Early Palliative Care Initiation: Role of the Primary Care Clinician

Palliative care provided to patients with chronic life-limiting illnesses shows improvement in symptom management, quality of life, and caregiver support while reducing cost of care. Early initiation of palliative care faces a multitude of barriers in the primary care setting, including provider confidence, coordination and implementation, education, and family and patient misconceptions. A team-based approach along with additional education, clear referral triggers, and resources for advanced-care planning discussions allows providers to overcome many of these barriers. With the population’s advancing age, it is essential that primary care providers are properly prepared for early initiation of palliative care.     

Advance care planning in Belgium and The Netherlands: a nationwide retrospective study via sentinel networks of general practitioners

Context

Advance care planning (ACP) is an important part of patient-centered palliative care. There have been few nationwide studies of ACP, especially in Europe.

Objectives

To investigate the prevalence and characteristics of ACP in two European countries and identify the associated factors.

Methods

A mortality follow-back study was undertaken in 2007 via representative nationwide Sentinel Networks of general practitioners (GPs) in Belgium and The Netherlands using similar standardized procedures. All GPs reported on each non-suddenly deceased patient in their practice. Our main outcome measure was whether or not ACP, that is, an agreement for medical treatment and/or medical decisions in the last phase of life in the case of the patient losing competence, was present.

Results

Among 1072 non-sudden deaths, ACP was done with 34% of patients and most often related to the forgoing of potential life-prolonging treatments in general (24%). In 8% of cases, ACP was made in consultation with the patient and in writing. In 23% of cases, care was planned with the patient’s family only. Multivariate analysis revealed that ACP was more often made with patients if they were capable of decision making during the last three days of life (odds ratio [OR] 3.86; 95% confidence interval [CI] 2.4-6.1), received treatment aimed at palliation in the last week (OR 2.57; 95% CI 1.6-4.2), had contact with a GP in the last week (OR 2.71; 95% CI 1.7-4.1), died of cancer (OR 1.46; 95% CI 1.1-2.0), or died at home (OR 2.16; 95% CI 1.5-3.0).

Conclusion

In these countries, ACP is done with approximately one-third of the studied terminally ill patient population. Most agreements are made only verbally, and care also is often planned with family only. ACP relates strongly both to patient factors and to health care measures performed at the very end of life.     

Consensus of the Millennium Conference on Teaching High Value Care

Issue: Healthcare costs have spiraled out of control, yet students and residents may lack the knowledge and skills to provide high value care, which emphasizes the best possible care while reducing unnecessary costs. Evidence: Mainly national campaigns are aimed at physicians to reconsider their test ordering behaviors, identify overused diagnostics, and disseminate innovative practices. These efforts will fall short if principles of high value care are not incorporated across the spectrum of training for the next generation of physicians. Implications: Consensus findings of an invitational conference of 7 medical school teams consisting of academic leaders included strategies for institutions to meaningfully incorporate high value care into their medical school, residency, and faculty development curricula.     

人文关怀在优质护理服务工作中的应用

目的探讨人文关怀在优质护理服务中的运用,强化护理责任感、落实基础护理,提高护理质量,提高患者满意度。方法通过营造良好的病区环境,增强护士综合素质和主动服务的意识,夯实基础护理,提供安全的护理,实施出院后的延续护理等措施,为患者提供优质护理。结果人文关怀在优质护理服务中的运用,切实提高了护士主动服务的意识,患者满意度和护理质量得到了提高,护理纠纷减少,患者满意度由85.77%提高到97.50%(P<0.01)。结论人文关怀在优质护理服务活动中,提升了护士与患者主动沟通的能力,促进患者的恢复,达到真正意义上的护患和谐、医患和谐和社会的和谐。     

ICUs worldwide: an overview of critical care medicine in South Africa

South Africa has undergone rapid changes in the political and social arenas since 1994. With new policy-makers in the Department of Health, the distribution of health care resources are being rationalised and redirected to benefit the majority of the previously disadvantaged population of the country. The role and rationalisation of intensive care medicine has to be re-evaluated to ascertain that it is at a level appropriate for a developing country. Despite progress made, the subspecialty of intensive care medicine faces challenges from changing disease patterns and from lack of human and financial resources as these are redirected to primary health care and other priorities facing the country.     

Use of Care by Home-dwelling Stroke Patients during Three Years following Hospital Discharge

Of 82 stroke survivors who had been discharged from hospital, 49 were still living at home after a three-year period. Thirty-three of these patients formed the population of the present study of the use of care at home. Sixty-one percent had received professional care and 88% had received family care. Although their overall functional status indicated only mild handicaps, after three years patients still reported a large number of disabilities and problems. The average weekly amount of family care was 37 h, and many family carers experienced a high burden of care and had emotional problems coping with the patients' disabilities. Concerning factors related to the use of care, in spite of the relatively small number of study patients, some interesting hypotheses can be advanced.     

