Showing papers on "End-of-life care published in 2017"
TL;DR: The findings provide benchmarks for gauging future policies and practices designed to motivate completion of advance directives, particularly among those people most likely to benefit from having these documents on record.
Abstract: Efforts to promote the completion of advance directives implicitly assume that completion rates of these documents, which help ensure care consistent with people’s preferences in the event of incapacity, are undesirably low. However, data regarding completion of advance directives in the United States are inconsistent and of variable quality. We systematically reviewed studies published in the period 2011–16 to determine the proportion of US adults with a completed living will, health care power of attorney, or both. Among the 795,909 people in the 150 studies we analyzed, 36.7 percent had completed an advance directive, including 29.3 percent with living wills. These proportions were similar across the years reviewed. Similar proportions of patients with chronic illnesses (38.2 percent) and healthy adults (32.7 percent) had completed advance directives. The findings provide benchmarks for gauging future policies and practices designed to motivate completion of advance directives, particularly among those...
393 citations
TL;DR: The GOC decision aid intervention is effective to improve end-of-life communication for nursing home residents with advanced dementia and enhance palliative care plans while reducing hospital transfers.
Abstract: Importance In advanced dementia, goals of care decisions are challenging and medical care is often more intensive than desired. Objective To test a goals of care (GOC) decision aid intervention to improve quality of communication and palliative care for nursing home residents with advanced dementia. Design, Setting, and Participants A single-blind cluster randomized clinical trial, including 302 residents with advanced dementia and their family decision makers in 22 nursing homes. Interventions A GOC video decision aid plus a structured discussion with nursing home health care providers; attention control with an informational video and usual care planning. Main Outcomes and Measures Primary outcomes at 3 months were quality of communication (QOC, questionnaire scored 0-10 with higher ratings indicating better quality), family report of concordance with clinicians on the primary goal of care (endorsing same goal as the “best goal to guide care and medical treatment,” and clinicians’ “top priority for care and medical treatment”), and treatment consistent with preferences (Advance Care Planning Problem score). Secondary outcomes at 9 months were family ratings of symptom management and care, palliative care domains in care plans, Medical Orders for Scope of Treatment (MOST) completion, and hospital transfers. Resident-family dyads were the primary unit of analysis, and all analyses used intention-to-treat assignment. Results Residents’ mean age was 86.5 years, 39 (12.9%) were African American, and 246 (81.5%) were women. With the GOC intervention, family decision makers reported better quality of communication (QOC, 6.0 vs 5.6; P = .05) and better end-of-life communication (QOC end-of-life subscale, 3.7 vs 3.0; P = .02). Goal concordance did not differ at 3 months, but family decision makers with the intervention reported greater concordance by 9 months or death (133 [88.4%] vs 108 [71.2%], P = .001). Family ratings of treatment consistent with preferences, symptom management, and quality of care did not differ. Residents in the intervention group had more palliative care content in treatment plans (5.6 vs 4.7, P = .02), MOST order sets (35% vs 16%, P = .05), and half as many hospital transfers (0.078 vs 0.163 per 90 person-days; RR, 0.47; 95% CI, 0.26-0.88). Survival at 9 months was unaffected (adjusted hazard ratio [aHR], 0.76; 95% CI, 0.54-1.08; P = .13). Conclusions and Relevance The GOC decision aid intervention is effective to improve end-of-life communication for nursing home residents with advanced dementia and enhance palliative care plans while reducing hospital transfers. Trial Registration clinicaltrials.gov Identifier:NCT01565642
165 citations
TL;DR: Patients who had a higher proportion of visits address treatment decisions were less likely to initiate chemotherapy or be hospitalized or use hospice in the 60 days before death and PC clinicians' focus on coping, treatment decisions, and advance care planning is associated with improved patient outcomes.
