Racial and ethnic disparities in health care access and quality are well documented for some minority groups. However, compared to other areas of health care, such as disease prevention, early ...detection, and curative care, research in disparities in palliative care is limited. Given the rapidly growing population of minority older adults, many of whom will face advanced serious illness, the availability of high-quality palliative care that meets the varied needs of older adults of all races and ethnicities is a priority. This paper reviews existing data on racial and ethnic disparities in use of and quality of palliative care and outlines priorities for future research.
By 2030 more people in the United States will be older than age sixty-five than younger than age five. Our health care system is unprepared for the complexity of caring for a heterogenous population ...of older adults-a problem that has been magnified by the coronavirus disease 2019 (COVID-19) pandemic. Here, as part of the National Academy of Medicine's Vital Directions for Health and Health Care: Priorities for 2021 initiative, we identify six vital directions to improve the care and quality of life for all older Americans. The next administration must create an adequately prepared workforce; strengthen the role of public health; remediate disparities and inequities; develop, evaluate, and implement new approaches to care delivery; allocate resources to achieve patient-centered care and outcomes, including palliative and end-of-life care; and redesign the structure and financing of long-term services and supports. If these priorities are addressed proactively, an infrastructure can be created that promotes better health and equitable, goal-directed care that recognizes the preferences and needs of older adults.
Background
Presently a median of 37.5% of the U.S. skilled nursing facility (SNF) workforce has been vaccinated for COVID‐19. It is essential to understand vaccine hesitancy among SNF workers to ...inform vaccine campaigns going forward.
Objective
To describe the concerns raised among healthcare workers and staff from SNFs during town hall meetings.
Design
Sixty‐three SNFs from four corporations were invited to send Opinion Leaders, outspoken staff from nursing, nurse aid, dietary, housekeeping or recreational therapy, to attend a 1‐h virtual town hall meeting. Meetings used a similar format where the moderator solicited concerns that the attendees themselves had or had heard from others in the facility about the COVID‐19 vaccine. Physicians and moderators used personal stories to address concerns and reaffirmed positive emotions.
Setting
Twenty‐six video town hall meetings with SNF staff.
Participants
Healthcare workers and staff, with physicians serving as content experts.
Measurement
Questions and comments about the COVID‐19 vaccines noted by physicians.
Results
One hundred and ninety three staff from 50 facilities participated in 26 meetings between December 30, 2020 and January 15, 2021. Most staff reported getting information about the vaccine from friends or social media. Concerns about how rapidly the vaccines were developed and side effects, including infertility or pregnancy related concerns, were frequently raised. There were no differences in concerns raised by discipline. Questions about returning to prior activities after being vaccinated were common and offered the opportunity to build on positive emotions to reduce vaccine hesitancy.
Conclusions
Misinformation about the COVID‐19 vaccine was widespread among SNF staff. Sharing positive emotions and stories may be more effective than sharing data when attempting to reduce vaccine hesitancy in SNF staff.
The State of the Science in Spirituality and Palliative Care was convened to address the current landscape of research at the intersection of spirituality and palliative care and to identify critical ...next steps to advance this field of inquiry. Part I of the SOS-SPC two-part series focuses on questions of 1) What is spirituality? 2) What methodological and measurement issues are most salient for research in palliative care? And 3) What is the evidence relating spirituality and health outcomes? After describing current evidence we make recommendations for future research in each of the three areas of focus. Results show wide variance in the ways spirituality is operationalized and the need for definition and conceptual clarity in research in spirituality. Furthermore, the field would benefit from hypothesis-driven outcomes research based on a priori specification of the spiritual dimensions under investigation and their longitudinal relationship with key palliative outcomes, the use of validated measures of predictors and outcomes, and rigorous assessment of potential confounding variables. Finally, results highlight the need for research in more diverse populations.
In the United States, colorectal cancer (CRC) is the third most common cancer diagnosed among men and women and the second leading cause of death from cancer. CRC largely can be prevented by the ...detection and removal of adenomatous polyps, and survival is significantly better when CRC is diagnosed while still localized. In 2006 to 2007, the American Cancer Society, the US Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology came together to develop consensus guidelines for the detection of adenomatous polyps and CRC in asymptomatic average-risk adults. In this update of each organization's guidelines, screening tests are grouped into those that primarily detect cancer early and those that can detect cancer early and also can detect adenomatous polyps, thus providing a greater potential for prevention through polypectomy. When possible, clinicians should make patients aware of the full range of screening options, but at a minimum they should be prepared to offer patients a choice between a screening test that primarily is effective at early cancer detection and a screening test that is effective at both early cancer detection and cancer prevention through the detection and removal of polyps. It is the strong opinion of these 3 organizations that colon cancer prevention should be the primary goal of screening.