A Case of Perceived Lack of Prenatal Caring

This qualitative case study tells the story of one woman’s experience of prenatal care through her own words and those of her mother, who is a nurse. Frequent sonograms, referral to a maternal–fetal medicine physician, and the unexpected recommendation to schedule an induction made this woman anxious about the well-being of her fetus, influenced her experience of pregnancy, and affected her developing identity as a mother. She felt neither cared for nor included as a partner in her own prenatal care. Although she reported feeling strong and capable in every other aspect of her life, she felt powerless to self-advocate with regard to her prenatal care experience. Ultimately, she asked her mother to accompany her to a prenatal appointment to advocate on her behalf.     

Oral care practices of intensive care nurses: A descriptive study

The aim of this study was to investigate intensive care unit (ICU) nurses’ views and practices on oral care and to define the factors related to oral care measures. A study was carried out in eight ICUs of a teaching hospital in 2008. One hundred one nurses constituted the study sample. The data were collected using ‘Oral Care Practices Survey’ which included demographic characteristics (5 items) and current oral care practices (13 items). Oral care was given the highest priority by nearly 60% of the nurses. The most commonly used solution was sodium bicarbonate (79.2%), and the most frequently used equipment was foam swab (82.2%). Oral care was carried out less than every 4 h per day by 44.5% of the nurses. The oral care products and solutions were reported to be different in almost every unit. The relationship between the use of toothpaste and the place of employment was statistically significant (x² = 24.566, d.f. = 6, P = 0.000). There was a statistical significance between the clinics and frequency of oral care (x² = 81.486, d.f. = 42, P = 0.000). This study suggests that there is a wide variety of type and frequency of oral care measures among ICU nurses. Optimal oral care supported by evidence is an effective prevention method for eliminating oral complications.     

Use and Types of Advance Care Planning Prior to Image-Guided Procedures

BackgroundAdvance care planning is a well-supported means of improving care for patients by clarifying goals and preferences prior to an intervention.PurposeThe purpose of this study was to assess the prevalence and types of advance care planning occurring prior to image-guided procedures.MethodsAll image-guided procedures performed at two healthcare systems over a 3-month period were reviewed, including 1384 procedures for 999 inpatients and 1255 procedures for 1217 outpatients.FindingsOf 2,639 total image-guided procedures, 36% of inpatient procedures and 18% of outpatient procedures had advance care planning documented within 3 months prior to the procedure. Use was more prevalent prior to procedures near the end of life (p < .01) and tended to be less structured forms such as goals of care discussions (p < .01). Use was more common in non-Hispanic and male patients (p = .04).DiscussionAdvance care planning prior to image-guided procedures may be underutilized with disparities in this care.     

Frequency and Characteristics of First-Time Palliative Care Referrals During the Last Day of Life

ContextPalliative care referrals (PCRs) improve symptom management, provide psychosocial and spiritual support, clarify goals of care, and facilitate discharge planning. However, very late PCR can result in increased clinician distress and prevent patients and families from benefiting from the full spectrum of interdisciplinary care.ObjectivesTo determine the frequency and predictors of PCR within 24 hours of death.MethodsConsecutive first-time inpatient PCR from September 1, 2013 to August 31, 2017 was identified to determine the frequency and predictors of referrals within 24 hours of death. We compared the clinical characteristics with a random sample of patients discharged alive or died more than 24 hours after first-time PCR as a control, stratified by year of consult in a 1:1 ratio.ResultsOf 7322 first-time PCRs, 154 (2%) died within 24 hours of referral. These patients were older (P = 0.003) and had higher scores for depression (P = 0.0009), drowsiness (P = 0.02), and shortness of breath (P = 0.008) compared with a random sample of 153 patients discharged alive or died more than 24 hours after first-time PCR. Patients who received a PCR within 24 hours of death were more likely than the control group to have Eastern Cooperative Oncology Group 4 (95% vs. 25%, P < 0.0001), delirium (89% vs. 17%, P < 0.0001), do-not-resuscitate code status (81% vs. 18%, P < 0.0001), and hematologic malignancies (39% vs. 16%, P < 0.0001). In the multivariate analysis, depression (odds ratio [OR] 1.4; P = 0.005), do-not-resuscitate code status (OR 9.1; P = 0.003), and Eastern Cooperative Oncology Group 4 (OR 9.8; P = 0.003) were independently associated with first-time PCR within 24 hours of death.ConclusionAlthough only a small proportion of first-time PCR occurred in the last 24 hours of life, the patients had a significant amount of distress, indicating a missed opportunity for timely palliative care intervention. These sentinel events call for specific guidelines to better support patients, families, and clinicians during this difficult time. Further research is needed to understand how to minimize very late PCR.     

Home care for terminally ill Turks and Moroccans and their families in the Netherlands: carers' experiences and factors influencing ease of access and use of services

The aim of this study was to explore the experiences of relatives of elderly terminally ill Turks and Moroccans regarding Dutch professional home care and the barriers to the use this care. Nine Turkish and ten Moroccan family members, who recently looked after dying members of their families, were interviewed using a semi-structured topic list. The data was analyzed using the method described by Glaser and Strauss. The results of this study make it clear that there is no uniform pattern in the use of home care. However, family members who did use home care facilities were all satisfied. Furthermore, on the basis of this study, several factors influencing access to and use of home care were discerned, e.g., illness, family structure, decision making, pressure from the community, information and formal referrals. In addition, the authors found that ‘preferences regarding family care’ influenced all former factors.     

