Thursday, 17 July 2008

Delivering effective end-of-life care: developing partnership working

Delivering effective end-of-life care: developing partnership working
Wednesday 15 October 2008, 10.00am–4.15pm Royal College of Obstetricians and Gynaecologists, London
Recognition of the need for good-quality end-of-life care is at the heart of the government's new End of Life Care Strategy. Produced in partnership between The King's Fund, Marie Curie Cancer Care and the National Council for Palliative Care, this one-day conference will highlight the key challenges involved in implementing the strategy.
Much pioneering work has been done by a wide range of organisations across health and social care. In order to enable greater choice for those at the end of their life, there is now a move towards more effective commissioning and co-ordination of this care. We will share good practice and innovation using case studies and interactive workshops, with a focus on partnership working.
We are delighted to announce that Professor Mike Richards CBE, Chair, End of Life Care Strategy Advisory Board and National Clinical Director for Cancer, will give the keynote address and that the full conference programme is available on our website.
Confirmed speakers include the following:
Dr James Beattie, National Clinical Lead, NHS Heart Improvement Programme and Consultant Cardiologist, Birmingham Heartlands Hospital, on delivering effective end-of-life care for non-cancer patients.
Dr Andrew Daley, Consultant, Bradford Teaching Hospitals NHS Foundation Trust, on identifying and better understanding your palliative care patients.
Martin Green, Chief Executive, English Community Care Association, on the challenges of partnership working.
Penny Hansford, Director of Nursing, St Christopher's Hospice, on delivering staff skills.
Martin McShane, Director of Strategic Planning and Health Outcomes, Lincolnshire Primary Care Trust, on the challenges of commissioning.

Journal of palliative medicine Mar 2008 vol. 11 no. 2

Trial of angioembolization of advanced stage tumors feeding arteries exemplifying aggressive and active interventional palliation.
p. 250-3

A bien experience.
p. 248-9
Case-Reports, Journal-Article.

Criminal prosecutions of physicians providing palliative or end-of- life care.
p. 233-41
Kollas-Chad-D, Boyer-Kollas-Beth, Kollas-James-W.
Although medical malpractice suits commonly occur in medical practice, few physicians experienced criminal prosecution related to adverse clinical outcomes before 1990. Criminal prosecutions of physicians increased in frequency early in that decade, however, including a handful of cases involving palliative or end-of-life care. Reviews published around the end of the 1990s examined those prosecutions, listing causative factors and offering recommendations to prevent further cases. In this paper, we provide an updated review of criminal prosecutions of physicians providing palliative or end- of-life care, presenting three cases that occurred after 1998. We summarize these newer cases' chronologies and outcomes, comparing them to cases described in past reviews. Our analysis suggests that important factors not described in earlier reviews, especially conflicting views of the standard of care in hospice and palliative medicine, contributed to the development of these prosecutions.

Determinants of do-not-resuscitate orders in palliative home care.
p. 226-32
Brink-Peter, Smith-Trevor-Frise, Kitson-Maureen.
OVERVIEW: Do-not-resuscitate (DNR) orders allow home care clients to communicate their own wishes over medical treatment decisions, helping to preserve their dignity and autonomy. To date, little is known about DNR orders in palliative home care. Basic research to identify rates of completion and determinants of DNR orders has yet to be examined in palliative home care. PURPOSE: The purpose of this exploratory study was to determine who in palliative home care has a DNR order as part of their advance directive. METHODS: Information on health was collected using the interRAI instrument for palliative care (interRAI PC). The sample included 470 home care clients from one community care access centre in Ontario. RESULTS: This study indicated that a preference to die at home (odds ratio (OR): 8.29, confidence interval (CI): 4.55-15.11); close proximity to death (OR: 0.99, CI: 0.99-1.00); daily incontinence (OR: 2.74, CI: 1.05-7.16); and sleep problems (OR: 1.85, CI: 1.02-3.37) are associated with DNR orders. In addition, clients who are more accepting of their situation are 5.67 times (CI: 1.67-19.27) more likely to have a DNR in place. CONCLUSION: This study represents an important first step to identifying issues related to DNR orders. In addition to proximity to death, incontinence, and sleep problems, acceptance of one's own situation and a preference to die at home are important determinants of DNR completion. The results imply that these discussions might often depend not only on the health of the clients but also on the clients' acceptance of their current situation and where they wish to die.

Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation.
p. 217-25
Levy-Cari, Morris-Monica, Kramer-Andrew.
OBJECTIVES: The objectives were (1) to describe the Making Advance Planning a Priority (MAPP) program, a program designed to identify nursing home (NH) residents at high risk of death and (2) to evaluate end-of-life care outcomes for NH residents at high risk of death. DESIGN: Program description and evaluation using a retrospective chart review before and after implementation of the MAPP program. PARTICIPANTS: NH residents who died 1 year before program implementation compared to NH residents who died 1 year after program implementation (n = 72). Program description: The MAPP program was designed to: (1) identify residents at high risk of death, (2) inform the attending physician of the residents' mortality risk, (3) obtain palliative care or, if the prognosis was 6 months of less, a hospice consultation, and (4) improve advance care planning documentation. Program evaluation: Site of death (hospital versus nursing home), presence of an advance directive, presence of an order for cardiopulmonary resuscitation, proportion of NH residents with palliative care and/or hospice consultation prior to death, length of palliative care and/or hospice services before death. Following implementation of the MAPP program, we hypothesized that there would be a reduction in hospitalizations, an increase in hospice/palliative care referrals, an increase hospice/palliative care length of service, an increase the utilization of advance directives, but no difference in days in the hospital before death. RESULTS: Following implementation of the MAPP program intervention, residents were less likely to die in the hospital (48.2% preintervention versus 8.9% postintervention, p < 0.0001). Every resident who died after implementation of the MAPP program had an advanced directive (p = 0.03). Residents were more also more likely to get palliative care referrals (7.4% preintervention versus 31.1% postintervention, p = 0.02). CONCLUSION: An intervention designed to address the end-of- life needs of NH residents at high risk of death improves end-of-life outcomes with a reduction in terminal hospitalizations, an increase in palliative care referrals and improvement of advance directive completion.

Is there a higher risk of respiratory depression in opioid-naive palliative care patients during symptomatic therapy of dyspnea with strong opioids?
p. 204-16
Clemens-Katri-Elina, Quednau-Ines, Klaschik-Eberhard.
Abstract OBJECTIVE: Dyspnea is a highly prevalent symptom in palliative care patients. Opioids are the first-line therapy for symptomatic relief of dyspnea. However, respiratory depression is still a feared side effect of therapy with WHO III opioids. The risk of respiratory depression in opioid-naive patients and in patients pretreated with strong opioids during symptomatic therapy of dyspnea was investigated in palliative care patients. PATIENTS AND METHODS: Twenty-seven patients were included in a prospective, nonrandomized study. All patients suffered from moderate to severe dyspnea. Transcutaneous measurement (earlobe sensor) of carbon dioxide partial pressure (tcpa CO(2)), pulse oximetry oxygen saturation (SaO(2)), and pulse frequency (PF) were monitored with SenTec Digital Monitor (SenTec AG, Therwill, CH). The following monitoring data were compared: baseline recording for 15 minutes, and 30, 60, 90, and 120 minutes after opioid application. RESULTS: The data obtained with transcutaneous measurement showed that there were no significant differences between the groups of opioid-naive patients and those pretreated with strong opioids with regard to tcpaCO(2) increase or SaO(2) decrease after the first opioid application. Neither SaO(2) decreased significantly nor tcpaCO(2) increased significantly after the initial opioid application, which means there was no opioid-induced respiratory depression. The first opioid application, however, resulted in a significant decrease in the intensity of dyspnea and respiratory rate. CONCLUSIONS: No higher risk of respiratory depression and increase in tcpaCO2 in opioid-naive palliative care patients, compared to patients pretreated with strong opioids, during symptomatic therapy of dyspnea with strong opioids could be found.

End-of-life care in adults with cystic fibrosis
p. 198-203
Philip-Jennifer-A-M, Gold-Michelle, Sutherland-Sharon et al
BACKGROUND: Cystic fibrosis (CF) is a life-limiting congenital disease, with most patients dying at a young age of progressive lung disease. Lung transplantation offers hope for many but may not occur. There is little to guide the provision of palliative care to this young population who maintain hope in the possibility of lung transplantation. METHODS: To inform the development of an appropriate model of palliative care, a medical record review of CF patients dying within a 5-year period without lung transplantation was undertaken. The aspects of care that were preventative, therapeutic, or palliative were quantified. RESULTS: Of the 20 records studied, all died in hospital. Only 15% of patients had a do-not-resuscitate order agreed to more than 1 week prior to death, increasing to 90% at the time of death (median of 2 days before death). Opioids were prescribed for 1 patient (5%) at 1 week prior to death, increasing to 85% of patients in the last 24 hours of life (median of 36 hours before death). During the last 24 hours of life, intravenous antibiotics continued in 85%, and assisted ventilation in 90% of subjects. CONCLUSION: We conclude that the circumstances surrounding the death of patients with CF holds challenges for their effective palliative care. CF patients continue life prolonging and preventative treatments until the last hours of life. There is an urgent need to examine palliative care approaches that may usefully coexist with maintaining transplantation options in the end-of-life care of this population.

