Palliative medicine reports最新文献

Background: Person-centered supportive care for older persons with acute illness is much needed but not easily achieved.

Aims of the study: To uncover processes and consequences of an educational intervention in acute geriatric wards intended as an exposure experience.

Design: General inductive qualitative analysis was conducted on data from a four-step intervention: group coaching, an open conversation with a patient and family member (PT/FM), reflection on transcribed conversations with co-participant, and group peer reflection.

Methods: Twelve participants engaged in the intervention. Transcripts from paired reflection sessions and peer reflections were analyzed using general inductive qualitative analysis.

Results: The exposure experience of the participants involved three major processes: (1) fear before the conversation, (2) presence during the conversation, and (3) responsiveness after the conversation. Each process entailed several substeps. Not only the open conversation but also the whole process of reflection with a co-participant after reading the transcript and the peer-reflection sessions seem to be needed to realize the exposure experience.

Conclusions: Through the educational intervention "open conversation and reflection," participants experienced that connecting with PT/FM and listening to what is important to them are essential to realize person-centered care. Thus, pending further studies, the educational intervention can be considered promising to enhance person-centeredness in older people's care.

Introduction: The Serious Illness Conversation Guide-Pediatrics (SICG-Peds) is a validated tool and training program that increases clinicians' confidence in leading complex conversations with seriously ill pediatric patients and their families. We initiated a pilot project incorporating bereaved parents as facilitators in SICG-Peds education.

Objectives: To assess how incorporating bereaved parents in a facilitator role in the SICG-Peds education program impacted the experience for clinician trainees and clinical facilitators and the parents themselves.

Methods: Four bereaved parents were onboarded and included as family facilitators. Workshop experience was measured through post-workshop surveys. Clinical facilitators and family facilitators provided feedback about the co-teaching experience.

Results: Clinicians reported that having bereaved parents as teaching faculty enriched their learning. Clinical facilitators found that family facilitators offered additional perspectives and value. Parents recognized that they could hone their story and experience to support the clinician learners in unique ways.

Conclusions: The addition of family facilitators in the delivery of SICG-Peds workshops enhanced clinicians' learning. Moreover, bereaved parents reported that functioning as workshop facilitators was a deeply meaningful experience.

Background: Patient-reported outcome measures (PROMs) enhance patient-centered care but routine implementation in oncology settings remains challenging. This study seeks to explore patients' experiences with routine PROM integration within a health care setting with employed strategies to maximize uptake and inclusivity.

Methods: A qualitative study employing a phenomenological approach was conducted at the National Cancer Centre Singapore. Seven breast cancer patients receiving routine screening using the Distress Thermometer and Problem List (DTPL) as part of a larger supportive care program were purposively sampled. Semi-structured interviews explored how implementation strategies influenced patients' experiences with PROM usability, accessibility, and perceived impact. Data were analyzed using thematic analysis based on the Consolidated Framework for Implementation Research.

Results: Participants perceived the DTPL as a meaningful PROM that validated their emotions but highlighted that presentation formats greatly influenced perceived simplicity of the tool. While multilingual and hybrid formats improved accessibility, digital literacy and cognitive burden remained as barriers. Education pamphlets provided initial awareness, but sustained engagement was impeded by a lack of time, reminders, and a conducive environment. PROMs were most useful during active treatment when symptoms fluctuated, yet frequent completion led to response fatigue. Timely responses to PROMs reinforced engagement, particularly when linked to referrals or symptom management. Some participants felt that formal PROM reviews by oncologists were unnecessary due to time constraints.

Conclusion: Successful PROM implementation requires balancing simplicity, accessibility, and clinical relevance. Embedding PROMs within broader supportive care programs ensures clinical responsiveness and improves patient outcomes in oncology care.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) carries high mortality rates and often requires critical family decisions about code status when complications occur. The American Heart Association provides treatment guidelines but acknowledges a significant knowledge gap regarding do-not-resuscitate or do-not-intubate (DNR/DNI) decisions in patients with aSAH, challenging clinicians in identifying appropriate timing for these discussions.

Aim: To identify demographic and clinical physiological factors associated with code status transition in adults with aSAH admitted to the intensive care unit, supporting value-based decision making through more informed and timely discussions between health care providers and families that align with patients' core values and preferences.

Methods: Retrospective cohort study analyzing Medical Information Mart for Intensive Care IV database (2008-2022) data from 731 patients with aSAH. Researchers collected demographics, vital signs, laboratory tests, disease severity scores, and code status transition, performing univariate and multivariate Cox regression analyses to identify significant predictors.