Abstract: Purpose We describe the key elements of early palliative care (PC) across the illness trajectory and examine whether visit content was associated with patient-reported outcomes and end-of-life care. Methods We performed a secondary analysis of patients with newly diagnosed advanced lung or noncolorectal GI cancer (N = 171) who were randomly assigned to receive early PC. Participants attended at least monthly visits with board-certified PC physicians and advanced practice nurses at Massachusetts General Hospital. PC clinicians completed surveys documenting visit content after each encounter. Patients reported quality of life (Functional Assessment of Cancer Therapy-General) and mood (Hospital Anxiety and Depression Scale and Patient Health Questionnaire-9) at baseline and 24 weeks. End-of-life care data were abstracted from the electronic health record. We summarized visit content over time and used linear and logistic regression to identify whether the proportion of visits addressing a content area was associated with patient-reported outcomes and end-of-life care. Results We analyzed data from 2,921 PC visits, most of which addressed coping (64.2%) and symptom management (74.5%). By 24 weeks, patients who had a higher proportion of visits that addressed coping experienced improved quality of life ( P = .02) and depression symptoms (Depression subscale of the Hospital Anxiety and Depression Scale, P = .002; Patient Health Questionnaire-9, P = .004). Patients who had a higher proportion of visits address treatment decisions were less likely to initiate chemotherapy ( P = .02) or be hospitalized ( P = .005) in the 60 days before death. Patients who had a higher proportion of visits addressing advance care planning were more likely to use hospice ( P = .03). Conclusion PC clinicians' focus on coping, treatment decisions, and advance care planning is associated with improved patient outcomes. These data define the key elements of early PC to enable dissemination of the integrated care model.
157 citations
01 Jan 2017
TL;DR: A facilitated discussion about end-of-life care between patients and their health care agents helps define and document the patient's wishes for both patient and agent.
133 citations
TL;DR: It is shown that palliative care is infrequently delivered particularly in community settings and to non-cancer patients and occurs close to death.
Abstract: Background:Little population-level information exists about the delivery of palliative care across multiple health sectors, important in providing a complete picture of current care and gaps in care.Aim:Provide a population perspective on end-of-life palliative care delivery across health sectors.Design:Retrospective population-level cohort study, describing palliative care in the last year of life using linked health administrative databases.Setting/participants:All decedents in Ontario, Canada, from 1 April 2010 to 31 March 2012 (n = 177,817).Results:Across all health sectors, about half (51.9%) of all decedents received at least one record of palliative care in the last year of life. Being female, middle-aged, living in wealthier and urban neighborhoods, having cancer, and less multi-morbidity were all associated with higher odds of palliative care receipt. Among 92,276 decedents receiving palliative care, 84.9% received care in acute care hospitals. Among recipients, 35 mean days of palliative care we...
126 citations
TL;DR: Estimation of the size of the population potentially in need of palliative care across 12 European and non-European countries provides robust indications of the challenge countries are facing if they want to seriously address palliatives care needs at the population level.
Abstract: BACKGROUND: To implement the appropriate services and develop adequate interventions, detailed estimates of the needs for palliative care in the population are needed.AIM: To estimate the proportio ...
116 citations
TL;DR: Although home is the most common first preference, it is polarising and for 16% it is the least preferred; inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there.
Abstract: Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death. We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors. One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40–9.90) and living with someone (OR 2.19, 1.33–3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14–5.03). Conversely, functional independence (OR 1.05, 1.04–1.06) and valuing quality of life (OR 3.11, 2.89–3.36) were associated with dying at home. There was a mismatch between preferences and achievements – of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference. Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply ‘achieved preferences’.
106 citations
TL;DR: In a single center, the ICD-9 code V66.7 had poor sensitivity and high specificity for identifying hospitalized patients who received a palliative care consultation.
Abstract: Background: Use of administrative data to study the effectiveness of specialized palliative care is limited by the lack of a reliable method to identify patients receiving palliative care consultation. The International Classification of Diseases, Ninth Revision (ICD-9) code V66.7 has been used, but its validity for this purpose is unknown. Objective: To examine the validity of the ICD-9 code V66.7 for identifying whether hospitalized patients received palliative care consultation. Design: Retrospective cohort study. Setting/Subjects: All patients of age ≥18 years admitted to a single academic medical center between August 2013 and August 2015. Measurements: Sensitivity and specificity of the V66.7 code for palliative care consultation for all patients and several a priori identified subgroups. The reference standard was the presence of a palliative care consultation note in the electronic medical record. Results: Of 100,910 admissions, 1999 received a palliative care consultation (2.0%) and 1846...
