Friday, 23 May 2008

Computer based hospice palliative care datasets in Canada

BMC Palliative Care, Volume 7
A comparative analysis of computer based hospice palliative care datasets in Canada
Craig E Kuziemsky, Francis LauBMC Palliative Care 2008, 7:6 (12 May 2008)[Abstract] [Full text] [PDF] [PubMed] [Related articles]

An evaluation of palliative care in the acute geriatric setting

An evaluation of palliative care in the acute geriatric setting
Philip Dainty
Age and Ageing 2008 ; VOL 37 ; PART 3 (2008-May)
Page: 327 - 330

How can we fulfil patients' wishes at end of life?

How can we fulfil patients' wishes at end of life?
The King's Fund has launched a discussion paper entitled Improving Choice at End of Life.
This paper provides a descriptive analysis of the Marie Curie Delivering Choice Programme. Delivery of care for patients at the end of their lives is becoming an increasing policy concern. Although the majority of people report that they would choose to die in their home, only a minority of patients achieve this wish. The Delivering Choice Programme aims to develop and help provide the best possible service for patients at the end of their lives.
Visit our website to download the paper.

Flu Pandemic Planning: Advice for Hospices

Flu Pandemic Planning: Advice for Hospices
Hospice support charity Help the Hospices has published useful guidance on procedures to follow in the event of a flu pandemic. The booklet includes information on levels of alert, a planning checklist and directions to useful resources.
Flu Pandemic Planning: Advice for Hospices is now available to download from the NHS Networks Pandemic Flu page
Flu Pandemic Planning: Advice for Hospices (PDF, 669KB)
Help the Hospices
NHS Networks Pandemic Flu page

Palliative care in nephrology.

Palliative care in nephrology.
Nephrology dialysis transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, Mar 2008 (epub: 11 Jan 2008), vol. 23, no. 3, p. 789-91
Brown-Edwina-A, Chambers-Elizabeth-Joanna, Eggeling-Celia.

Patients' use of digital pens for pain assessment

Patients' use of digital pens for pain assessment in advanced palliative home healthcare.
International journal of medical informatics, Feb 2008 (epub: 23 Mar 2007), vol. 77, no. 2, p. 129-36
Lind-Leili, Karlsson-Daniel, Fridlund-Bengt.
BACKGROUND: Appropriate pain assessment is a necessary prerequisite for adequate pain control. A way to follow-up on the pain is to let patients use paper-based or electronic pain diaries. PURPOSE: The aim was to explore and describe palliative home care patients' experiences of assessing their pain by using a pain diary together with digital pen and mobile Internet technology. METHODS: A system for the follow-up of pain treatment was developed and evaluated by means of a qualitative cross-case content analysis. From December 2002 until September 2003 12 palliative patients, who initially assessed VAS pain>or=35 mm (VAS 0-100 mm), used the system. Patients reported their momentary pain intensity and the number of consumed extra doses of analgesics three times per day. Analysis data were collected from interviews with patients and spouses, questionnaires, medical records, and the system log. RESULTS: In spite of severe illness and difficulties in comprehending the technology and system intervention, patients found the pain diary and digital pen easy to use for pain assessment. Patients took a greater part in their own care and experienced an improved contact with their caregivers, which led to a sense of increased security. The medical records showed a quick response to variations in the patients' health status by means of changes in medical treatment. CONCLUSIONS: The pain assessment system for palliative patients using pain diaries together with digital pen and wireless Internet technology constitutes an effortless method and has positive influences on the care.

Journal of pain and symptom management, Mar 2008 (epub: 28 Jan 2008), vol. 35, no. 3

Haloperidol as a palliative anti-emetic in a toddler: an evidence base challenge.
p. 235-8
Case-Reports, Letter.

Perceptions of specialized inpatient palliative care: a population- based survey in Japan.
p. 275-82
Sanjo-Makiko, Miyashita-Mitsunori, Morita-Tatsuya, Hirai-Kei et al
This study aimed to clarify and compare the awareness and perceptions of the specialized inpatient palliative care service. A cross- sectional questionnaire survey was performed on the general population selected by stratified two-stage random sampling (n=2,548) and bereaved families who actually received specialized inpatient palliative care at 12 palliative care units (PCUs) in Japan (n=513). The respondents reported their awareness and perceptions of PCUs. Thirty-eight percent of the general population answered that they had considerable or moderate knowledge of PCUs, but 24% answered that they had no knowledge. Bereaved families who received PCU care (PCU- bereaved families) were likely to have better perceptions of PCUs than the general population: alleviates pain (68% of the general population and 87% of PCU-bereaved families agreed), provides care for families (67% and 86%, respectively), and provides compassionate care (67% and 87%, respectively). Both groups, however, expressed concerns about PCUs: a place where people only wait to die (30% and 40%, respectively) and shortens the patient's life (8% and 17%, respectively). These perceptions were associated with overall satisfaction with received care, and differed among the 12 PCUs. In conclusion, public awareness of PCUs was insufficient in Japan. Although PCU-bereaved families were generally likely to have better perceptions of PCUs than the general population, both groups shared concerns that a PCU was a place where people only wait to die. To facilitate appropriate use of specialized palliative care services, more efforts to inform the general population about the actual palliative care system are needed. In addition, the role of PCUs might be reconsidered in terms of the continuum of cancer care.