Results: Among patients initially with full-code status, 25.8% transitioned to DNR/DNI during hospitalization. Multivariate analysis identified four independent predictors: advanced age (hazard ratio [HR] = 1.024), lower mean blood pressure (HR = 0.987), higher simplified acute physiology score II (SAPS II) score (HR = 1.018, each one-point increase raises transition risk by 1.8%), and hospice services (HR = 6.951). Patients with code status limitations received less invasive therapy, more hospice services, and had higher mortality rates.

Conclusion: Age, blood pressure, SAPS II, and hospice services predict code status transitions in patients with aSAH. Identifying high-risk patients enables timely code status discussions, ensuring treatment aligns with patient values and improving family decision making during critical situations.

The field of hospice and palliative care in the United States is experiencing serious problems and faces an uncertain future. Quality of hospice care is highly variable. Unethical hospice business practices are common in some regions. Palliative care's integration within American health care has stalled, despite demonstrating that much better care for seriously ill and dying people is both feasible and affordable. Corrective steps have been halting. Urgent work is needed to safeguard seriously ill patients and their families and ensure quality and reliability of hospice and palliative care programs and services. The moment has come for the clinical specialties and corporate community of hospice and palliative care to chart a strategic path forward. Efforts must start with zero tolerance of fraudulent business and clinical practices that harm vulnerable patients. The four components of this strategic approach are (1) publishing clear clinical and programmatic standards, (2) making meaningful data readily available, (3) driving quality-based competition, and (4) embracing the field's authentic brand of expert care that fosters well-being for patients and their families. Part I of this white paper examines the root causes of the key problems facing the field. Part II presents the rationale and practical considerations for each of the four components of this strategy. This path forward addresses the hard problems the field faces and enables it to realize its dual mission of caring well for ill and dying people and helping society integrate illness, caregiving, dying, and grieving within a continuum of full and healthy living.

Objective: To explore the role of sex as a predictive factor for dignity-related distress among advanced cancer patients.

Methods: The study employed a cross-sectional survey design, utilizing a Chinese version of the Patient Dignity Inventory (PDI). The participants were 294 patients with advanced cancer who were receiving treatment at a hospital in Xinjiang, China. Univariate analyses were conducted to compare scores on the total PDI and its five dimensions between sexes. Hierarchical multiple regression analyses were then performed with the PDI scores that exhibited significant sex differences designated as the dependent variable.

Results: The total and existential distress subscale PDI scores were found to be significantly higher in men than in women. However, this sex disparity in the total PDI score was not statistically significant in the multivariable model. The multivariable model revealed that factors such as sex, the method of medical care payment, cancer stage, treatment status, and performance status were significantly associated with existential distress.

Conclusions: The present findings suggest that the disparities in dignity-related distress between men and women can be better understood by examining how a patient's sex affects the experience of existential distress. The findings also show that men tend to need more support to protect their dignity in terms of their sex roles than women. Also, addressing existential distress in men can play a crucial role not only in reducing dignity-related distress but also in addressing clinical issues such as performance status.

Background: Serious illness communication skills (SICS) are essential competencies for clinicians to possess. Unfortunately, SICS teaching is not routinely taught and many clinician teachers (CTs) never received training on how to teach them. We funded two cohorts of CTs to learn an evidence-based approach to SICS teaching to scale a unified approach to such training.

Objective: The primary aim of this study was to explore CT experiences and attitudes toward SICS teaching following completion of VitalTalk Faculty Development training. Our secondary aim was to identify perceived barriers and enablers experienced by CTs in the translation of newly acquired skills into the workplace.

Design/measurements: Survey and semi-structured interviews administered post-training.

Setting: Large metropolitan academic hospital in Canada. Fifteen (83%) of CTs completed the survey and 6 (40%) were interviewed. Participants were 38 years old (avg), female (80%), physicians (87%), nurse practitioners (13%), and in practice 8 years (avg).

Results: One-hundred percent of participants would recommend the course to colleagues, believing it increased their SICS teaching quality and comfort to teach this topic in varied settings. Post-training, 90% of cohort 1 and 0% of cohort 2 taught SICS in workshops. Seventy percent of cohort 1 and 60% of cohort 2 taught SICS at the bedside across 10 specialties and interdisciplinary groups. Top cited teaching enablers were funding, protected time, and administrative support. All participants reported being likely to teach a workshop within the year. Eighty percent reported training increased their comfort to lead such conversations and 67% reported more frequently engaging in them. Qualitative analysis revealed that successful implementation requires SICS teaching to be valued at every level of the institution.

Conclusion: Investing in faculty development for a group of CTs led to increased confidence in teaching about and having serious illness conversations and informed needs for a local community-of-practice primed to rapidly scale SICS teaching.

Background: Public health research includes end-of-life care. Place of death is an indicator of end-of-life care quality.