104 citations
Economic Policy Institute1, University College London2, University of York3, Erasmus University Rotterdam4, National Graduate Institute for Policy Studies5, Aarhus University6, Tohoku University7, National Taiwan University8, Université de Sherbrooke9, École Normale Supérieure10, University of Copenhagen11, Federal Reserve System12, University of Duisburg-Essen13, Tilburg University14, HEC Montréal15, Dartmouth College16, Cornell University17
TL;DR: In all nine countries, medical spending at the end of life was high relative to spending at other ages, and high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.
Abstract: Although end-of-life medical spending is often viewed as a major component of aggregate medical expenditure, accurate measures of this type of medical spending are scarce. We used detailed health care data for the period 2009–11 from Denmark, England, France, Germany, Japan, the Netherlands, Taiwan, the United States, and the Canadian province of Quebec to measure the composition and magnitude of medical spending in the three years before death. In all nine countries, medical spending at the end of life was high relative to spending at other ages. Spending during the last twelve months of life made up a modest share of aggregate spending, ranging from 8.5 percent in the United States to 11.2 percent in Taiwan, but spending in the last three calendar years of life reached 24.5 percent in Taiwan. This suggests that high aggregate medical spending is due not to last-ditch efforts to save lives but to spending on people with chronic conditions, which are associated with shorter life expectancies.
104 citations
TL;DR: A comprehensive picture of the epidemiology and care patterns of people in the last stage of life is presented, identifying three key trends in end-of-life care: increasing diversity in the primary diagnoses of decedents, increases in multimorbidity and illness complexity among people with terminal illnesses, and shifts in patterns of care at the end of life and in sites of death.
Abstract: In 2015 an estimated 2.7 million people in the United States (1 percent of the population) died. Although decedents’ illness experience varies substantially, important trends in care at the end of life are evident. To identify the most pressing health care policy issues related to end-of-life care, we present a comprehensive picture of the epidemiology and care patterns of people in the last stage of life. We identify three key trends in end-of-life care: increasing diversity in the primary diagnoses of decedents, increases in multimorbidity and illness complexity among people with terminal illnesses, and shifts in patterns of care at the end of life and in sites of death. This changing epidemiology of those in the last phase of life puts new pressures on the Medicare hospice benefit to ensure the availability of high-quality end-of-life care. In addition, health care policy makers must grapple with the fact that even with increasing use of hospice care, care intensity increases at the end of life. We hig...
96 citations
TL;DR: Involvement of the PC team was associated with the receipt of less intensive treatments and fewer deaths in the ICU, and involved patients followed by thePC team were less likely to die in the intensive care unit.
Abstract: Background: Adolescent and young adult oncology (AYAO) patients often receive intensive medical care and experience significant symptoms at the end of life (EOL). Objective: This study aimed to describe the characteristics of AYAO patients aged 15–26 years who died as inpatients in a hospital and to compare the illness and EOL experiences of AYAO patients who did and did not receive palliative care (PC). Design and Setting: A standardized data extraction tool was used to collect information about demographics, treatment, terminal characteristics, and symptoms during the last month of life (LMOL) for 69 AYAO patients who died while hospitalized between 2008 and 2014. Measurements and Results: AYAO patients who died in the hospital required considerable medical and psychosocial care and experienced numerous symptoms during the LMOL. Compared to those patients who received no formal PC services, patients followed by the PC team were less likely to die in the intensive care unit (ICU) (38% vs. 68%, p...
TL;DR: One in eight respondents stated care in the last months of life was inconsistent with patients' wishes; such care was associated with worse ratings of care, pain management, and communication with clinicians.
