The Bow Tie Model of 21st Century Palliative Care Hawley, Philippa H., BMed, FRCPC
Journal of pain and symptom management,
2014, January 2014, 2014-Jan, 2014-01-00, 20140101, Letnik:
47, Številka:
1
Journal Article
Canada legalized cannabis use for medical purposes in 1999. Legalization of cannabis for recreational purposes in October 2018 offered the opportunity to assess the impact of recreational ...legalization on cancer patients' patterns of use to identify learning points that could be helpful to other countries considering similar legislation.
Two identical anonymous cross-sectional surveys were administered to cancer patients in British Columbia 2 months before and 3 months following legalization, with the same eligibility criteria. The prevalence of medical cannabis use, the distribution of symptoms leading to use, the most common types of cannabis products and sources, reasons for stopping using cannabis, and barriers to access were assessed.
The overall response rate was 27%. Both cohorts were similar regarding age (median = 66 yrs), gender (53% female), and education (approximately 85% of participants had an education level of high school graduation and higher). Respondents had multiple motives for taking cannabis, including to manage multiple symptoms, to treat cancer, and for recreational reasons. The majority of patients in both surveys did not use the legal medical access system. Comparison of the two cohorts showed that after legalization the prevalence of current cannabis use increased by 26% (23·1% to 29·1%, p-value 0·01), including an increased disclosure of recreational motive for use, from 32 to 40%. However, in the post-legalization cohort more Current Users reported problems getting cannabis (18%) than the pre-legalization cohort (8%), (p-value < 0·01). The most common barrier cited was lack of available preferred products, including edibles, as these were only available from illegal dispensaries.
Results showed that legalization of cannabis for recreational purposes may have an impact on those who use medical cannabis. Impacts include an increase in prevalence of use; problems accessing preferred products legally; higher cost, and difficulties using a legal access system. The desired goal of regulation in reducing harms from use of illegal cannabis products are unlikely to be achieved if the legal process is less attractive to patients than use of illegal sources.
Background
Few treatments have the potential to reduce the severity of radiation-induced mucositis in head and neck cancer patients. Some small studies have suggested that organic honey may be a ...useful preventive treatment.
Methods
This investigator-initiated double-blind randomized placebo-controlled trial investigated whether honey reduced the severity of radiation-induced oral mucositis (ROM). One hundred six head and neck cancer patients from the Vancouver and Sudbury Cancer Centers in Canada were randomized to swish, hold, and swallow either 5 ml of irradiated organic manuka honey or a placebo gel, four times a day throughout radiation treatment, plus seven more days. Severity of oral mucositis according to the Radiation Therapy Oncology Group (RTOG), World Health Organization (WHO), and Oral Mucositis Assessment Scale scales, weight, and subjects' symptom severity and quality of life were assessed weekly. Sialometry was performed at baseline and at the last study visit.
Results
One hundred six patients were recruited. Twenty-four did not attend any mucositis assessments. One was removed from the study because of off-study consumption of store-bought manuka honey. The remaining 81 patients had at least one mucositis assessment and were included in the analysis. Sixty-two percent of subjects received concurrent chemotherapy; 81 % were male. The groups were well-matched, and blinding was excellent. Dropouts were mostly due to nausea and were similar in both arms, with 78 % being able to tolerate the study products for more than 1 week. The dropout rate was 57 % in those who received honey and 52 % in those who received placebo gel. The dropout rate in those who had concurrent chemotherapy was 59 % and in those who only received radiation was 47 %. There was no statistically significant difference between the honey and placebo arms in any of the outcome indicators. Those who completed the study in both treatment arms had low rates of RTOG greater than or equal to grade 3 mucositis; 35 % in the honey group and 43 % in the placebo group.
Conclusion
Despite promising earlier reports, manuka honey was not tolerated well by our patients and, even when used as directed, did not have a significant impact on the severity of ROM.