Objective: We assessed the place of death of cancer patients treated at a Comprehensive Cancer Center (CCC), caring for an average of 2220 primary cases per year.

Methods: Dataset includes information on cancer patients who were treated at least once in a German CCC, died between 2009 and 2013, and for whom a place of death could be assigned. Data-reported following the "REporting of Studies Conducted Using Observational Routinely Collected Data" guideline-were retrieved from death registration and analyzed retrospectively. Descriptive analyses, frequency calculations, Pearson/Cramer's V chi-square tests, and t tests in SPSS 28.0 were used.

Results: A total of 5855 patients were analyzed (metastases n = 2830, 48.3%; recurrent cancer n = 1930, 33.1%). Finally, 3523 (60.2%) died in a clinical setting (CCC: 28.9%/other hospital: 31.3%). Patients who died in the CCC (mean age 66.3 years) were younger than those who died in other hospitals (mean age 67.8 years; p = 0.034) or at home (ø 70.2 years; p = 0.000). Cancer patients who died in the CCC (n = 1693) had over time a median of 356 contacts with specialized palliative care within 30 days before death (standard deviation [SD]: 319-377, mean 352). One-third of patients died within one year of diagnosis (p < 0.001). For patients dying in the CCC, the rate was even higher (50.6%, p < 0.001).

Conclusion: Even if treated in certified centers, CCC cancer patients have a high in-hospital mortality rate. The place of death reflects care structures and disease progression, highlighting the need for palliative care. As frequent death sites, CCCs should offer specialized palliative services. Further research is needed to better align the place of death with patient wishes.

Background: The Serious Illness Conversation Guide was developed to support high quality goals of care conversations with seriously ill patients; however, guide implementation for patients with limited English proficiency (LEP) has not been studied. This evaluation aimed to explore serious illness conversations with hospitalized LEP patients, defined as those with a non-English language documented, from clinician and interpreter perspectives; and assess differences in documentation in the electronic medical record (EMR) as a quality improvement effort.

Methods: Parallel mixed methods evaluation including thematic analysis of observations and interviews with medical interpreters (n = 14), occupational therapists (n = 9), registered dietitians (n = 6), and resident physicians (n = 3) of a quaternary academic hospital in the United States. Comparison of EMR documentation for hospital admissions with English proficient (N = 7396) and LEP patients (N = 2326).

Results: Six themes characterized serious illness communication and guide use with LEP patients. As compared to other clinical encounters, both interpreters and clinicians perceived serious illness communication as unique. Both groups acknowledged that interpreters convey meaning, though being an effective voice of the clinician required advanced preparation of the interpreter, even when the guide was used. There were no differences in documentation between the groups (4.7% (345/7396) versus 5.4% (126/2326); p = 0.21).

Conclusions: Even when the guide is used, there may be differences in serious illness communication quality with LEP patients depending on how clinicians engage with the guide and interpreter preparation. The guide may be a method to enhance communication quality, but for LEP patients, requires the parallel implementation of workflows that support high-quality communication.

Background: In home-based hospice care, frontline nurses frequently need to take unscheduled incoming calls while out in the field. This interrupts critical tasks and disrupts patient rapport, potentially lowering care quality for patients. At HCA Hospice in Singapore, the 30 frontline nurses could receive up to 135 calls/day. In mitigation, a telemedicine call-center system (MediHELP) was conceived in September 2023 for frontline nurses to divert incoming calls to a dedicated team for timely management remotely. However, call diversion to MediHELP remained low. A Quality Improvement project (December 2023-July 2024) was designed to catalyze the process change.

Methods: Using the plan-do-study-act (PDSA) model, we aimed to increase call diversion rates to MediHELP by 50%. Initial root cause analysis, corroborated with surveys and focus groups, revealed key challenges: inconsistent processes, inconvenient diversion procedures, and lack of awareness. The first PDSA cycle focused on developing a standardized communication protocol with nurse input, while the second cycle broadened operational hours and improved outreach efforts. Outcomes were evaluated by examining call diversion rates and conducting feedback surveys among stakeholders to assess confidence in the MediHELP team and perception of its effectiveness.

Results: Implementations led to a significant increase in call diversions (from 11% to 65%), achieving 600 calls per month within six months, passing the targeted diversion rate of 50%. Home care nurses reported increased confidence with the MediHELP team, improvement in its perceived effectiveness, and acknowledged that call diversion had led to less stress and greater focus at work.

Conclusion: Successful implementation of a new initiative that reduced nurse burden was achieved by addressing workflow barriers. This initiative could support the future expansion of home care capacity. Additionally, MediHELP services would be extended to patients under day-hospice support within the organization.