Abstract: Background: Despite its importance, little is known about the prevalence of, and factors associated with, end-of-life care that is consistent with patients' wishes. Objective: To document the proportion of bereaved respondents who reported care inconsistent with patients' wishes and characterize the predictors of end-of-life care associated with inconsistent care. Design: Retrospective analysis of nationally representative survey data of persons aged >65 years. Settings/Subjects: Bereaved family members responding to the last month of life component of the National Health and Aging Trends Study. Methods/Measurements: Bereaved family members assessed treatment decisions and their consistency with patients' wishes, unmet needs, and quality of care. We examined differences between patients receiving inconsistent versus consistent care. Results: A total of 1212 family members were interviewed, representing (when weighted) 4.8 million decedents. Thirteen percent stated that care was inconsistent with ...
TL;DR: Consumer narratives help to provide a clearer direction as to what is important for hospital end-of-life care, in accordance with consumer priorities, and embedded into routine hospital care.
Abstract: Background:Despite most expected deaths occurring in hospital, optimal end-of-life care is not available for all in this setting.Aim:To gain a richer and deeper understanding of elements of end-of-life care that consumers consider most important within the hospital setting.Design:A meta-synthesis.Data sources:A systematic search of Academic Search Complete, AMED, CINAHL, MEDLINE, EMBASE, PsycINFO, PubMed, Google, Google Scholar and CareSearch for qualitative studies published between 1990 and April 2015 reporting statements by consumers regarding important elements of end-of-life hospital care. Study quality was appraised by two independent researchers using an established checklist. A three-stage synthesis approach focusing on consumer quotes, rather than primary author themes, was adopted for this review.Results:Of 1922 articles, 16 met the inclusion criteria providing patient and family data for analysis. Synthesis yielded 7 patient and 10 family themes including 6 common themes: (1) expert care, (2) e...
TL;DR: Quality EOL care for older populations requires many core components but the local context and implementation issues may ultimately determine if these elements can be incorporated into the system to improve care.
TL;DR: The MOQI achieved a 30% reduction in all-cause hospitalizations and statistically significant reductions in 4 single quarters of the 2.75 years of full implementation of the intervention for long-stay nursing home residents.
TL;DR: This guidance represents an update of the 1994 statement from the American Academy of Pediatrics on forgoing life-sustaining medical treatment (LSMT), and helps practitioners understand specific applicability of institutional, regional, state, and national regulations related to forgoing LSMT.
Abstract: Pediatric health care is practiced with the goal of promoting the best interests of the child. Treatment generally is rendered under a presumption in favor of sustaining life. However, in some circumstances, the balance of benefits and burdens to the child leads to an assessment that forgoing life-sustaining medical treatment (LSMT) is ethically supportable or advisable. Parents are given wide latitude in decision-making concerning end-of-life care for their children in most situations. Collaborative decision-making around LSMT is improved by thorough communication among all stakeholders, including medical staff, the family, and the patient, when possible, throughout the evolving course of the patient's illness. Clear communication of overall goals of care is advised to promote agreed-on plans, including resuscitation status. Perceived disagreement among the team of professionals may be stressful to families. At the same time, understanding the range of professional opinions behind treatment recommendations is critical to informing family decision-making. Input from specialists in palliative care, ethics, pastoral care, and other disciplines enhances support for families and medical staff when decisions to forgo LSMT are being considered. Understanding specific applicability of institutional, regional, state, and national regulations related to forgoing LSMT is important to practice ethically within existing legal frameworks. This guidance represents an update of the 1994 statement from the American Academy of Pediatrics on forgoing LSMT.
TL;DR: Given the importance of clarifying prognostic expectations and end-of-life care wishes in the advanced cancer context, the communication support program appears to be an effective and well-received solution to encourage early information seeking related to these issues though, its long-term impact remains unclear.
TL;DR: The current state of end‐of‐life care is reviewed, the clinical and financial impact of palliative care is analyzed, and areas of future research and development are proposed.
Abstract: This article reviews the current state of end‐of‐life care, analyzes the clinical and financial impact of palliative care, and proposes areas of future research and development.
TL;DR: In this article, a cross-sectional survey of the general Hong Kong adult population on the knowledge, attitude, and preferences of advance decisions, EOL care, and place of death was conducted.
TL;DR: This paper will describe initiatives within the RHS frameworks of the National Health Group (NHG) and the Alexandra Health System (AHS) to forge a frailty-ready healthcare system across the spectrum, which includes the well healthy, the well unhealthy, the unwell unhealthy, and the end-of-life (EoL) (“dying well”).
