Palliative care (PC) research has grown over the last 20 years. Yet, the causal components and pathways of PC interventions remain unclear.
To document the prevalence and application of theoretical ...frameworks in developing and testing PC interventions.
We conducted a secondary analysis of previously published systematic reviews of PC randomized clinical trials. Trials were evaluated for explicit mention of a theoretical framework, process or delivery model, or clinical practice guideline that supported the development of the intervention. We used a structured data extraction form to document study population, outcomes, and whether and how authors used a theoretical framework, process/delivery model, or clinical practice guideline. We applied an adapted coding scheme to evaluate use of theoretical frameworks.
We reviewed 85 PC trials conducted between 1984 and 2021. Thirty-eight percent (n = 32) of trials explicitly mentioned a theoretical framework, process or delivery model, or clinical practice guideline as a foundation for the intervention design. Only nine trials included a theoretical framework, while the remaining 23 cited a process/delivery model or clinical practice guideline.
Most PC trials do not cite a theoretical foundation for their intervention design. Future work should focus on developing and validating new theoretical frameworks and modifying existing theories and models to better explain the mechanisms of the variety of PC interventions.
Background: Palliative medicine in Canada continues to be limited by system-wide resource and funding constraints precluding its early integration into standard treatments. Specialist palliative care ...(SPC) services continue to be underutilized among surgical patients, even in regions that exhibit widespread cultural acceptance of SPC. Moral distress in health care is linked with systemic and institutional resource limitations resulting in clinician burnout. The objective of this study was to explore the perceptions about palliative care among BC general surgeons. Methods: This report represents part of a larger exploratory study designed to gain an understanding of palliative care delivery from the experiences of BC general surgeons. Participants were recruited through the BC Surgical Society (BCSS) to complete a self-administered, computer-based survey and invited to participate in an optional semistructured interview. Interviews were recorded, deidentified and transcribed. Analyses were conducted via interpretive description in thematic analysis. Codes and emergent themes were identified through iterative discussions and comparisons. Results: Forty-one general surgeons completed surveys, and 11 consented to semistructured interviews conducted between November 2020 and April 2021. Three overarching perspectives were identified central to a theme of moral distress: 1) systemic resource limitations delay the delivery of primary palliative care in surgery, 2) caring for patients with life-limiting disease poses emotional and professional exhaustion, and 3) surgeons perceived a poor delineation of responsibilities in integrating primary and SPC into surgical practice. These themes correlated with feelings of distress related to personal uncertainty, discomfort, and of poor access to SPC for surgical patients throughout the province. Conclusion: General surgeons acknowledged the need and emerging role of SPC in surgical practice. These perceptions remain focused toward end-of-life and definitively noncurative trajectories as opposed to an integrative approach where outcomes are uncertain. Moral distress is a negative perpetuating phenomenon that forestalls the earlier integration of palliative care in surgical practice.
Despite the expansion of palliative care (PC) services, the public has little knowledge and holds misperceptions about PC, creating barriers to accessing timely specialty PC.
To systematically review ...the evidence regarding the efficacy of educational interventions to improve knowledge and attitudes about PC among nonhealthcare workers.
We searched five databases (PubMed/MEDLINE, Embase, CIANHL, Web of Science, and Scopus) for studies investigating educational interventions about specialty PC in adults who identified as patients, caregivers, or members of the public. We included studies that were available in English and had a comparator group. We excluded studies that only sampled health professionals or children. We used the Mixed Methods Appraisal Tool to assess quality and risk of bias.
Of 12,420 records identified, we screened 5948 abstracts and assessed 526 full texts for eligibility. Twenty-one articles were extracted for analysis, representing 20 unique educational interventions. Common methodologies included quasi-experimental (9, 45%), randomized controlled trial (4, 20%), and nonrandomized trial (2, 10%). Common components of the educational interventions included video presentations (9, 45%), written materials (8, 40%), and lectures (4, 20%). Content included definition (14, 70%) and philosophy (14, 70%) of PC, distinctions between PC and hospice (11, 55%), and eligibility for PC (11, 55%). Fourteen (70%) interventions showed statistically significant positive differences in either knowledge or attitudes about PC.
While educational interventions can positively impact knowledge and attitudes about PC among nonhealthcare workers, more research is needed to inform the design, delivery, and evaluation of interventions to increase knowledge and attitudes about PC.
Communication with family of critically ill patients is often poor and associated with family distress.
To determine if an intensive care unit (ICU) communication facilitator reduces family distress ...and intensity of end-of-life care.
We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict.
Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001).
Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. Clinical trial registered with www.clinicaltrials.gov (NCT 00720200).
As demand for palliative care (PC) services rise, there are insufficient numbers of PC specialists to provide PC for the US population. “Primary palliative care” refers to PC services that are ...administered by non-specialist PC providers. Educating trainees in graduate medical education (GME) programs is 1 strategy for expanding primary palliative care, though questions remain regarding the impact of PC education for GME trainees and where additional education is needed. This study is a multicenter, cross-sectional, web-based survey study of GME trainees assessing the needs for and impacts of primary palliative care education. The survey assessed the implementation of and participants’ confidence with fundamental PC skills. The survey also asked about prior exposure to PC education and for participants’ beliefs regarding areas that would be particularly helpful for future education. 170 residents and fellows from diverse training backgrounds participated in the survey out of 851 potential participants (response rate 19.98%). Exposure to PC education was associated with higher confidence and increased frequency of implementation of fundamental PC skills. Of the forms of education that were assessed, clinical/experiential education was associated most often with higher confidence and higher frequency of use of PC skills. Discussing goals of care, pain management for seriously ill patients, and communicating difficult information were those skills most frequently identified as important for additional training. This study demonstrates that by improving existing PC education or increasing access to PC education for GME trainees, it may be possible to improve primary palliative care.
