Abstract
Kalluri M, Lu-Song J, Younus S, et al.: Health care costs at end-of-life for patients with idiopathic pulmonary fibrosis: Evaluation of a pilot multidisciplinary clinic. Ann Am Thoracic Soc 2020. [E-pub ahead of print]; DOI: 10.1513/AnnalsATS.201909-707OC
Even though idiopathic pulmonary fibrosis (IPF) is a disease with high morbidity and mortality and no cure, palliative care is rarely implemented, leading to high symptom burden and unmet care needs. In 2012, the authors implemented a multidisciplinary collaborative (MDC) care model linking clinic and community multidisciplinary teams to provide an early integrated palliative approach, focusing on early symptom management and advanced care planning (ACP). The intention of this study was to evaluate the differences in resource utilization and associated costs of end-of-life care between early integrated palliative and conventionally treated IPF patients. The authors utilized administrative health data and identified all patients in Alberta, Canada, who presented to hospital with an IPF diagnosis between January 1, 2012, and December 31, 2018, and died within this timeframe. The authors then compared three groups of patients: those who received (1) MDC care (our clinic patients), (2) specialist care (SC; respirologist), and (3) non-SC (no contact with a respiratory clinic). The primary outcomes were health care resource utilization and costs in the year before death. Results demonstrated that of 2768 patients across three groups, MDC patients were over three times more likely to have received antifibrotic therapies over SC patients, almost twice as likely to receive pulmonary rehabitation and 36% more likely to receive opiates in the last year of life. The median total health care costs in the last three months of life were ∼$7,700 CDN lower for MDC patients than those receiving SC, driven primarily by fewer hospitalizations and ED visits. MDC patients were also less likely to die in hospital and had the highest rates of no hospitalization in the last year of life. The authors conclude that an integrated palliative approach in IPF is associated with improvements in the quality of end-of-life care and reduction in costs. Transformation of care models is required to deliver a palliative approach in IPF. MDC teams within such models can address the high burden of unmet needs for symptom management, ACP, and community support in this complex population.
Gemmell R, Yousaf N, Droney J: “Triggers” for early palliative care referral in patients with cancer: a review of urgent unplanned admissions and outcomes. Support Care Cancer 2019. [E-pub ahead of print]; DOI: 10.1007/s00520-019-05179-0
Benefits of early palliative referral in oncology are well documented. Palliative care referral “triggers” may help identify patients for referral. Many triggers have been proposed, but are not commonly used. This retrospective cohort study reviewed the timing of palliative care involvement for patients in a tertiary referral oncology hospital, and whether the use of a trigger tool before admission would have facilitated earlier referral. This study included cancer patients who died during an unplanned admission between November 2014 and October 2015. A literature review identified seven palliative care referral tools that were included in this analysis, and compared by identifying common themes. Each tool was applied to patients by reviewing electronic patient records. Timing of palliative referral and whether patients met any triggers within six months before their terminal admission were assessed. Results demonstrated that a total of 159 patients were identified. Forty-six percent of patients were referred to palliative care before terminal admission. Application of six out of seven trigger tools would have resulted in the majority of patients (up to 91.2%) referred to palliative care before admission. Most patients (52.2%) were referred only during their terminal admission. Patients known to palliative care before admission (N = 73) were reviewed quicker than those who were not (N = 86) [median (range) 1 day (0–23 days) vs. 5 days (0–59 days), p < 0.00001]. The authors conclude that in this patient cohort, a palliative referral trigger tool may have proactively identified most patients before their terminal admission. Prospective testing of trigger tools in oncology populations is warranted.
Visser R, Borgstrom E, Holti R: The overlap between geriatric medicine and palliative care: A scoping literature review. J App Gerontol 2020. [E-pub ahead of print]; DOI: 10.1177/0733464820902303
With an increasing aging population worldwide, there is a growing need for both palliative care and geriatric medicine. It is presumed in medical literature that both specialties share similar goals about patient care and could collaborate. To inform future service development, the objective of this review was to identify what is currently empirically known about overlapping working practices. This article provides a scoping literature review on the relationship between geriatric medicine and palliative care within the United Kingdom. The review encompassed literature written between 1997 and 2019 accessed through Scopus, Web of Science, PubMed, and Google Scholar. Three themes were identified: (1) unclear boundaries between specialties, (2) communication within and between specialisms, and (3) ambiguity of how older people fit in the current health care system. The authors suggest that more empirical research is conducted about the overlap between palliative care and geriatric medicine to understand how interprofessional working and patient care can be improved.
