention were assessed through patient and clinician interviews. The analysis produced three themes in each phase: (i) Preparation (patient preparedness; healthcare professionals' perspectives on palliative care; administration, data and communication); (ii) STEP consultation (defining perspectives on palliative care; how palliative care fits with the current treatment plan; permission to explore future care); (iii) Outcomes (changes in perspective and approaches to coping; opening the door to future conversations; referrals and involvement of palliative services). CONCLUSIONS The STEP intervention generated important early conversations about end-of-life care that may otherwise not have occurred. No patients regretted having the STEP consultation, which resulted in palliative care referrals for some. Others felt better informed about the support services available and better able to have further conversations. Participating clinicians found the structured conversation guide useful, as it acted as a prompt for areas to cover, as well as providing an explicit way to open discussion about difficult topics.
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Affiliation(s)
- S Pini
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - H L Bekker
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - M Bennett
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
| | - L Ziegler
- Academic Unit of Palliative Care, University of Leeds, Leeds, UK
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11
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Burghi G, Metaxa V, Pickkers P, Soares M, Rello J, Bauer PR, van de Louw A, Taccone FS, Loeches IM, Schellongowski P, Rusinova K, Antonelli M, Kouatchet A, Barratt-Due A, Valkonen M, Pène F, Mokart D, Jaber S, Azoulay E, De Jong A. End of life decisions in immunocompromised patients with acute respiratory failure. J Crit Care 2022; 72:154152. [PMID: 36137351 DOI: 10.1016/j.jcrc.2022.154152] [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: 07/29/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To identify patient, disease and organizational factors associated with decisions to forgo life-sustaining therapies (DFLSTs) in critically ill immunocompromised patients admitted to the intensive care unit (ICU) for acute respiratory failure. MATERIAL AND METHODS We performed a secondary analysis of the international EFRAIM prospective study, which enrolled 1611 immunocompromised patients with acute respiratory failure admitted to 68 ICUs in 16 countries between October 2015 and June 2016. Multivariate logistic analysis was performed to identify independent predictors of DFLSTs. RESULTS The main causes of immunosuppression were hematological malignancies (50%) and solid tumor (38%). Patients had a median age of 63 yo (54-71). A pulmonologist was involved in the patient management in 38% of cases. DFLSTs had been implemented in 28% of the patients. The following variables were independently associated with DFLSTs: 1) patient-related: older age (OR 1.02 per one year increase, 95% confidence interval(CI) 1.01-1.03,P < 0.001), poor performance status (OR 2.79, 95% CI 1.98-3.93, P < 0.001); 2) disease-related: shock (OR 2.00, 95% CI 1.45-2.75, P < 0.001), liver failure (OR 1.59, 95% CI 1.14-2.21, P = 0.006), invasive mechanical ventilation (OR 1.79, 95% CI 1.31-2.46, P < 0.001); 3) organizational: having a pulmonologist involved in patient management (OR 1.85, 95% CI 1.36-2.52, P < 0.001), and the presence of a critical care outreach services (OR 1.63, 95% CI 1.11-2.38, P = 0.012). CONCLUSIONS A DFLST is made in one in four immunocompromised patient admitted to the ICU for acute respiratory failure. Involving a pulmonologist in patient's management is associated with less non beneficial care.
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Affiliation(s)
- Gaston Burghi
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | | | - Peter Pickkers
- The Department of Intensive Care Medicine (710), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marcio Soares
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | - Jordi Rello
- CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andry van de Louw
- Penn State University College of Medicine, Division of Pulmonary and Critical Care, Hershey, PA, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | | | - Katerina Rusinova
- Department of Anesthesiology and Intensive Care Medicine and Institute for Medical Humanities, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Massimo Antonelli
- Agostino Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, France
| | - Andreas Barratt-Due
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Miia Valkonen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki 00014, Finland
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University Paris Descartes, Paris, France
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis and Paris Diderot Sorbonne University, 1 avenue Claude Vellefaux, cedex 10 75475, Paris
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France.
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12
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Sedhom R, Kamal AH. Is Improving the Penetration Rate of Palliative Care the Right Measure? JCO Oncol Pract 2022; 18:e1388-e1391. [DOI: 10.1200/op.22.00370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Ramy Sedhom
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, Philadelphia, PA
| | - Arif H. Kamal
- Duke Cancer Institute, Durham, NC
- American Cancer Society, Atlanta, GA
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13
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Paiva CE, Teixeira AC, Minto Lourenço B, Preto DD, Valentino TCDO, Mingardi M, Paiva BSR. Anticancer Treatment Goals and Prognostic Misperceptions among Advanced Cancer Outpatients. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:6272. [PMID: 35627808 PMCID: PMC9141160 DOI: 10.3390/ijerph19106272] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/14/2022] [Accepted: 05/18/2022] [Indexed: 11/23/2022]
Abstract
(1) Background: In the context of cancer incurability, the communication processes involving clinicians and patients with cancer are frequently complex. (2) Methods: A cross-sectional study that investigated outpatients with advanced cancers and their oncologists. Both were interviewed immediately after a medical appointment in which there was disease progression and/or clinical deterioration, and were asked about the patient’s chance of curability and the goals of the prescribed cancer treatment. The patients were asked whether they would like to receive information about prognosis and how they would like to receive it. The analyses of agreement on perceptions were performed using the Kappa’s test. (3) Results: the sample consisted of 90 patients and 28 oncologists. Seventy-eight (87.6%) patients answered that they wanted their oncologist to inform them about their prognosis; only 35.2% (n = 31) of them said they received such information at their present appointment. Regarding how they would prefer prognostic disclosure, 61.8% (n = 55) mentioned that the oncologist should consider ways to keep the patient’s hope up; 73% (n = 65) of the patients reported odds >50% of cure. The agreement between oncologists’ and their patients’ perceptions regarding the treatment goals and curability was slight (k = 0.024 and k = 0.017, respectively). (4) Conclusions: The perceptions of patients and their oncologists regarding the goals of treatment and their chances of cure were in disagreement. New approaches are needed to improve the communication process between oncologists and patients with advanced cancer.