Over the past decade, a large body of evidence has accumulated supporting the integration of palliative care into oncology practice for patients with advanced cancer. The question is no longer ...whether palliative care should be offered, but what is the optimal model of delivery, when is the ideal time to refer, who is in greatest need of a referral, and how much palliative care should oncologists themselves be providing. These questions are particularly relevant given the scarcity of palliative care resources internationally. In this state‐of‐the‐science review directed at the practicing cancer clinician, the authors first discuss the contemporary literature examining the impact of specialist palliative care on various health outcomes. Then, conceptual models are provided to support team‐based, timely, and targeted palliative care. Team‐based palliative care allows the interdisciplinary members to address comprehensively the multidimensional care needs of patients and their caregivers. Timely palliative care, at its best, is preventive care to minimize crises at the end of life. Targeted palliative care involves identifying the patients most likely to benefit from specialist palliative care interventions, akin to the concept of targeted cancer therapies. Finally, the strengths and weaknesses of innovative care models, such as outpatient clinics, embedded clinics, nurse‐led palliative care, primary palliative care provided by oncology teams, and automatic referral, are summarized. Moving forward, more research is needed to determine how different health systems can best personalize palliative care to provide the right level of intervention, for the right patient, in the right setting, at the right time. CA Cancer J Clin. 2018;680:00‐00. 2018 American Cancer Society, Inc.
The Global Atlas of Palliative Care (GAPC) ranked Mexico's palliative care services at a preliminary integration stage into mainstream healthcare services. However, this data does not reflect ...pediatric palliative care (PPC) development.
To analyze the current need and level of development of PPC within Mexico.
PPC need was estimated using causes of death associated with serious health-related suffering from national mortality data from the General Directorate of Health Information. The level of development was measured through six indicators involving access to PPC services and opioids, then classified using the GAPC development categories adapted to regional territories based on available data.
In 2021, 37,444 children died in Mexico. Of those, 10,677 (28.29%) died from conditions with serious health-related suffering, averaging a need for PPC of 25/100,000 children. Out of Mexico's 32 states, two (6.2%) had no PPC activity (category 1), twenty (62.6%) were in a capacity-building phase (category 2), eight (25%) had isolated PPC provision (category 3a), while two (6.2%) had generalized PPC provision (category 3b). No state had early (category 4a) or advanced PPC integration (category 4b). Overall, Mexico was classified as category 2.
PPC services are distributed unevenly across the country, leading to inequitable access to care and an inability to meet the needs of patients and families. There is a disparity between the level of development of adult palliative care services and the underdevelopment of PPC in Mexico. This information can help stakeholders guide the development of PPC where it is needed most.
Palliative care is associated with improved survival and quality of life among patients with lung cancer; however, its influence on health-care utilization and quality of care is unclear.
Is ...palliative care, and the setting in which it occurs, associated with health-care resource utilization and quality of care among patients with advanced lung cancer?
This was a retrospective cohort study of 23,142 patients with stage IIIB/IV lung cancer in the Veterans Affairs HealthCare System between 2007 and 2013. Exposures included the receipt of specialist-delivered palliative care, and the setting of the initial palliative care encounter (inpatient or outpatient) received after cancer diagnosis. Primary outcomes included rates of ED visits, along with rates of hospitalization and odds of ICU admission within the last 30 days of life. Secondary outcomes included any health-care utilization (ED, hospital, or ICU) related to chemotherapy toxicity. We used propensity score methods to perform Poisson and logistic regression modeling.
Among the 23,142 patients, 57% received palliative care, and 36% of initial palliative care encounters were outpatient. Compared with no palliative care, initial palliative care encounter in the outpatient setting was associated with reduced rates of ED visits (adjusted incidence rate ratio aIRR, 0.86; 95% CI, 0.77-0.96) and hospitalizations in the last 30 days of life (aIRR, 0.64; 95% CI, 0.59-0.70). Initial palliative care encounters in both inpatient (adjusted OR aOR, 0.63; 95% CI, 0.53-0.75) and outpatient (aOR, 0.42; 95% CI, 0.35-0.52) settings were associated with reduced odds of ICU admission in the last 30 days of life. Palliative care was also associated with reduced health-care utilization related to chemotherapy toxicity (aOR, 0.88; 95% CI, 0.82-0.95).
Palliative care (particularly in outpatient settings) is associated with reduced health-care utilization at the end of life and may improve the quality of care among patients with advanced lung cancer. These findings support the role of palliative care as an important component of comprehensive cancer care and highlight the potential benefits of outpatient palliative care services.
The Heart Failure Association of the European Society of Cardiology has published a previous position paper and various guidelines over the past decade recognizing the value of palliative care for ...those affected by this burdensome condition. Integrating palliative care into evidence‐based heart failure management remains challenging for many professionals, as it includes the identification of palliative care needs, symptom control, adjustment of drug and device therapy, advance care planning, family and informal caregiver support, and trying to ensure a ‘good death’. This new position paper aims to provide day‐to‐day practical clinical guidance on these topics, supporting the coordinated provision of palliation strategies as goals of care fluctuate along the heart failure disease trajectory. The specific components of palliative care for symptom alleviation, spiritual and psychosocial support, and the appropriate modification of guideline‐directed treatment protocols, including drug deprescription and device deactivation, are described for the chronic, crisis and terminal phases of heart failure.
Integrating palliative care throughout the heart failure trajectory
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