Abstract: The beginning of the 21st century has seen health systems worldwide struggling to deliver quality healthcare amidst challenges posed by ageing populations. The increasing prevalence of frailty with older age and accompanying complexities in physical, cognitive, social and psychological dimensions renders the present modus operandi of fragmented, facility-centric, doctor-based, and illness-centered care delivery as clearly unsustainable. In line with the public health framework for action in the World Health Organization's World Health and Ageing Report, meeting these challenges will require a systemic reform of healthcare delivery that is integrated, patient-centric, team-based, and health-centered. These reforms can be achieved through building partnerships and relationships that engage, empower, and activate patients and their support systems. To meet the challenges of population ageing, Singapore has reorganised its public healthcare into regional healthcare systems (RHSs) aimed at improving population health and the experience of care, and reducing costs. This paper will describe initiatives within the RHS frameworks of the National Health Group (NHG) and the Alexandra Health System (AHS) to forge a frailty-ready healthcare system across the spectrum, which includes the well healthy ("living well"), the well unhealthy ("living with illness"), the unwell unhealthy ("living with frailty"), and the end-of-life (EoL) ("dying well"). For instance, the AHS has adopted a community-centered population health management strategy in older housing estates such as Yishun to build a geographically-based care ecosystem to support the self-management of chronic disease through projects such as "wellness kampungs" and "share-a-pot". A joint initiative by the Lien Foundation and Khoo Teck Puat Hospital aims to launch dementia-friendly communities across the island by building a network comprising community partners, businesses, and members of the public. At the National Healthcare Group, innovative projects to address the needs of the frail elderly have been developed in the areas of: (a) admission avoidance through joint initiatives with long-term care facilities, nurse-led geriatric assessment at the emergency department and geriatric assessment clinics; (b) inpatient care, such as the Framework for Inpatient care of the Frail Elderly, orthogeriatric services, and geriatric surgical services; and (c) discharge to care, involving community transitional care teams and the development of community infrastructure for post-discharge support; and an appropriate transition to EoL care. In the area of EoL care, the National Strategy for Palliative Care has been developed to build an integrated system to: provide care for frail elderly with advance illnesses, develop advance care programmes that respect patients' choices, and equip healthcare professionals to cope with the challenges of EoL care.
TL;DR: Nearly two-thirds of children who died of cancer experienced intense end-of-life care, with a bimodal association between age and intensity: ages <5 years and 15 to 21 years was associated with intense care.
Abstract: BACKGROUND: Many adult patients with cancer who know they are dying choose less intense care; additionally, high-intensity care is associated with worse caregiver outcomes. Little is known about intensity of end-of-life care in children with cancer. METHODS: By using the California Office of Statewide Health Planning and Development administrative database, we performed a population-based analysis of patients with cancer aged 0 to 21 who died between 2000 and 2011. Rates of and sociodemographic and clinical factors associated with previously-defined end-of-life intensity indicators were determined. The intensity indicators included an intense medical intervention (cardiopulmonary resuscitation, intubation, ICU admission, or hemodialysis) within 30 days of death, intravenous chemotherapy within 14 days of death, and hospital death. RESULTS: The 3732 patients were 34% non-Hispanic white, and 41% had hematologic malignancies. The most prevalent intensity indicators were hospital death (63%) and ICU admission (20%). Sixty-five percent had ≥1 intensity indicator, 23% ≥2, and 22% ≥1 intense medical intervention. There was a bimodal association between age and intensity: ages CONCLUSIONS: Nearly two-thirds of children who died of cancer experienced intense end-of-life care. Further research needs to determine if these rates and disparities are consistent with patient and/or family goals.
TL;DR: In this paper, the authors discuss barriers to palliative care integration in hematology, highlight several reports of successful integration, and suggest specific indications for involving palliate care in the management of hematologic malignancy patients.