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Affiliation(s)
- Carlos Eduardo Paiva
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil; (A.C.T.); (B.M.L.); (D.D.P.); (T.C.d.O.V.); (M.M.); (B.S.R.P.)
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil
- Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil
| | - Ana Clara Teixeira
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil; (A.C.T.); (B.M.L.); (D.D.P.); (T.C.d.O.V.); (M.M.); (B.S.R.P.)
| | - Bruna Minto Lourenço
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil; (A.C.T.); (B.M.L.); (D.D.P.); (T.C.d.O.V.); (M.M.); (B.S.R.P.)
| | - Daniel D’Almeida Preto
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil; (A.C.T.); (B.M.L.); (D.D.P.); (T.C.d.O.V.); (M.M.); (B.S.R.P.)
- Department of Clinical Oncology, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil
| | - Talita Caroline de Oliveira Valentino
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil; (A.C.T.); (B.M.L.); (D.D.P.); (T.C.d.O.V.); (M.M.); (B.S.R.P.)
| | - Mirella Mingardi
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil; (A.C.T.); (B.M.L.); (D.D.P.); (T.C.d.O.V.); (M.M.); (B.S.R.P.)
| | - Bianca Sakamoto Ribeiro Paiva
- Palliative Care and Quality of Life Research Group, Post-Graduate Program, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil; (A.C.T.); (B.M.L.); (D.D.P.); (T.C.d.O.V.); (M.M.); (B.S.R.P.)
- Researcher Support Centre, Learning and Research Institute, Barretos Cancer Hospital, Barretos 14784-400, SP, Brazil
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14
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Sigler LE, Althouse AD, Thomas TH, Arnold RM, White D, Smith TJ, Chu E, Rosenzweig M, Smith KJ, Schenker Y. Effects of an Oncology Nurse-Led, Primary Palliative Care Intervention (CONNECT) on Illness Expectations Among Patients With Advanced Cancer. JCO Oncol Pract 2022; 18:e504-e515. [PMID: 34767474 PMCID: PMC9014423 DOI: 10.1200/op.21.00573] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 09/21/2021] [Accepted: 10/04/2021] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Patients with advanced cancer often have unrealistic expectations about prognosis and treatment. This study assessed the effect of an oncology nurse-led primary palliative care intervention on illness expectations among patients with advanced cancer. METHODS This study is a secondary analysis of a cluster-randomized trial of primary palliative care conducted at 17 oncology clinics. Adult patients with advanced solid tumors for whom the oncologist would not be surprised if died within 1 year were enrolled. Monthly visits were designed to foster realistic illness expectations by eliciting patient concerns and goals for their medical care and empowering patients and families to engage in discussions with oncologists about treatment options and preferences. Baseline and 3-month questionnaires included questions about life expectancy, treatment intent, and terminal illness acknowledgment. Odds of realistic illness expectations at 3 months were adjusted for baseline responses, patient demographic and clinical characteristics, and intervention dose. RESULTS Among 457 primarily White patients, there was little difference in realistic illness expectations at 3 months between intervention and standard care groups: 12.8% v 11.4% for life expectancy (adjusted odds ratio [aOR] = 1.15; 95% CI, 0.59 to 2.22; P = .684); 24.6% v 33.3% for treatment intent (aOR = 0.76; 95% CI, 0.44 to 1.27; P = .290); 53.6% v 44.7% for terminal illness acknowledgment (aOR = 1.28; 95% CI, 0.81 to 2.00; P = .288). Results did not differ when accounting for variation in clinic sites or intervention dose. CONCLUSION Illness expectations are difficult to change among patients with advanced cancer. Additional work is needed to identify approaches within oncology practices that foster realistic illness expectations to improve patient decision making.