Cultural beliefs and values are thought to account for differences between African Americans and whites in the use of advance directives and beliefs about hospice care, but few data clarify which ...beliefs and values explain these differences. Two hundred five adults aged 65 and older who received primary care in the Duke University Health System were surveyed. The survey included five scales: Hospice Beliefs and Attitudes, Preferences for Care, Spirituality, Healthcare System Distrust, and Beliefs About Dying and Advance Care Planning. African Americans were less likely than white subjects to have completed an advance directive (35.5% vs 67.4%, P<.001) and had less favorable beliefs about hospice care (Hospice Beliefs and Attitudes Scale score, P<.001). African Americans were more likely to express discomfort discussing death, want aggressive care at the end of life, have spiritual beliefs that conflict with the goals of palliative care, and distrust the healthcare system. In multivariate analyses, none of these factors alone completely explained racial differences in possession of an advance directive or beliefs about hospice care, but when all of these factors were combined, race was no longer a significant predictor of either of the two outcomes. These findings suggest that ethnicity is a marker of common cultural beliefs and values that, in combination, influence decision‐making at the end of life. This study has implications for the design of healthcare delivery models and programs that provide culturally sensitive end‐of‐life care to a growing population of ethnically diverse older adults.
Advanced heart failure (HF) is characterized by high morbidity and mortality. Conventional therapy may not sufficiently reduce patient suffering and maximize quality of life.
The authors investigated ...whether an interdisciplinary palliative care intervention in addition to evidence-based HF care improves certain outcomes.
The authors randomized 150 patients with advanced HF between August 15, 2012, and June 25, 2015, to usual care (UC) (n = 75) or UC plus a palliative care intervention (UC + PAL) (n = 75) at a single center. Primary endpoints were 2 quality-of-life measurements, the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary and the Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal), assessed at 6 months. Secondary endpoints included assessments of depression and anxiety (measured via the Hospital Anxiety and Depression Scale HADS), spiritual well-being (measured via the FACIT-Spiritual Well-Being scale FACIT-Sp), hospitalizations, and mortality.
Patients randomized to UC + PAL versus UC alone had clinically significant incremental improvement in KCCQ and FACIT-Pal scores from randomization to 6 months (KCCQ difference = 9.49 points, 95% confidence interval CI: 0.94 to 18.05, p = 0.030; FACIT-Pal difference = 11.77 points, 95% CI: 0.84 to 22.71, p = 0.035). Depression improved in UC + PAL patients (HADS-depression difference = -1.94 points; p = 0.020) versus UC-alone patients, with similar findings for anxiety (HADS-anxiety difference = -1.83 points; p = 0.048). Spiritual well-being was improved in UC + PAL versus UC-alone patients (FACIT-Sp difference = 3.98 points; p = 0.027). Randomization to UC + PAL did not affect rehospitalization or mortality.
An interdisciplinary palliative care intervention in advanced HF patients showed consistently greater benefits in quality of life, anxiety, depression, and spiritual well-being compared with UC alone. (Palliative Care in Heart Failure PAL-HF; NCT01589601).
This series focuses on addressing the intersection of race and racism in palliative care through roundtable discussions with interdisciplinary clinicians, researchers, educators, and leaders in ...palliative care. These short discussions are intended to stimulate readers to examine issues of race and racism within the field of hospice and palliative care - in the various forms that it appears - as well as serve as a continual call to action to facilitate and promote equity.
Abstract Background Historically, palliative care has been focused on those with cancer. While these ties persist, palliative care is rapidly integrating into the care of patients with common, ...non-cancer serious illnesses. Despite this, the bulk of literature informing palliative care practices stems from the care of cancer patients. Objectives We compared functionality, advanced care planning, hospital admissions, prognosis, quality of life, pain, dyspnea, fatigue, and depression between patients with cancer and three non-cancer diagnoses--end stage renal disease (ESRD), heart failure (HF), and chronic obstructive pulmonary disease (COPD). Methods We conducted a cross-sectional, retrospective analysis of the characteristics and symptoms of patient’s with ESRD, HF, COPD and cancer at time of first specialty palliative care referral. Using a web based point of care quality assessment and reporting tool, Quality Data and Collection Tool-Palliative care (QDACT-PC), this analysis evaluated all eligible patients who received a palliative care consultation between October 1, 2012 and November 25, 2014. Data was obtained from 13 participating sites. The primary outcome for the study was functionality using the palliative performance scale. Hospital admission in the last 30 days, prognosis, patient’s understanding of prognosis, advanced care planning including code status and appointed decision maker, pain, fatigue, depression and dyspnea were also evaluated as secondary outcomes. We tested for an association between our outcomes with disease type (cancer vs. non-cancer) fitting multivariable logistic regression models. Results We found that the patients with primary diagnoses other than cancer were less functional at time of referral (OR: 1.6; 95%CI: 1.1, 2.3; p<0.05). Conclusion Patients with COPD, ESRD and HF were less functional and more likely to be hospitalized at time of referral to palliative care than cancer patients. These findings may be reflective of the slower and more varied trajectory of non-cancer serious illness. One aim of palliative care for those with non-cancer severe illness should be directed towards improving and assisting with functionality and decreasing frequency of hospital admissions. These interventions could take place in the palliative care office, but could also be integrated into hospital discharge plans.
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