Palliative care has long been described in medical literature but only recently is being discussed in the surgical domain. Mounting evidence suggests that early integration of palliative care ...improves patient outcomes and this is especially true of oncology patients. Thus, the pendulum is swinging toward recognizing that palliative care and active disease management are not mutually exclusive but rather synergistic in modern surgical oncology. Here we use a patient vignette to demonstrate the new challenges and possibilities in modern surgical oncology, we then discuss the historic perspective of palliative care and describe how the paradigm is shifting. Finally, we introduce a model that may be beneficial in conceptualizing this new way of thinking about and integrating palliative care into surgical oncology.
ObjectivesThe Serious Illness Conversation Guide (SICG) has emerged as a framework for conversations with patients with a serious illness diagnosis. This study reports on narratives generated from ...open-ended questions of a novel assessment tool, the Serious Illness Conversation-Evaluation Exercise (SIC-Ex), to assess resident-led conversations with patients in oncology outpatient clinics.DesignQualitative study using template analysis.SettingThree academic cancer centres in Canada.Participants7 resident physicians (trainees), 7 patients from outpatient cancer clinics, 10 preceptors (raters) consisting of medical oncologists, palliative care physicians and radiation oncologists.InterventionsEach trainee conducted an SIC with a patient, which was videotaped. The raters watched the videos and evaluated each trainee using the novel SIC-Ex and the reference Calgary-Cambridge Guide (CCG) initially and again 3 months later. Two independent coders used template analysis to code the raters’ narrative comments and identify themes/subthemes.Outcome measuresHow narrative comments aligned with elements of the CCG and SICG.ResultsTemplate analysis yielded four themes: adhering to SICG, engaging patients and family members, conversation management and being mindful of demeanour. Narrative comments identified numerous verbal and non-verbal elements essential to SICG. Some comments addressing general skills in engaging patients/families and managing the conversation (eg, setting agenda, introduction, planning, exploring, non-verbal communication) related to both the CCG and SICG, whereas other comments such as identifying substitute decision maker(s), affirming commitment and introducing Advance Care Planning were specific to the SICG.ConclusionsNarrative comments generated by SIC-Ex provided detailed and nuanced insights into trainees’ competence in SIC, beyond the numerical ratings of SIC-Ex and the general communication skills outlined in the CCG, and may contribute to a more fulsome assessment of SIC skills.
To explore the impact of implementation of a symptom screening and supportive/palliative care referral pathway in patients newly referred to a Canadian gastrointestinal medical oncology ...clinic.PurposeTo explore the impact of implementation of a symptom screening and supportive/palliative care referral pathway in patients newly referred to a Canadian gastrointestinal medical oncology clinic.Eighty-eight subjects were recruited in each study arm. Intervention subjects were assessed by a member of the supportive/palliative care team if they had a severity score of >3/10 on the Edmonton Symptom Assessment System. Controls received normal care, including discretionary referral. Symptom severity was assessed over the subsequent five months. Data on survival, care setting of death (home, hospice or hospital) and long-term resource use were also collected.MethodsEighty-eight subjects were recruited in each study arm. Intervention subjects were assessed by a member of the supportive/palliative care team if they had a severity score of >3/10 on the Edmonton Symptom Assessment System. Controls received normal care, including discretionary referral. Symptom severity was assessed over the subsequent five months. Data on survival, care setting of death (home, hospice or hospital) and long-term resource use were also collected.Screening led to 141 specialist supportive/palliative care visits in the intervention arm versus only nine in the control arm. There were, however, no subsequent significant differences in symptom severity or the long-term outcomes measured. Many patients identified by the >3/10 severity threshold did not need/want specialist supportive/palliative care referral, and those with severe distress were either identified by the oncology team already or were too unwell or overwhelmed to participate in the study. The specialist service was not overwhelmed. Important considerations on timing and mode of administration of screening tools were revealed.ResultsScreening led to 141 specialist supportive/palliative care visits in the intervention arm versus only nine in the control arm. There were, however, no subsequent significant differences in symptom severity or the long-term outcomes measured. Many patients identified by the >3/10 severity threshold did not need/want specialist supportive/palliative care referral, and those with severe distress were either identified by the oncology team already or were too unwell or overwhelmed to participate in the study. The specialist service was not overwhelmed. Important considerations on timing and mode of administration of screening tools were revealed.Routine symptom screening can be burdensome for oncology patients and needs to be as simple as possible. Triaging positive screens is an important role for oncology nurses. Investment in training oncology teams to manage uncomplicated distress in the oncology clinic allows for optimal use of scarce supportive/palliative care specialist resources for patients with complex needs.ConclusionRoutine symptom screening can be burdensome for oncology patients and needs to be as simple as possible. Triaging positive screens is an important role for oncology nurses. Investment in training oncology teams to manage uncomplicated distress in the oncology clinic allows for optimal use of scarce supportive/palliative care specialist resources for patients with complex needs.