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Affiliation(s)
- Lauren E. Sigler
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Emory Palliative Care Center, Emory University School of Medicine, Atlanta, GA
| | - Andrew D. Althouse
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Teresa H. Thomas
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Robert M. Arnold
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
| | - Douglas White
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Department of Critical Care Medicine, Program on Ethics and Decision Making in Critical Illness, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Thomas J. Smith
- Division of General Internal Medicine, Section of Palliative Medicine, Johns Hopkins University School of Medicine and Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Edward Chu
- Albert Einstein Cancer Center, Albert Einstein College of Medicine, New York, NY
| | - Margaret Rosenzweig
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- University of Pittsburgh School of Nursing, Pittsburgh, PA
| | - Kenneth J. Smith
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Yael Schenker
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, Palliative Research Center (PaRC), University of Pittsburgh, Pittsburgh, PA
- Division of General Internal Medicine, Section of Palliative Care and Medical Ethics, University of Pittsburgh, Pittsburgh, PA
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15
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Kaufmann TL, Getz KD, Hsu JY, Bennett AV, Takvorian SU, Kamal AH, DeMichele A. Identification of Patient-Reported Outcome Phenotypes Among Oncology Patients With Palliative Care Needs. JCO Oncol Pract 2021; 17:e1473-e1488. [PMID: 33760637 PMCID: PMC8791824 DOI: 10.1200/op.20.00849] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/03/2021] [Accepted: 02/09/2021] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Despite evidence-based guidelines recommending early palliative care, it remains unclear how to identify and refer oncology patients, particularly in settings with constrained access to palliative care. We hypothesize that patient-reported outcome (PRO) data can be used to characterize patients with palliative care needs. To determine if PRO data can identify latent phenotypes that characterize indications for specialty palliative care referral. METHODS We conducted a retrospective study of self-reported symptoms on the Edmonton Symptom Assessment System collected from solid tumor oncology patients (n = 745) referred to outpatient palliative care. Data were collected as part of routine clinical care from October 2012 to March 2018 at eight community and academic sites. We applied latent profile analysis to identify PRO phenotypes and examined the association of phenotypes with clinical and demographic characteristics using multinomial logistic regression. RESULTS We identified four PRO phenotypes: (1) Low Symptoms (n = 295, 39.6%), (2) Moderate Pain/Fatigue + Mood (n = 180, 24.2%), (3) Moderate Pain/Fatigue + Appetite + Dyspnea (n = 201, 27.0%), and (4) High Symptoms (n = 69, 9.3%). In a secondary analysis of 421 patients, we found that two brief items assessing social and existential needs aligned with higher severity symptom and psychological distress phenotypes. CONCLUSION Oncology patients referred to outpatient palliative care in a real-world setting can be differentiated into clinically meaningful phenotypes using brief, routinely collected PRO measures. Latent modeling provides a mechanism to use patient-reported data on a population level to identify distinct subgroups of patients with unmet palliative needs.
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Affiliation(s)
- Tara L. Kaufmann
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
- Livestrong Cancer Institutes, Dell Medical School, The University of Texas at Austin, Austin, TX
| | - Kelly D. Getz
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- University of Pennsylvania, Philadelphia, PA
- The Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Antonia V. Bennett
- Cancer Outcomes Research Program, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Samuel U. Takvorian
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Penn Center for Cancer Care Innovation, Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | | | - Angela DeMichele
- Division of Hematology and Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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16
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Tagami K, Masukawa K, Inoue A, Morita T, Hiratsuka Y, Sato M, Kohata K, Satake N, Kizawa Y, Tsuneto S, Shima Y, Miyashita M. Appropriate referral timing to specialized palliative care service: survey of bereaved families of cancer patients who died in palliative care units. Support Care Cancer 2021; 30:931-940. [PMID: 34417885 DOI: 10.1007/s00520-021-06493-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 08/07/2021] [Indexed: 11/29/2022]
Abstract
Few studies have investigated appropriate referral timing of specialized palliative care (SPC) from the perspective of cancer patients' and families' experiences. We aimed to clarify appropriate SPC referral timing for patients with advanced cancer and their families. We used data from a nationwide bereaved family survey in Japan. We sent a questionnaire to 999 bereaved families of cancer patients who died in 164 palliative care units (PCUs) and analyzed the first SPC referral timing and how patients evaluated it. We defined SPC as outpatient or inpatient palliative care service comprising certified palliative care physicians, advanced-practice nurses, and multidisciplinary practitioners. Finally, 51.6% (n = 515) of all responses were analyzed. The SPC referral timing was evaluated as appropriate (26.1%), late or too late (20.2%), early or too early (1.2%), or none of these (52.5%). Of these, 32.3% reported that they were referred to an SPC when diagnosed with advanced or incurable cancer or during anti-cancer treatment, and 62.6% reported they were referred after anti-cancer treatment. Patient-perceived appropriateness of SPC referral timing was associated with their good death process. After excluding "none of these" responses, a significantly higher proportion of respondents who reported being referred to SPC at diagnosis and during anti-cancer treatment evaluated the response timing as appropriate, compared to those who reported being referred after anti-cancer treatment. Appropriate timing for SPC referrals relates to quality of death; findings suggest that appropriate timing is at the time of diagnosis or during anti-cancer treatment.