Impact of Palliative Care on Quality of End-of-Life Care Among Brazilian Patients With Advanced Cancers

ContextMany patients with advanced cancer experience aggressive care during the end of life (EOL). Several studies have evaluated the benefits of palliative care (PC) on the reduction of aggressive measures; however, limited data are available about their benefit in Brazilian patients.ObjectivesTo evaluate the impact of PC on the reduction of aggressive measures at the EOL.MethodsLongitudinal study analyzed retrospectively medical records of patients who died of advanced cancer from 2010 to 2014. Data were obtained on PC referral and five quality-of-care indicators at the EOL; that is, emergency department visits, hospital admission, intensive care unit admission, use of systemic antineoplastic therapy within the last 30 days of life, and place of death in hospital as well as the use of a composite score for aggressiveness of care.ResultsOf the 1284 patients, 832 (65%) received some aggressive measures in EOL care. Over the years, there was a reduction in the aggressiveness of care (score = 0: 33.2% vs. 47.1%; P < 0.001). Patients not seen by PC received greater aggressive care compared with patients consulted by PC (score ≥1: 87.4% vs. 52.8%; P < 0.001). Early PC was associated with less chemotherapy (P = 0.001) and fewer emergency department visits (P = 0.004) in the last 30 days of life, when compared with late PC. However, there were no demonstrated benefits to significantly reduce the composite score at EOL care aggressiveness.ConclusionPatients with an advanced cancer consultation by PC staff received less aggressive care at the EOL when compared with patients without PC.     

A Profile of Freestanding Emergency Departments in the United States, 2007

Background

Freestanding Emergency Departments (FSEDs) have emerged as an alternative to traditional hospital-based emergency care.

Study Objective

We sought to determine the number, basic types, distribution, and characteristics of United States (US) FSEDs in 2007.

Methods

Combining data from the 2007 National Emergency Department Inventory-USA database, the 2007 American Hospital Association Annual Survey of Hospitals, Internet searches, and telephone calls, we established an inventory of FSEDs. We define FSEDs as emergency care facilities physically distinct from a hospital. FSEDs include “satellite” Emergency Departments (EDs), which are owned by a parent hospital, and “autonomous” EDs, which lack such an affiliation.

Results

We identified 80 FSEDs operating in 2007, representing 1.6% of all US EDs; 73 (91%) in 20 states were satellite EDs, and seven (9%) in three states were autonomous EDs. Most FSEDs (92%; 95% confidence interval 83–97%) were located in urban areas, which is considerably higher than the proportion for hospital-based EDs (58%). The median distance from a satellite ED to a parent hospital ED was 10.6 miles. In 2007, FSED annual visit volumes ranged from 700 to 56,545 visits. The 2007 median visit volume was 18,769 (interquartile range 11,106–23,504; n = 52). This value did not vary by geographic region and is almost identical to the 2007 median visit volume for hospital-based EDs (18,776 visits).

Conclusions

FSEDs represent <2% of US EDs, with satellite EDs comprising a majority of all FSEDs. Most (92%) FSEDs are located in urban areas.     

无缝隙护理在优质护理服务中的应用

目的 探讨无缝隙护理在优质护理服务中的应用,旨在为患者提供更人性化的护理,进而提高患者的满意度.方法 通过弹性排班,实行对患者包干到人的工作制度,加强护理的责任心,提高工作积极性.结果患者满意度较改革前提高8.2%,护理工作质量明显提高,护患关系更加和谐.结论 开展无缝隙护理是提供优质护理服务的重要手段,强调以患者为中心的整体护理理念,提高护理服务质量,提升医院的核心竞争力.     

Assessment of the Quality of Nursing Care of Postoperative Pain in Patients Undergoing Vascular Procedures

PurposeThe purpose of this study was to evaluate the quality of nursing care of postoperative pain management in patients who underwent vascular procedures.DesignA survey using patient questionnaires.MethodsThe sample was composed of 100 patients, aged 52 to 86 years, admitted to the Clinic of Cardiac and Vascular Surgery, University Clinical Centre, Gdansk, Poland. The study included the use of an interview questionnaire, that is,.e. a standardized research tool—the Strategic and Clinical Quality Indicators in Postoperative Pain Management scale and a questionnaire designed to record sociodemographic characteristics.FindingsAnalysis of the data indicated that the most numerous group of patients were men (80%). The total mean score obtained with the Strategic and Clinical Quality Indicators in Postoperative Pain Management scale was 59.2 points (range, 14 to 70) meaning that the high quality of nursing care in each area was not provided. The results of this research revealed areas for improvement in postoperative pain management on the subscales: communication (12.9 points), action (15.3 points), and environment (12.5 points).ConclusionsThe overall level of quality of nursing care in terms of postoperative pain management as reported by patients after vascular procedures was not fully satisfying, and nursing care should improve. This indicates the need to educate nurses in postoperative pain management, its monitoring and prophylaxis, and communication techniques with patients. Our study indicates that gender, place of residence, education level, and satisfaction with pain management influence the assessment of the quality of care.