Clinical findings of a palliative care consultation team at a comprehensive cancer center.
p. 191-7
Dhillon-Navneet, Kopetz-Scott, Pei-Be-Lian, Fabbro-Egidio-Del, Zhang- Tao, Bruera-Eduardo. Abstract BACKGROUND: Palliative care consultation teams (PCCTs) are being established in cancer centers for the management of patients' physical and psychosocial distress. As clinical findings of these teams have been reported infrequently, we aim to describe the experience of our high-volume inpatient PCCT. PATIENTS AND METHODS: We obtained clinical and demographic data on patients referred to our PCCT from the palliative care departmental database from September 1, 2003, to August 31, 2004. RESULTS: In 1 year, 1067 consultations took place for 922 hospitalized patients. The patients' mean age was 60 (range, 3-98) years. The most common cancers were thoracic/head and neck, gastrointestinal, genitourinary, gynecologic cancers, and lymphoma. Thirty-four percent of the patients were transferred to the inpatient palliative care unit, while the remainder were followed by the PCCT as consultants. The main problems requiring PCCT consultation were pain (56%), delirium (34%), dyspnea (25%), fatigue (14%), and end-of-life psychosocial (EOL) issues (12%). Twenty-four percent of patients died during the hospitalization. Death during the hospitalization was more common in patients with delirium, dyspnea, and EOL issues and less likely in patients referred to the PCCT for pain or depression. Constipation was more common in patients with solid tumors, whereas EOL issues were more common in patients with hematologic malignancies. Of the patients who were able to be discharged, 56% went home, 37% to hospice, and 7% elsewhere. CONCLUSIONS: These results provide insight into the demand and utility of this service for those considering the establishment of a PCCT.

Impact of an inpatient palliative care team: a randomized control trial.
p. 180-90
Gade-Glenn, Venohr-Ingrid, Conner-Douglas, McGrady-Kathleen, Beane- Jeffrey et al
Abstract BACKGROUND: Palliative care improves care and reduces costs for hospitalized patients with life-limiting illnesses. There have been no multicenter randomized trials examining impact on patient satisfaction, clinical outcomes, and subsequent health care costs. OBJECTIVE: Measure the impact of an interdisciplinary palliative care service (IPCS) on patient satisfaction, clinical outcomes, and cost of care for 6 months posthospital discharge. METHODS: Multicenter, randomized, controlled trial. IPCS provided consultative, interdisciplinary, palliative care to intervention patients. Controls received usual hospital care (UC). SETTING AND SAMPLE: Five hundred seventeen patients with life-limiting illnesses from a hospital in Denver, Portland, and San Francisco enrolled June 2002 to December 2003. MEASURES: Modified City of Hope Patient Questionnaire, total health care costs, hospice utilization, and survival. RESULTS: IPCS reported higher scores for the Care Experience scale (IPCS: 6.9 versus UC: 6.6, p = 0.04) and for the Doctors, Nurses/Other Care Providers Communication scale (IPCS: 8.3 versus UC: 7.5, p = 0.0004). IPCS patients had fewer intensive care admissions (ICU) on hospital readmission (12 versus 21, p = 0.04), and lower 6-month net cost savings of $4,855 per patient (p = 0.001). IPCS had longer median hospice stays (24 days versus 12 days, p = 0.04). There were no differences in survival or symptom control. CONCLUSIONS: IPCS patients reported greater satisfaction with their care experience and providers' communication, had fewer ICU admissions on readmission, and lower total health care costs following hospital discharge.