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Affiliation(s)
- Keita Tagami
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan. .,Department of Palliative Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
| | - Kento Masukawa
- Department of Palliative Nursing, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Akira Inoue
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Department of Palliative Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Palliative Care Team, Seirei Mikatahara General Hospital, 3453 Mikatahara-cho, Kita-ku, Hamamatsu, Shizuoka, 433-8558, Japan
| | - Yusuke Hiratsuka
- Department of Palliative Medicine, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.,Department of Palliative Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Mamiko Sato
- Department of Palliative Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Katsura Kohata
- Department of Palliative Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Noriaki Satake
- Department of Palliative Medicine, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Yoshiyuki Kizawa
- Department of Palliative Medicine, Kobe University Hospital, 1 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan
| | - Satoru Tsuneto
- Department of Human Health Sciences, Kyoto University Graduate School of Medicine, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Yasuo Shima
- Tsukuba Medical Center Hospital, 1-3-1, Amakubo, Tsukuba, Ibaraki, 305-8558, Japan
| | - Mitsunori Miyashita
- Department of Palliative Nursing, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
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Bakitas M, Cheville AL, Mulvey TM, Peppercorn J, Watts K, Dionne-Odom JN. Telehealth Strategies to Support Patients and Families Across the Cancer Trajectory. Am Soc Clin Oncol Educ Book 2021; 41:413-422. [PMID: 34010046 DOI: 10.1200/edbk_320979] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Effective delivery of cancer care via telehealth requires a planned care system that accounts for myriad patient, provider, and practice/cancer center resources before, during, and after the care episode. Telehealth is broadly defined as a method to have virtual, bidirectional communication between patients and providers. Telehealth can include methods such as audio-only, video-consultation, and tele-monitoring, which can occur in a synchronous, asynchronous, or blended format. The purpose of this review is to present common foundational principles for providing clinical cancer care via telehealth, followed by an overview of three distinct examples of comprehensive telehealth programs that have been developed to meet the needs of patients and families across the cancer trajectory, including survivorship, rehabilitation, and palliative care phases. The programs described are exemplars that were developed and implemented prior to the coronavirus pandemic, so they reflect many years of planning and evidence. Lessons learned include the need for ongoing patient support, clinician training, and cancer health system/practice programmatic considerations such as billing, scheduling, reimbursement, software, and hardware/platform security. Although the COVID-19 pandemic produced an explosive shift in regulations and implementation, sustainability of these changes may not be long-term. Nevertheless, a permanent shift in cancer care to include telehealth is likely here to stay.
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Affiliation(s)
- Marie Bakitas
- School of Nursing, Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | | | | | | | - J Nicholas Dionne-Odom
- School of Nursing, Center for Palliative and Supportive Care, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
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18
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Sedhom R, Nudotor R, Freund KM, Smith TJ, Cooper LA, Owczarzak JT, Johnston FM. Can Community Health Workers Increase Palliative Care Use for African American Patients? A Pilot Study. JCO Oncol Pract 2021; 17:e158-e167. [PMID: 33476179 PMCID: PMC8257996 DOI: 10.1200/op.20.00574] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/01/2020] [Accepted: 11/30/2020] [Indexed: 12/16/2022] Open
Abstract
PURPOSE African American patients with cancer underutilize advance care planning (ACP) and palliative care (PC). This feasibility study investigated whether community health workers (CHWs) could improve ACP and PC utilization for African American patients with advanced cancer. METHODS African American patients diagnosed with an advanced solid organ cancer (stage IV or stage III disease with a palliative performance score < 60%) were enrolled. Patients completed baseline surveys that assessed symptom burden and distress at baseline and 3 months post-CHW intervention. The CHW intervention consisted of a comprehensive assessment of multiple PC domains and social determinants of health. CHWs provided tailored support and education on the basis of iterative assessment of patient needs. Intervention feasibility was determined by patient and caregiver retention rate above 50% at 3 months. RESULTS Over a 12-month period, 24 patients were screened, of which 21 were deemed eligible. Twelve patients participated in the study. Patient retention was high at 3 months (75%) and 6 months (66%). Following the CHW intervention, symptom assessment as measured by Edmonton Symptom Assessment System improved from 33.8 at baseline to 18.8 (P = .03). Psychological distress improved from 5.5 to 4.7 (P = .36), and depressive symptoms from 42.2 to 33.6 (P = .09), although this was not significant. ACP documentation improved from 25% at baseline to 75% at study completion. Sixty-seven percentage of patients were referred to PC, with 100% of three decedents using hospice. CONCLUSION Utilization of CHWs to address PC domains and social determinants of health is feasible. Although study enrollment was identified as a potential barrier, most recruited patients were retained on study.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD
| | - Richard Nudotor
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Karen M. Freund
- Department of Medicine, Tufts University School of Medicine, Boston, MA
| | - Thomas J. Smith
- Palliative Care Program, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Lisa A. Cooper
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jill T. Owczarzak
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Fabian M. Johnston
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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Pini S, Hackett J, Taylor S, Bekker HL, Kite S, Bennett MI, Ziegler L. Patient and professional experiences of palliative care referral discussions from cancer services: A qualitative interview study. Eur J Cancer Care (Engl) 2020; 30:e13340. [PMID: 33051957 DOI: 10.1111/ecc.13340] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 05/20/2020] [Accepted: 08/07/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The aim of this paper was to identify current barriers, facilitators and experiences of raising and discussing palliative care with people with advanced cancer. METHODS Semi-structured interviews were conducted with patients with advanced cancer and healthcare professionals (HCPs). Patients were included who had and had not been referred to palliative care. Transcripts were analysed using framework analysis. RESULTS Twenty-four patients and eight HCPs participated. Two overarching themes and five sub-themes emerged: Theme one-referral process: timing and triggers, responsibility. Theme two-engagement: perception of treatment, prognosis and palliative care, psychological and emotional preparedness for discussion, and understanding how palliative care could benefit present and future care. CONCLUSION There is a need to identify suitable patients earlier in their cancer trajectory, address misconceptions about palliative care, treatment and prognosis, and better prepare patients and HCPs to have meaningful conversations about palliative care. Patients and HCPs need to establish and communicate the relevance of palliative care to the patient's current and future care, and be clear about the referral process.