Objet : Mesurer l’effet de la mise en œuvre du dépistage des symptômes et de voies d’aiguillage vers les soins de soutien et les soins palliatifs pour les patients récemment dirigés vers une clinique ...canadienne d’oncologie gastro-intestinale.
Méthodologie : On a recruté 88 sujets pour chaque groupe de traitement. Les sujets du groupe expérimental, lorsque l’intensité de leurs symptômes dépassait 3 sur 10 sur l’échelle d’évaluation des symptômes d’Edmonton (Edmonton Symptom Assessment System ou ESAS), ont été évalués par un membre de l’équipe des soins palliatifs et de soutien. Les sujets du groupe témoin ont reçu les soins usuels, et ont été dirigés vers d’autres services selon l’évaluation du professionnel de la santé. L’intensité des symptômes a été évaluée pendant les 5 mois qui ont suivi. On a aussi colligé les données sur la survie, le lieu du décès (domicile, maison de soins palliatifs, hôpital) et le séjour en établissement de soins de longue durée.
Résultats : Le dépistage a mené à 141 visites de spécialistes des soins palliatifs et de soutien dans le groupe expérimental contre seulement 9 dans le groupe témoin. On n’a cependant noté aucune autre différence significative dans l’intensité des symptômes ou l’évolution à long terme. Plusieurs patients dont l’intensité des symptômes dépassait 3 sur 10 ne voulaient pas consulter de spécialiste des soins palliatifs et de soutien ou n’en avaient pas besoin; en ce qui concerne les personnes ressentant de la détresse aiguë, soit elles avaient déjà été dépistées par l’équipe d’oncologie, soit elles étaient trop malades ou accablées pour participer à l’étude. Les spécialistes n’ont pas été débordés. L’étude a révélé l’importance de bien choisir le moment et le mode d’administration des outils de dépistage.
Conclusion : Le dépistage de routine des symptômes peut être lourd pour les patients; il doit donc rester le plus simple possible. Le triage des malades nécessitant un suivi (selon les résultats du dépistage) échoit aux infirmières en oncologie. Le fait de former les équipes d’oncologie à la prise en charge de cas simples de détresse permet d'utiliser de façon optimale les quelques rares spécialistes soins palliatifs et de soutien aux patients ayant des besoins complexes.
Abstract Limited information is available regarding the quality of end-of-life care at cancer centers. We sought to characterize the end-of-life decision-making process for advanced cancer patients ...admitted to our tertiary cancer center, and to examine the association between goals of care and practice patterns. Information on patient characteristics, investigations, cancer treatments, and goals of care was collected retrospectively for consecutive patients who died at the inpatient unit of the Vancouver Cancer Center between January 1, 2005 and December 31, 2006. One hundred eighteen advanced cancer patients had a median admission duration of 10 days (range 1–64 days). A median of two tests per day was performed, with a decreasing trend over time ( P < 0.001). Forty percent received cancer treatments during hospitalization, with 75% terminated prematurely. Do-not-resuscitate orders, supportive care plans, and diagnosis of dying were documented for 96%, 86%, and 76% of the patients, respectively. Early establishment of supportive care plan and diagnosis of dying were associated with timely discontinuation of cancer treatments (Spearman coefficients 0.47 and 0.60, respectively). Multivariate analysis revealed that timely diagnosis of dying was associated with early establishment of code status ( P = 0.042), supportive care plans ( P < 0.001), and discontinuation of cancer therapy ( P = 0.005). Cancer patients who died at our oncology center were investigated and treated intensively during their short hospitalization. Early establishment of goals of care may be associated with changes in practice consistent with improved quality of care.
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