Abstract: Evidence points to many benefits of "early palliative care," the provision of specialist palliative care services upstream from the end of life, to improve patients' quality of life while living with a serious illness. Yet most trials of early palliative care have not included patients with hematologic malignancies. Unfortunately, patients with hematologic malignancies are also known to have substantial illness burden, poor quality of life, and aggressive care at the end of life, including a greater likelihood of dying in the hospital, receiving chemotherapy at the end of life, and low hospice utilization, compared to patients with solid tumors. Given these unmet needs, one must wonder, why is palliative care so underutilized in this population? In this article, we discuss barriers to palliative care integration in hematology, highlight several reports of successful integration, and suggest specific indications for involving palliative care in the management of hematologic malignancy patients.
TL;DR: The ACP does not support legalization of physician-assisted suicide because it is problematic given the nature of the patient-physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession's role in society.
Abstract: Calls to legalize physician-assisted suicide have increased and public interest in the subject has grown in recent years despite ethical prohibitions. Many people have concerns about how they will die and the emphasis by medicine and society on intervention and cure has sometimes come at the expense of good end-of-life care. Some have advocated strongly, on the basis of autonomy, that physician-assisted suicide should be a legal option at the end of life. As a proponent of patient-centered care, the American College of Physicians (ACP) is attentive to all voices, including those who speak of the desire to control when and how life will end. However, the ACP believes that the ethical arguments against legalizing physician-assisted suicide remain the most compelling. On the basis of substantive ethics, clinical practice, policy, and other concerns articulated in this position paper, the ACP does not support legalization of physician-assisted suicide. It is problematic given the nature of the patient-physician relationship, affects trust in the relationship and in the profession, and fundamentally alters the medical profession's role in society. Furthermore, the principles at stake in this debate also underlie medicine's responsibilities regarding other issues and the physician's duties to provide care based on clinical judgment, evidence, and ethics. Society's focus at the end of life should be on efforts to address suffering and the needs of patients and families, including improving access to effective hospice and palliative care. The ACP remains committed to improving care for patients throughout and at the end of life.
TL;DR: This critical conceptual paper considers an alternative approach to framing this debate, drawn from a subaltern and post-colonial studies perspective and suggests that adopting a truly global perspective will require acceptance of the plurality of past and present local problems and issues relating to end of life care.
TL;DR: A systematic review of studies investigating preferred death place among cancer patients found the incongruence between preferred and actual death place seems to be substantial, however, study designs must improve and publications of socioeconomic data should be unified to ease interpretation in future studies.
Abstract: The importance to die at preferred death place is substantial among terminally ill cancer patients. Previously, several studies have investigated this issue, but no systematic review has been made ...
TL;DR: Quality indicators that emerged from this integrative review provide a two-fold application in palliative and end-of-life care, to guide the planning and implementation of team and organizational changes that improve the quality delivery of CCC.
Abstract: Compassion and collaborative practice are individually associated with high quality healthcare. When combined in a compassionate collaborative care (CCC) practice framework, they are reported to improve health, strengthen care provision, and control health costs. Little is known about how to integrate and measure CCC, yet it is fundamentally applied in palliative and end-of-life care settings. This study aimed to identify quality indicators of CCC by systematically reviewing and synthesizing the current state of the palliative and end-of-life care literature. An integrative review of the palliative and end-of-life care literature was conducted using Whittemore and Knafl’s method. Donabedian’s healthcare quality framework was applied in the data analysis phase to organize and display the data. The analysis involved an iterative process that applied a constant comparative method. The final literature sample included 25 articles. Patient and family-centered care emerged as a primary structure for CCC, with overarching values including empathy, sharing, respect, and partnership. The analysis revealed communication, shared decision-making, and goal setting as overarching processes for achieving CCC at end-of-life. Patient and family satisfaction, enhanced teamwork, decreased staff burnout, and organizational satisfaction are exemplars of outcomes that suggest high quality CCC. Specific quality indicators at the individual, team and organizational levels are reported with supporting exemplar data. CCC is inextricably linked to the inherent values, needs and expectations of patients, families and healthcare providers. Compassion and collaboration must be enacted and harmonized to fully operationalize and sustain patient and family-centered care in palliative and end-of-life practice settings. Towards that direction, the quality indicators that emerged from this integrative review provide a two-fold application in palliative and end-of-life care. First, to evaluate the existing structures, processes, and outcomes at the patient-family, provider, team, and organizational levels. Second, to guide the planning and implementation of team and organizational changes that improve the quality delivery of CCC.