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Affiliation(s)
- Simon Pini
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Julia Hackett
- Martin House Research Centre, Social Policy Research Unit, University of York, York, UK
| | - Sally Taylor
- The Christie NHS Foundation Trust, Manchester, UK
| | - Hilary L Bekker
- Leeds Unit for Complex Intervention Development (LUCID), Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Michael I Bennett
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Lucy Ziegler
- Academic Unit of Palliative Care, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
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Exploring a Nursing Home-Specific Interdisciplinary Approach: Toward Palliative Care for the Demented and Complex-Disabled Elderly. J Hosp Palliat Nurs 2020; 21:E9-E15. [PMID: 31162151 DOI: 10.1097/njh.0000000000000579] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The number of elderly suffering from dementia and complex disabilities is gradually increasing in nursing homes, and they form a differentiated group that requires palliative care provided by practitioners in various disciplines from the time of their admission to improve the quality of their remaining lives. The purpose of this study was to explore an interdisciplinary care approach by nurses and related practitioners for the demented and complex-disabled elderly in nursing homes that focuses on palliative care based on an ethical point of view. A qualitative thematic analysis was conducted through in-depth interviews of 29 interdisciplinary practitioners working at 5 nursing homes. From them, 3 themes and 9 subthemes were extracted as the key results. First, practitioners set up cooperative care plans based on constantly tracking down clues to gradual functional deteriorations. Second, practitioners establish a cooperative committee to link residents and practitioners for responding to the subtle expressions of the elderly. Finally, practitioners maximize the opportunities for improving the quality of the elderly's remaining lives. These results can be the basis for the first prototype in developing interdisciplinary practical guidelines for nursing home-specific palliative care and can provide new insights for the practical care concept of palliative care.
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Sedhom R, Gupta A, MacNabb L, Smith TJ. The Impact of Palliative Care Dose Intensity on Outcomes for Patients with Cancer. Oncologist 2020; 25:913-915. [PMID: 32813308 DOI: 10.1634/theoncologist.2020-0551] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 08/04/2020] [Indexed: 12/25/2022] Open
Affiliation(s)
- Ramy Sedhom
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Institute, Baltimore, Maryland, USA
| | - Arjun Gupta
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Institute, Baltimore, Maryland, USA
| | - Lindsey MacNabb
- Section of Palliative Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Thomas J Smith
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Institute, Baltimore, Maryland, USA
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Sedhom R, Gupta A, Shah M, Hsu M, Messmer M, Murray J, Browner I, Smith TJ, Marrone K. Oncology Fellow-Led Quality Improvement Project to Improve Rates of Palliative Care Utilization in Patients With Advanced Cancer. JCO Oncol Pract 2020; 16:e814-e822. [PMID: 32339469 DOI: 10.1200/jop.19.00714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
PURPOSE ASCO guidelines recommend palliative care (PC) referral for patients with advanced or metastatic cancer. Despite this, implementation has considerable hurdles. First-year oncology fellows at our institution identified low rates of PC utilization in their longitudinal clinic as a metric needing improvement. METHODS A fellow-led multidisciplinary team aimed to increase PC utilization for patients with advanced cancer followed in he first-year fellows' clinic from a baseline of 11.5% (5 of 43 patients, July to December of 2018) to 30% over a 6-month period. Utilization was defined as evaluation in the outpatient PC clinic hosted in the cancer center. The team identified the following barriers to referral: orders difficult to find in the electronic medical record (EMR), multiple consulting mechanisms (EMR, by phone, or in person), EMR request not activating formal consult, no centralized scheduler to contact or confirm appointment, and poor awareness of team structure. Plan-Do-Study-Act (PDSA) cycles were implemented based on identified opportunities. Data were obtained from the EMR. RESULTS The first PDSA cycle included focus groups with stakeholders, standardizing referral process via single order set, identifying a single scheduler with bidirectional communication, and disseminating process changes. PDSA cycles were implemented from January to June of 2019. Rates of PC use increased from 11.5% before the intervention to 48.4% (48 of 99 patients) after the intervention. CONCLUSION A multidisciplinary approach and classic quality improvement methodology improved PC use in patients with advanced cancer. The pilot succeeded given the small number of fellows, buy-in from stakeholders, and institutional and leadership support. Straightforward EMR interventions and ancillary staff use are effective in addressing underreferrals.
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Affiliation(s)
- Ramy Sedhom
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Arjun Gupta
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Mirat Shah
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Melinda Hsu
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Marcus Messmer
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Joseph Murray
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Ilene Browner
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Thomas J Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Kristen Marrone
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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Huang HL, Tsai JS, Yao CA, Cheng SY, Hu WY, Chiu TY. Shared decision making with oncologists and palliative care specialists effectively increases the documentation of the preferences for do not resuscitate and artificial nutrition and hydration in patients with advanced cancer: a model testing study. BMC Palliat Care 2020; 19:17. [PMID: 32019540 PMCID: PMC7001377 DOI: 10.1186/s12904-020-0521-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/20/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Communication in do not resuscitate (DNR) and artificial nutrition and hydration (ANH) at the end of life is a key component of advance care planning (ACP) which is essential for patients with advanced cancer to have cares concordant with their wishes. The SOP model (Shared decision making with Oncologists and Palliative care specialists) aimed to increase the rate of documentation on the preferences for DNR and ANH in patients with advanced cancer. METHODS The SOP model was implemented in a national cancer treatment center in Taiwan from September 2016 to August 2018 for patients with advanced cancer visiting the oncology outpatient clinic. The framework was based on the model of shared decision making as "choice talk" initiated by oncologists with "option talk" and "decision talk" conducted by palliative care specialists. RESULTS Among 375 eligible patients, 255 patients (68%) participated in the model testing with the mean age of 68.5 ± 14.7 years (mean ± SD). Comparing to 52.3% of DNR documentation among patients with advanced cancer who died in our hospital, the rate increased to 80.9% (206/255) after the decision talk in our model. Only 6.67% (n = 17) of the participants documented their preferences on ANH after the model. A worse Eastern Cooperative Oncology Group Performance Status was the only statistically significant associating factor with a higher rate of DNR documentation in the multiple logistic regression model. CONCLUSIONS The SOP model significantly increased the rate of DNR documentation in patients with advanced cancer in this pilot study. Dissemination of the model could help the patients to receive care that is concordant with their wishes and be useful for the countries having laws on ACP.