Intravenous morphine for breakthrough (episodic-) pain in an acute palliative care unit: a confirmatory study.
p. 307-13
Mercadante-Sebastiano, Intravaia-Giuseppe, Villari-Patrizia et al
The aim of this prospective cohort study was to confirm the safety of intravenous morphine (IV-M) used in doses proportional to the basal opioid regimen for the management of breakthrough pain and to record the nurse compliance on regularly recording data regarding breakthrough pain treated by IV-M. Over a one-year period, 99 patients received IV-M for breakthrough pain during 116 admissions. The IV-M dose was 1/5 of the oral daily dose, converted using an equianalgesic ratio of 1/3 (IV/oral). For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to reassess the patient 15minutes after IV-M injection (T15). Nurses were unaware of the aim of the study and just followed department policy. In total, 945 breakthrough events treated by IV-M were recorded and the mean number of events per patient per admission was eight (95% confidence interval (CI) 6.9-9.5). The mean dose of IV-M was 12mg (95% CI 9-14mg). In the 469 events (49.6%) with a complete assessment, a decrease in pain of more than 33% and 50% was observed in 287 (61.2%) and 115 (24.5%) breakthrough events, respectively. The mean pain intensity decreased from 7.2 (T0) to 2.7 (T15). In eight episodes, no changes in pain intensity were observed and a further dose of IV-M was given. The remaining patients did not require further interventions. No clinical events requiring medical intervention were recorded. In this confirmatory study, IV-M was administered for the management of breakthrough pain in doses proportional to the basal opioid regimen to all patients, including older patients and those requiring relatively large doses. This did not result in life- threatening adverse effects in a large number of patients and was effective in most cases. The role of nurses is of paramount importance in monitoring and collecting data and gathering information for audit purposes on the unit.
Clinical-Trial, Journal-Article.

Do palliative consultations improve patient outcomes?

Do palliative consultations improve patient outcomes?
Journal of the American Geriatrics Society, Apr 2008 (epub: 16 Jan 2008), vol. 56, no. 4, p. 593-9
Casarett-David, Pickard-Amy, Bailey-F-Amos, Ritchie-Christine et al
OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care. DESIGN: Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life. SETTING: Five VA Medical Centers or their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey. MEASUREMENTS: The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items). RESULTS: Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62-66) versus 54 (95% CI=51-56; P<.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (beta=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support. CONCLUSION: Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.

Integration of palliative care practices into the ongoing care of children with cancer

This issue of the Clinics is devoted to padiatric oncology. Available in the Health Sciences Library.
Integration of palliative care practices into the ongoing care of children with cancer: individualized care planning and coordination.
Pediatric clinics of North America, Feb 2008, vol. 55, no. 1, p. 223-50, xii, 98 refs
Baker-Justin-N, Hinds-Pamela-S, Spunt-Sheri-L, Barfield-Raymond-C et al
Most parents of children with cancer have dual primary goals: a primary cancer-directed goal of cure and a primary comfort-related goal of lessening suffering. Early introduction of palliative care principles and practices into their child's treatment is respectful and supportive of these goals. The Individualized Care Planning and Coordination Model is designed to integrate palliative care principles and practices into the ongoing care of children with cancer. Application of the model helps clinicians to generate a comprehensive individualized care plan that is implemented through Individualized Care Coordination processes as detailed here. Clinicians' strong desire to provide compassionate, competent, and sensitive care to the seriously ill child and the child's family can be effectively translated into clinical practice through these processes.

Role of the family physician in the referral and management of hospice patients.