Gonella S, Basso I, Clari M, et al.: A qualitative study of nurses' perspective about the impact of end-of-life communication on the goal of end-of-life care in nursing home. Scand J Caring Sci 2020. [E-pub ahead of print]; DOI: org/10.1111/scs.12862
With a growing nursing home population suffering from chronic progressive illnesses and evolving patterns of comorbidities, end-of-life communication takes on a critical role to enable health care professionals to gather information about the resident's wishes for care at the end of life and organize the care plan accordingly. The aim of this study was to explore nurses' perspective about the process by which end-of-life communication impacts on the goal of end-of-life care in nursing home residents. A qualitative descriptive research design based on thematic analysis was performed. Fourteen nurses involved in the care of residents during their last week of life were recruited across 13 Italian nursing homes and accounted for 34 semistructured interviews. A combined approach of analysis that incorporated a data-driven inductive approach and a theory-driven one was adopted. Results demonstrated that 12 themes described how end-of-life communication may contribute to adjust the care plan in nursing home according to the nurses' perspective. Five antecedents (i.e., life crisis or transitions, patient-centered environment, arising the question of possible dying, quality of relationships, and culture of care) influenced the establishment and quality of communication, and five attributes depicted the characteristics and potential mechanisms of end-of-life communication (i.e., health care professional-resident and health care professional-family carers communication, knowledge of family carers' preferences, knowledge of residents' preferences, family carers and residents understanding, and shared decision making), whereas curative-oriented and palliative-oriented care goals emerged as consequences. The authors conclude that this study provides insight into the nursing perspective of end-of-life communication between health care professionals and bereaved family carers of nursing home residents. Several factors influenced the occurrence and quality of end-of-life communication, which contributed to the transition toward palliative-oriented care by using and improving knowledge about family cares' and resident's preferences for end-of-life care, promoting family carers and residents understanding about prognosis and treatments available, and fostering shared decision making.
Gallagher R, Passmore MJ, Baldwin C: Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error. Med Hypotheses 2020. [E-pub ahead of print]; DOI: 10.1016/j.mehy.2020.109727
All health care services strive to achieve the six factors of quality health care—safe, effective, patient centered, timely, efficient, and equitable. Yet multiple structural, process, policy, and people factors can combine to result in medical error and patient harm. Measuring the quality of palliative care has many challenges due to its presence across multiple health sectors, variable skill and experience of providers, and lack of defined processes for providing services. In Canada, there is screening for symptoms and distress in most cancer centers, but not in noncancer diseases. Screening for distress and disease burden can identify suffering, which, when properly addressed, improves quality of life and reduces depression and hopelessness that can lead to requests for hastened death. The authors' hypothesis is that some requests for hastened death (known as Medical Assistance in Dying or MAiD in Canada) are driven by lack of access to palliative care or lack of quality in the palliative care attempting to address disease burden and distress such that the resulting provision of hastened death is a medical error. The root cause of the error is in the lack of quality palliative care in the previous weeks, months, and years of the disease trajectory—a known therapy that the system fails to provide. The evidence for palliative care addressing symptoms and improving quality of life and mood as well as providing carer support is established. Early evidence supporting the use of psychotherapeutics in emotional and existential distress is also considered.
The authors present three cases of request for assisted death that could be considered medical error. The article references preliminary evidence from a review of previous access to palliative care in a limited number of MAiD cases, showing that only a minority were identified as having palliative care needs before the admission where MAiD was provided. The evidence linking disease burden to hopelessness, depression, and hastened death is provided. The many studies revealing the inequity or underservicing of the Canadian population with regard to palliative care are reviewed. The authors examine a recent framework for palliative care in Canada and point out the need for more aggressive use of standards, process, and policies to ensure that Canadians are receiving quality palliative care and that it is equitably accessible to all.