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Affiliation(s)
- Hsien-Liang Huang
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Jaw-Shiun Tsai
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Chien-An Yao
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Shao-Yi Cheng
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan
| | - Wen-Yu Hu
- School of Nursing, College of Medicine and Hospital, National Taiwan University, Taipei, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, College of Medicine and Hospital, National 7 Chung-Shan South Road, Taipei, 100, Taiwan.
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Wittenberg E, Goldsmith J, Ferrell B, Buller H, Mendoza Y, Ragan SL. Palliative Care Communication: Outcomes From COMFORT, a Train-the-Trainer Course for Providers. Clin J Oncol Nurs 2020; 24:E1-E6. [PMID: 31961850 PMCID: PMC7271967 DOI: 10.1188/20.cjon.e1-e6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND With increasing support for the integration of palliative care and standard oncology, communication training programs are needed to teach oncology nurses and other providers about palliative care communication. OBJECTIVES This study reports on the outcomes of COMFORTTM SM Communication for Oncology Nurses, a train-the-trainer communication course to educate oncology nurses about palliative care communication and improve patient-centered communication and cancer care. METHODS 355 oncology nurses attended the two-day course. This study used 6- and 12-month follow-up data from nurses who provided feedback on the progress of these goals. FINDINGS Nurses taught an additional 9,720 oncology providers, conducted needs assessments of communication processes, and initiated institutionwide palliative care communication training. Barriers to completing outcome goals included a lack of institutional support, specifically an absence of leadership, financial backing, and dedicated time.
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Affiliation(s)
- Elaine Wittenberg
- Associate Professor, Department of Communication Studies, California State University, Los Angeles, 5151 State University Drive, Los Angeles, CA 90032
| | - Joy Goldsmith
- Professor, Department of Communication, University of Memphis
| | - Betty Ferrell
- Professor and Division Chair, Nursing Research and Education, City of Hope
| | - Haley Buller
- Research Supervisor, Nursing Research and Education, City of Hope
| | - Yesenia Mendoza
- Graduate Student, Department of Communication Studies, California State University, Los Angeles
| | - Sandra L. Ragan
- Professor Emerita, Department of Communication, University of Oklahoma
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Reiser V, Rosenzweig M, Welsh A, Ren D, Usher B. The Support, Education, and Advocacy (SEA) Program of Care for Women With Metastatic Breast Cancer: A Nurse-Led Palliative Care Demonstration Program. Am J Hosp Palliat Care 2019; 36:864-870. [PMID: 30974954 DOI: 10.1177/1049909119839696] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Women with metastatic breast cancer (MBC) experience unique symptom management and psychosocial needs due to aggressive, yet palliative treatment with a progressive, chronic illness. OBJECTIVE This article describes the effect of a quality improvement project for coordination of supportive care in MBC. Program evaluations included referral rates for supportive services, patient-reported outcomes of symptom distress, generalized anxiety, and overall well-being. DESIGN An interdisciplinary Support, Education and Advocacy Program (MBC-SEA) was developed. The 1-hour, weekly, patient review included collaborative assessments to determine needs for social service, psychological counseling, and palliative care. A prospective pre- and postexperimental cohort design with convenience sampling was used. Analysis was conducted with paired t test analysis of pre- and postimplementation outcomes. SETTING/PARTICIPANTS Program outcomes of 118 women with MBC visiting an urban outpatient breast cancer clinic during September 2016 to November 2016 (pre) and January 2017 to March 2017 (post) were evaluated. MEASUREMENTS Referral rates to social work and palliative care, symptom, anxiety, and overall well-being scores. RESULTS Following program implementation, referrals to palliative care and social work supportive services increased significantly including patient-reported outcomes symptom distress scores mean difference 1.4 (95% confidence interval [CI]: 0.4306-2.6428), P = .004; generalized anxiety scores mean difference 1.5 (95% CI: 0.5406-2.5781), P = .003; and overall well-being mean difference of -0.7 (95% CI: -1.3498 to -0.0570), P = .03. CONCLUSIONS Purposeful nurse-led assessment for social service and palliative care needs increases referrals with improvement in patient-reported outcomes.