TL;DR: Palliative care substantially decreased health-care use among Medicare beneficiaries with advanced cancer, and the importance of early integration of palliatives care alongside standard oncologic care is emphasized.
Abstract: Purpose:Palliative care’s role in oncology has expanded, but its effect on aggressiveness of care at the end of life has not been characterized at the population level.Methods:This matched retrospective cohort study examined the effect of an encounter with palliative care on health-care use at the end of life among 6,580 Medicare beneficiaries with advanced prostate, breast, lung, or colorectal cancer. We compared health-care use before and after palliative care consultation to a matched nonpalliative care cohort.Results:The palliative care cohort had higher rates of health-care use in the 30 days before palliative care consultation compared with the nonpalliative cohort, with higher rates of hospitalization (risk ratio [RR], 3.33; 95% CI, 2.87 to 3.85), invasive procedures (RR, 1.75; 95% CI, 1.62 to 1.88), and chemotherapy administration (RR, 1.61; 95% CI, 1.45 to 1.78). The opposite pattern emerged in the interval from palliative care consultation through death, where the palliative care cohort had lowe...
TL;DR: A comprehensive set of quality indicators of appropriate and inappropriate end-of-life care in people with Alzheimer’s disease, cancer or chronic obstructive pulmonary disease, to be used in population-level research is developed.
Abstract: Background:A substantial amount of aggressive life-prolonging treatments in the final stages of life has been reported for people with progressive life-shortening conditions. Monitoring appropriate and inappropriate end-of-life care is an important public health challenge and requires validated quality indicators.Aim:To develop indicators of appropriate and inappropriate end-of-life care for people with cancer, chronic obstructive pulmonary disease or Alzheimer’s disease, measurable with population-level administrative data.Design:modified RAND/UCLA appropriateness method.Setting/participants:Potential indicators were identified by literature review and expert interviews and scored in a survey among three panels of experts (one for each disease group). Indicators for which no consensus was reached were taken into group discussions. Indicators with consensus among the experts were retained for the final quality indicator sets.Results:The final sets consist of 28 quality indicators for Alzheimer’s disease, ...
TL;DR: There is greater consistency in the content being delivered as part of end-of-life care education within medical schools, and teaching institutions are also utilising a broader range of teaching modalities.
Abstract: Purpose:There is an increasing demand for quality palliative care teaching within undergraduate medical education. Studies suggest that many junior doctors feel underprepared to perform end-of-life care. Previous systematic reviews on palliative care teaching within medical schools have identified significant variability and lack of consistency in teaching. This review aims to update the literature on the current status of palliative care teaching to undergraduates within medical schools.Method:A systematic review was undertaken on articles published from December 2001 to November 2015 on palliative care teaching for undergraduate medical students. In all, 650 abstract citations were obtained, of which 126 were relevant to the research questions. Thematic analysis was performed on remaining articles according to whether they discussed content and/or methodology of palliative care education, and data collated.Results:There is greater consistency in the content being delivered as part of end-of-life care ed...
TL;DR: The aims of this study were to assess the barriers associated with a lack of implementation of palliative care for people with dementia and to explore whether there is a gap in knowledge necessitating further study.
Abstract: People with dementia often fail to receive palliative care, despite increased recognition of their need and eligibility for such care. The aims of this study were to assess the barriers associated with a lack of implementation of palliative care for people with dementia and to explore whether there is a gap in knowledge necessitating further study. We reviewed the English literature published from 2000 to 2016, related to barriers to palliative care for people with dementia. Twenty-two articles met inclusion criteria for the review. Most originated in Europe or North America and were qualitative in nature. Four key themes were identified: administrative/policy issues, education, communication, and staff personal characteristics. Barriers to the delivery of palliative care for people with dementia have been studied for more than a decade, yet at present, there is a lack of consensus in practice. More research is needed related to barriers associated with personal characteristics. Such investigations have the potential to improve and better understand the complex nature of palliative care in this population.