Building the field of cancer pain
p. 176-9

Growing pains: health care enters team-age
p. 171-5

Introduction of a pediatric palliative care curriculum for pediatric residents.
p. 164-70
Schiffman-Joshua-D, Chamberlain-Lisa-J, Palmer-Laura, Contro-Nancy et al
Abstract INTRODUCTION: The Pediatric Palliative Care Curriculum (PPCC) was introduced as a pilot study in response to the published need for increased pediatric education in end-of-life (EOL) care. The PPCC was designed to better train residents in EOL issues so they could become more comfortable and knowledgeable in caring for children and adolescents with life-threatening illnesses. METHOD: The PPCC consisted of six hour-long sessions run by a clinical psychologist, a licensed social worker, and faculty with experience in EOL care. The curriculum repeated every 6 weeks for 1 year. Residents in the training program at Stanford University rotating through oncology, pulmonology, and pediatric intensive care unit (PICU) were invited to attend. Session topics included: (1) personal coping skills, (2) being a caring professional, (3) recognizing cultural and familial differences, (4) pain management, (5) practical issues, and (6) meeting a bereaved parent. Pretest and posttest surveys with five- point Likert scale questions were used to measure curricular impact. RESULTS: Statistically significant improvement was found in resident self-report of: feeling prepared to initiate do-not-resuscitate discussions

End-of-life care in UK critical care units

End-of-life care in UK critical care units - a literature review.
Nursing in critical care, May-Jun 2008, vol. 13, no. 3
p. 152-61
AIM: To appraise literature concerning end-of-life care (ELC) in adult critical care units in the UK in order to improve clinical practice. OBJECTIVE: To understand the interplay between legal and ethical, political, societal aspects of ELC for sustainable quality care. BACKGROUND: Significant changes in health care policy for the critically ill patient have occurred since 1999. Simultaneously, the government is committed to improving care for the dying by integrating the palliative care ethos across the National Institutes of Health (NHS) to include non-cancer sufferers. Death continues to be a feature of critical illness, particularly following the decision to withhold/withdraw life-prolonging treatments. SEARCH STRATEGY: A search of MEDLINE, BNI, CINAHL and PSYCinfo using key words revealed very few results; consequently, the search was broadened to include ASSIA, King's Fund, TRIP, Healthstar, NHS Economic Evaluation Data, Cochrane, professional journals and government documents. CONCLUSIONS: The literature reveals a paradigm shift from critical to palliative care, in other words, from a reductionist approach to a more humanistic approach in the acute setting. When treatment is deemed futile, quality ELC involving the assessment, ongoing assessment and care after death becomes the new goal for the critical care team. To practice ELC competently, nurses require organizational and educational support at local and national levels. RELEVANCE TO CLINICAL PRACTICE: Although medico-legal decision-making is not part of their professional role, critical care nurses have an extraordinary opportunity to make a difference to the dying patient and their family and their acceptance of death.

Understanding palliative nursing care

Understanding palliative nursing care.
Full text available at ProQuest
The Journal of practical nursing, Spring 2008, vol. 58, no. 1
p. 6-9; quiz 10-1
Palliative care is care that is given to patients and their significant others who are experiencing life-threatening or life- altering illnesses by providing emotional, spiritual, and physical support. Patients can continue to receive aggressive medical treatment while receiving palliative care and recovery is possible. Pain control is a top priority in palliative care. Non- pharmacological interventions have also been shown to be effective in palliative care as well. Palliative care is truly a holistic, collaborative practice engaging many disciplines in the care of the patient and their love ones.

BMC medical research methodology, 2008 (epub) , vol. 8

The changing causal foundations of cancer-related symptom clustering during the final month of palliative care: a longitudinal study.
p. 36
Olson-Karin, Hayduk-Leslie, Cree-Marilyn, Cui-Ying et al
BACKGROUND: Symptoms tend to occur in what have been called symptom clusters. Early symptom cluster research was imprecise regarding the causal foundations of the coordinations between specific symptoms, and was silent on whether the relationships between symptoms remained stable over time. This study develops a causal model of the relationships between symptoms in cancer palliative care patients as they approach death, and investigates the changing associations among the symptoms and between those symptoms and well-being. METHODS: Complete symptom assessment scores were obtained for 82 individuals from an existing palliative care database. The data included assessments of pain, anxiety, nausea, shortness of breath, drowsiness, loss of appetite, tiredness, depression and well-being, all collected using the Edmonton Symptom Assessment System (ESAS). Relationships between the symptoms and well-being were investigated using a structural equation model. RESULTS: The model fit acceptably and explained between 26% and 83% of the variation in appetite, tiredness, depression, and well-being. Drowsiness displayed consistent effects on appetite, tiredness and well-being. In contrast, anxiety's effect on well-being shifted importantly, with a direct effect and an indirect effect through tiredness at one month, being replaced by an effect working exclusively through depression at one week. CONCLUSION: Some of the causal forces explaining the variations in, and relationships among, palliative care patients' symptoms changed over the final month of life. This illustrates how investigating the causal foundations of symptom correlation or clustering can provide more detailed understandings that may contribute to improved control of patient comfort, quality of life, and quality of death.