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Affiliation(s)
- Victoria Reiser
- 1 University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | | | - Ann Welsh
- 2 Magee Women's Hospital of UPMC, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Dianxu Ren
- 3 Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Barbara Usher
- 3 Department of Health and Community Systems, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
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Reynolds EE, Buss MK, Schlechter BL, Tess A. Would You Refer This Patient With Cancer to a Palliative Care Specialist?: Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2019; 170:488-496. [PMID: 30934082 DOI: 10.7326/m19-0361] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
In 2016, the American Society of Clinical Oncology published a guideline recommending that all patients with advanced cancer be referred to palliative care providers. This recommendation was based on a series of trials showing that palliative care, when added to standard oncology treatment, improves outcomes, including quality of life. Here, 2 oncologists, 1 of whom is also a palliative care specialist, debate the guideline and discuss how best to care for a 71-year-old woman with metastatic neuroendocrine carcinoma who has a short life expectancy but feels well and has no symptoms related to her cancer or chemotherapy.
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Affiliation(s)
- Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.E.R., M.K.B., B.L.S., A.T.)
| | - Mary K Buss
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.E.R., M.K.B., B.L.S., A.T.)
| | - Benjamin L Schlechter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.E.R., M.K.B., B.L.S., A.T.)
| | - Anjala Tess
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (E.E.R., M.K.B., B.L.S., A.T.)
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Finlay E, Newport K, Sivendran S, Kilpatrick L, Owens M, Buss MK. Models of Outpatient Palliative Care Clinics for Patients With Cancer. J Oncol Pract 2019; 15:187-193. [DOI: 10.1200/jop.18.00634] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
PURPOSE: Early integration of outpatient palliative care (OPC) benefits patients with advanced cancer and also the health care systems in which these patients are seen. Successful development and implementation of models of OPC require attention to the needs and values of both the patients being served and the institution providing service. SUMMARY: In the 2016 clinical guideline, ASCO recommended integrating palliative care early in the disease trajectory alongside cancer-directed treatment. Despite strong endorsement and robust evidence of benefit, many patients with cancer lack access to OPC. Here we define different models of care delivery in four successful palliative care clinics in four distinct health care settings: an academic medical center, a safety net hospital, a community health system, and a hospice-staffed clinic embedded in a community cancer center. The description of each clinic includes details on setting, staffing, volume, policies, and processes. CONCLUSION: The development of robust and capable OPC clinics is necessary to meet the growing demand for these services among patients with advanced cancer. This summary of key aspects of functional OPC clinics will enable health care institutions to evaluate their specific needs and develop programs that will be successful within the environment of an individual institution.
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Affiliation(s)
- Esme Finlay
- University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Kristina Newport
- Penn State Hershey, Hershey, PA
- Hospice & Community Care, York, PA
| | - Shanthi Sivendran
- Ann B. Barshinger Cancer Institute, Penn Medicine at Lancaster General Health, Lancaster, PA
| | | | | | - Mary K. Buss
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA
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Finlay E, Rabow MW, Buss MK. Filling the Gap: Creating an Outpatient Palliative Care Program in Your Institution. Am Soc Clin Oncol Educ Book 2018; 38:111-121. [PMID: 30231351 DOI: 10.1200/edbk_200775] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Well-designed, randomized trials demonstrate that outpatient palliative care improves symptom burden and quality of life (QOL) while it reduces unnecessary health care use in patients with cancer. Despite the strong evidence of benefit and ASCO recommendations, implementation of outpatient palliative care, especially in community oncology settings, faces considerable hurdles. This article, which is based on published literature and expert opinion, presents practical strategies to help oncologists make a strong clinical and fiscal case for outpatient palliative care. This article outlines key considerations for how to build an outpatient palliative care program in an institution by (1) defining the scope and benefits; (2) identifying strategies to overcome common barriers to integration of outpatient palliative care into cancer care; (3) outlining a business case; (4) describing successful models of outpatient palliative care; and (5) examining important factors in design and operation of a palliative care clinic. The advantages and disadvantages of different delivery models (e.g., embedded vs. independent) and different methods of referral (triggered vs. physician discretion) are reviewed. Strategies to make the case for outpatient palliative care that align with institutional values and/or are supported by local institutional data on cost savings are included.
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Affiliation(s)
- Esme Finlay
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Michael W Rabow
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Mary K Buss
- From the Division of Palliative Medicine, Department of Internal Medicine, University of New Mexico, Albuquerque, NM; Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA; Section of Palliative Care, Division of General Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Balboni TA, Hui KKP, Kamal AH. Supportive Care in Lung Cancer: Improving Value in the Era of Modern Therapies. Am Soc Clin Oncol Educ Book 2018; 38:716-725. [PMID: 30231310 DOI: 10.1200/edbk_201369] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Driven by a discipline-wide imperative to maximize patient centeredness and value, supportive care services have experienced remarkable growth and acceptance in oncology care. Two such services with a growing evidence base and examples of routine integration into usual oncology care are palliative care and integrative medicine. Both focus on the patient experience with cancer during and after cancer-directed treatments occur, from diagnosis through survivorship or end-of-life care. With a frame of increasing value for all in the oncology care ecosystem, we highlight the evidence for how these two disciplines can improve the experience of patients with cancer and their loved ones. We further highlight how additional focus in palliative care and integrative medicine can continue to build toward a shared vision of high-value, high-quality cancer care.