The role of the family physician in the referral and management of hospice patients.
American family physician, 15 Mar 2008, vol. 77, no. 6, p. 807-12, 42 refs
Hospice is available for any patient who is terminally ill and chooses a palliative care approach. Because of the close relationship that primary care physicians often have with their patients, they are in a unique position to provide end-of-life care, which includes recognizing the need for and recommending hospice care when appropriate. The hospice benefit covers all expenses related to the terminal illness, including medication, nursing care, and equipment. Hospice should be considered when a patient has New York Heart Association class IV heart failure, severe dementia, activity- limiting lung disease, or metastatic cancer. Timely referrals are beneficial to both patient and hospice because of the cost related to initiating services and the time required to form a therapeutic relationship. Once the decision to refer to hospice is made, the family physician typically continues to be the patient's primary attending physician. The attending physician is expected to remain in charge of the patient's care, write orders, see the patient for office visits, and complete and sign the death certificate. Hospice, in turn, is a valuable physician resource when it comes to medication dosages, symptom management, and communication with patients and their families.

A study of the prevalence of vitamin K deficiency in patients with cancer

A study of the prevalence of vitamin K deficiency in patients with cancer referred to a hospital palliative care team and its association with abnormal haemostasis.
Full text available at BMJ Publishing Group for NHS BMJ Publishing Group

Journal of clinical pathology, Apr 2008 (epub: 08 Oct 2007), vol. 61, no. 4, p. 537-40
Harrington-D-J, Western-H, Seton-Jones-C, Rangarajan-S, Beynon-T, Shearer-M-J.
BACKGROUND: Many patients with advanced cancer are malnourished. Anorexia is common, as is the use of chemotherapy, which may cause nausea and poor appetite. Ten per cent of these patients experience haemorrhagic events. AIM: Since vitamin K deficiency (VKD) causes bleeding, to establish the prevalence of VKD in patients with advanced cancer receiving palliative care. METHODS: Serum concentrations of vitamin K(1) and undercarboxylated factor II (PIVKA-II) were determined in 46 (17 male/29 female) inpatients aged 26-85 (mean 58) years. INR and liver function tests (bilirubin, ALT, GGT and ALP) were also performed. RESULTS: Vitamin K(1) was below the lower limit of the reference range (0.33 nmol/l) in 22% of patients. 78% of patients had some degree of functional VKD indicated by raised (>0.2 AU/ml) PIVKA-II. Six patients (13%) had a prolonged INR, all of whom had raised PIVKA-II and GGT; 4 also had vitamin K(1) <0.33>1.5, PIVKA-II >10 AU/ml, and undetectable vitamin K(1). CONCLUSIONS: Patients with advanced cancer are prone to VKD which, while usually subclinical, may develop to a clinically relevant prolongation of the INR. Serum measurements of vitamin K(1) and PIVKA-II can be used to detect VKD and monitor vitamin K status before an increased risk of bleeding develops.

Critical care medicine, Apr 2008, vol. 36, no. 4

Not euthanasia, simply compassionate clinical care.
Full text available at OVID for NHS
p. 1387-8; author reply 1389
Comment, Letter.
Comment on: Crit Care Med. 2007 Oct; 35(10):2428-30.

The search for a good death--are there quality insights accessible from medical records?
Full text available at OVID for NHS
p. 1372-3
Comment, Editorial.
Comment on: Crit Care Med. 2008 Apr; 36(4):1138-46.

Using the medical record to evaluate the quality of end-of-life care in the intensive care unit.
Full text available at OVID for NHS
p. 1138-46
Glavan-Bradford-J, Engelberg-Ruth-A, Downey-Lois, Curtis-J-Randall.
RATIONALE: We investigated whether proposed quality markers within the medical record are associated with family assessment of the quality of dying and death in the intensive care unit (ICU). OBJECTIVE: To identify chart-based markers that could be used as measures for improving the quality of end-of-life care. DESIGN: A multicenter study conducting standardized chart abstraction and surveying families of patients who died in the ICU or within 24 hrs of being transferred from an ICU. SETTING: ICUs at ten hospitals in the northwest United States. PATIENTS: Overall, 356 patients who died in the ICU or within 24 hrs of transfer from an ICU. MEASUREMENTS: The 22-item family assessed Quality of Dying and Death (QODD-22) questionnaire and a single item rating of the overall quality of dying and death (QODD-1). ANALYSIS: The associations of chart-based quality markers with QODD scores were tested using Mann-Whitney U tests, Kruskal-Wallis tests, or Spearman's rank-correlation coefficients as appropriate. RESULTS: Higher QODD-22 scores were associated with documentation of a living will (p = .03), absence of cardiopulmonary resuscitation performed in the last hour of life (p = .01), withdrawal of tube feeding (p = .04), family presence at time of death (p = .02), and discussion of the patient's wish to withdraw life support during a family conference (p < .001). Additional correlates with a higher QODD-1 score included use of standardized comfort care orders and occurrence of a family conference (p < or = .05). CONCLUSIONS: We identified chart-based variables associated with higher QODD scores. These QODD scores could serve as targets for measuring and improving the quality of end-of-life care in the ICU.