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Affiliation(s)
- Tracy A Balboni
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
| | - Ka-Kit P Hui
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
| | - Arif H Kamal
- From the Departments of Radiation Oncology and Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Brigham and Women's Hospital, Boston, MA; Department of Medicine, David Geffen School of Medicine, UCLA Center for East West Medicine, University of California, Los Angeles, CA; Duke Cancer Institute and Duke Fuqua School of Business, Duke University, Durham, NC
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Abstract
OBJECTIVE To describe palliative care integration into oncology, including several models that facilitate this integration, important considerations when initiating a program, special oncologic populations that would benefit from palliative care, and challenges to consider. DATA SOURCES Palliative care and oncology literature over the past decade. CONCLUSION Multiple models exist to facilitate the integration of palliative care based on the needs of the providers or payers. There are several special populations that would benefit from early integration of palliative care. IMPLICATIONS FOR NURSING PRACTICE Nurses play a critical role in identifying patients, providing early primary palliative care, and facilitating collaborative relationships with and referring to specialist palliative care.
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Understanding and Addressing the Religious and Spiritual Needs of Advanced Cancer Patients. Semin Oncol Nurs 2018; 34:274-283. [DOI: 10.1016/j.soncn.2018.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Chaaya G, Abdelghani R, Kheir F, Komiya T, Vander Velde N. NSCLC: State of the Art Diagnosis, Treatment, and Outcomes. CURRENT PULMONOLOGY REPORTS 2018. [DOI: 10.1007/s13665-018-0198-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Chambers S, Healy H, Hoy WE, Kark A, Ratanjee S, Mitchell G, Douglas C, Yates P, Bonner A. Health service utilisation during the last year of life: a prospective, longitudinal study of the pathways of patients with chronic kidney disease stages 3-5. BMC Palliat Care 2018; 17:57. [PMID: 29622009 PMCID: PMC5887240 DOI: 10.1186/s12904-018-0310-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/21/2018] [Indexed: 12/22/2022] Open
Abstract
Background Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries’ populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent. Methods The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable. Results Participants (n = 19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable. Conclusions Few patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughout the long, slow decline of CKD. Proactive end-of-life care earlier in the disease trajectory through integrating renal and palliative care teams may avoid acute presentations to hospital through better symptom management and planned care pathways.
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Affiliation(s)
- Shirley Chambers
- Faculty of Health, Queensland University of Technology, Brisbane, Australia. .,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.
| | - Helen Healy
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Wendy E Hoy
- National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Adrian Kark
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Sharad Ratanjee
- Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia
| | - Geoffrey Mitchell
- National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Carol Douglas
- Palliative Care Service, Royal Brisbane and Women's Hospital, Queensland Health, Brisbane, Australia
| | - Patsy Yates
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Centre for Palliative Care Research and Education, Queensland Health, Brisbane, Australia
| | - Ann Bonner
- Faculty of Health, Queensland University of Technology, Brisbane, Australia.,National Health and Medical Research Council, Centre for Research Excellence in End of Life Care, Brisbane, Australia.,Kidney Health Service, Metro North Hospital and Health Service, Queensland Health, Brisbane, Australia.,National Health and Medical Research Council, Chronic Kidney Disease Centre for Research Excellence, Brisbane, Australia
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Khoshab H, Nouhi E, Tirgari B, Ahmadi F. Invisible cobwebs in teamwork—Impediments to the care of patients with heart failure: A qualitative study. Int J Health Plann Manage 2018; 33:e663-e673. [DOI: 10.1002/hpm.2518] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 02/22/2018] [Accepted: 02/27/2018] [Indexed: 11/07/2022] Open
Affiliation(s)
- Hadi Khoshab
- Nursing Research Center, Razi School of Nursing and MidwiferyKerman University of Medical Sciences Kerman Iran
| | - Esmat Nouhi
- Nursing Research Center, Razi School of Nursing and MidwiferyKerman University of Medical Sciences Kerman Iran
| | - Batool Tirgari
- Nursing Research Center, Razi School of Nursing and MidwiferyKerman University of Medical Sciences Kerman Iran
| | - Fazlollah Ahmadi
- Nursing Department, Faculty of Medical SciencesTarbiat Modares University Tehran Iran
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National Council of State Boards of Nursing. Progress and Precision: The NCSBN 2018 Environmental Scan. JOURNAL OF NURSING REGULATION 2018. [DOI: 10.1016/s2155-8256(18)30014-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Affiliation(s)
- Lou A. Lukas
- Nebraska Methodist Health System; and University of Nebraska Medical Center, Omaha, NE
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Saiki C, Ferrell B, Longo-Schoeberlein D, Chung V, Smith TJ. Goals-of-care discussions. ACTA ACUST UNITED AC 2017; 15:e190-e194. [PMID: 30148185 DOI: 10.12788/jcso.0355] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Goals-of-care conversations led by the oncologist are key to advancing the prognostic awareness of the patient and family, but too frequently do not occur or are ineffective in leading to advance care planning and appropriate planning for end-of-life care. At our institution, a phase 3 trial of palliative care added to usual care of phase 1 clinical trial patients gave us the opportunity to develop an electronic medical record-based goals-of-care template for discussions. We can complete all or parts of the form with patients, use it to ensure full coverage of important tasks such as planning for transition to hospice and legacy work, and make sure all the providers are "on the same page" about treatment plans. We have this within our EMR as a SmartPhrase that can be brought up for completion, and have found that it helps to clarify patient understanding. The form can also be used to document advance care planning for both clinical care and billing. Although this tool has not been formally tested, we have found that it is effective in day-to-day practice as well as in research, and we share it here.
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Affiliation(s)
- Catherine Saiki
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | - Thomas J Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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