Content and effects of palliative care courses for nurses

The content and effects of palliative care courses for nurses: a literature review.
International journal of nursing studies, Mar 2008 (epub: 16 May 2007), vol. 45, no. 3, p. 471-85, 69 refs
Adriaansen-Marian, van-Achterberg-Theo
OBJECTIVES: The present literature review describes the literature (1990-2005) that concerns the effects of courses in palliative care at the pre- and postgraduate levels. DATA SOURCES: A search was made for literature from the period between 1990 and 2005 using CINAHL, Pubmed and Psychlit, supplemented with a search for relevant systematic reviews from the Cochrane Library. DESIGN: The research questions were directed on the areas of expertise and skills, the didactical methods, the effects of the courses and the standards to measure these effects. RESULTS: The studies were all focused on general palliative care. Out of 27 studies 21 reported positive effects for communication, attitude, empathy and pain. Six of these 21 positive trails were studies with good quality designs, whereas 15 had moderate designs. The six studies with a lack of effects was one study with good quality and five studies with moderate quality designs. The effects on patients were described in only a few cases. There was still frequent use of self-constructed rating scales, where data about validity and reliability were lacking or where these aspects were not studied. CONCLUSIONS: The most successful were integrated courses focused on several themes with a variety of didactical methods.

Measuring patient-oriented outcomes in palliative care

Measuring patient-oriented outcomes in palliative care: functionality and quality of life.
Full text available at ProQuest
Clinical journal of oncology nursing, Feb 2008, vol. 12, no. 1, p. 65-77, 75 refs
Granda-Cameron-Clara, Viola-Sara-R, Lynch-Mary-Pat, Polomano- Rosemary-C.
Outcomes measurement is necessary to evaluate quality of care, increase knowledge about experiences with cancer and therapies, and determine the effectiveness of interventions directed toward improving symptoms and quality of life (QOL) in research and clinical care. Recent attention on outcomes measurement and research in palliative care settings has emphasized the need to incorporate patient-reported outcomes. Unlike other areas of research in oncology, palliative care research is comprised largely of descriptive studies elucidating the process involved with palliative care, with a notable void in well-designed patient-oriented studies employing standard instruments for measuring functional status, QOL, symptoms, and psychosocial well-being. Outcomes programs in practice settings where palliative care is an integral part of clinical services can offer important information about patient experiences across the continuum of care and help to identify patients most likely to benefit from palliative care interventions. Therefore, oncology nurses must be informed about outcome-measurement issues, including ways to select reliable and valid instruments and determine which ones are appropriate for palliative care populations. Content related to the measurement of patient-oriented outcomes is presented to assist nurses in developing outcomes programs in palliative care settings.

Palliative care and end of life issues in UK pre-registration, undergraduate nursing programmes.

Palliative care and end of life issues in UK pre-registration, undergraduate nursing programmes.
Nurse education today, Feb 2008 (epub: 23 Apr 2007), vol. 28, no. 2, p. 163-70
Dickinson-George-E, Clark-David, Sque-Magi.
Palliative and end of life care topics have traditionally not been in nursing school curricula. Only in recent years have these been included. The aim of this research was to determine the current status of such an emphasis in programmes in the United Kingdom (UK). A mailed survey in 2006 to the 66 undergraduate (pre-registration) nursing programmes in the UK (return rate of 79%) determined that palliative and end of life care play a significant role in these programmes. Forty-five teaching hours on average were devoted to these topics. All of the schools have some provision on palliative and end of life care, and over 95% of students participated in these courses. A nurse was usually the primary instructor, although non- nurses were sometimes used. Attitudes toward dying and death and communicating with terminally-ill patients and family members were emphasised. By highlighting dying and death in the curricula, nursing schools appeared to be giving nursing students an opportunity to face the issue of death, thus helping them to be better prepared to help their patients and their families to do so.

Hospital-based palliative care: cost-effective care

Hospital-based palliative care: cost-effective care for patients with advanced disease.
The Journal of nursing administration, Mar 2008, vol. 38, no. 3, p. 143-5
Palliative care programs in acute care facilities provide a safety net for patients with advanced disease. While providing aggressive symptom management for patients, these programs are also cost- effective. This author discusses the economic advantages of improving care for patients with advanced disease.

American Thoracic Society clinical policy statement

An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses.

Full text available at ProQuest
American journal of respiratory and critical care medicine, {Am-J- Respir-Crit-Care-Med}, 15 Apr 2008, vol. 177, no. 8, p. 912-27, ISSN: 1535-4970.
Lanken-Paul-N, Terry-Peter-B, Delisser-Horace-M, Fahy-Bonnie-F et al
ATS End-of-Life Care Task Force.