Survey of palliative care programs in United States teaching hospitals

In order to estimate the prevalence of palliative care programs in academic hospitals in the United States, we surveyed a random sample of 100 hospitals in the Council of Teaching Hospitals and Health Systems directory. Sixty percent of hospitals provided information. At least 26% of hospitals had either a palliative care consultation service or inpatient unit and 7% had both. Eighteen percent of hospitals had a palliative care consultation service alone, 19% had an inpatient palliative care unit, 22% reported a hospice affiliation, and 17% had a hospice inpatient contract. Additionally, at least 20% of the remaining hospitals were planning a palliative care program. The consultation services had an average daily census of 6; the inpatient units had an average of 12 beds. Palliative care consultation programs were largely affiliated with departments of medicine or hematology/oncology, and were typically staffed by a physician and a nurse. Only half had a dedicated social worker, one third had a chaplain, one third had a pharmacist, and a few included a bereavement coordinator or volunteer director, suggesting that the hospice model of interdisciplinary care is not being adopted regularly in palliative care programs. In comparison, almost half of hospitals noted established pain services. In conclusion, palliative care programs, although found in a minority of surveyed hospitals, are becoming an established feature of academic medical centers in the United States. More detailed information is needed about the type and quality of care they provide.     

Bringing palliative care to a Canadian cancer center: the palliative care program at Princess Margaret Hospital

It is increasingly recognized that complete care of the patient with cancer includes palliative care, which is applicable early in the course of illness, in conjunction with life-prolonging treatment. Princess Margaret Hospital (PMH) is Canada’s largest center for cancer care and research, and it is an international referral center for patients with cancer. The Palliative Care Program at PMH has developed into a comprehensive clinical, educational, and research program, with an acute palliative care unit, daily palliative care clinics, a cancer pain clinic, and a consultation service that sees urgent consultations on a same-day basis in inpatient and outpatient areas. We will describe the components, successes, and challenges of our program, which may be useful for others, who are developing palliative care programs in an academic setting.     

Hospital doctors' attitudes towards palliative care in Germany

Experts from different areas strongly criticize the current level of palliative care in Germany, both inpatient and home care services. Apart from the experts' opinions, little is known in this context about the perspectives of hospital doctors working in different disciplines, such as surgery, internal medicine, gynaecology or anaesthesia. These doctors presumably treat many incurably ill patients with palliative care needs, but they usually have very little experience in palliative medicine. Their attitudes are particularly important because they are affected by the criticism and by future improvement strategies. To study their viewpoints, questionnaire surveys in five hospitals in the federal state of Brandenburg were performed, with 203 (69%) physicians participating. The results showed that the level of palliative care in hospitals was graded better than in the home care setting. Main needs for improvement were seen in the psychosocial support services and in the co-operation with outpatient services. In [corrected] the hospital physicians' view, palliative nursing care was of a higher standard than medical aspects [corrected] of care [corrected] The physicians showed great interest in improving their knowledge of [corrected] palliative care and in new specialist palliative care services. The conclusions were that three main strategies for improvement should be embarked on: (1) the establishment of integrated care systems to overcome financial and structural barriers between in- and outpatient care; (2) the establishment of further specialist palliative care services (eg, hospital-based palliative care teams); and (3) better education in palliative medicine.     

Hospice care and palliative care: a perspective from experience

The establishment of the first Department of Pain Medicine and Palliative Care in a Medical Center in the United States is noteworthy. Since the design of the Department integrates a full-functioning hospice program within it, that has both a dedicated inpatient unit and extensive home care program, this Department represents a milestone in the development of the hospice movement, with full interrelationship between palliative care and hospice care. This paper will explore this interrelationship, its implications, and some of the background.     

A program of hospice and palliative care in a private, nonprofit U.S. Teaching hospital

A hospice and palliative care program was established at Northwestern Memorial Hospital, a 773-bed private nonprofit hospital located in the urban center of Chicago. The program consists of three components: consultation service, acute inpatient unit, and home-hospice program. The consultation service saw an average of 57 new patients per month (range 45-80) in fiscal year 1997. The 12-bed acute care inpatient unit had an average midnight census of 9.8 in fiscal 1996. This decreased to 6.9 in fiscal 1997 due to new treatment approaches for AIDS and has rebounded to nine in the third quarter of fiscal 1998. The unit cares for more than one third of dying patients in the hospital. Patients do not have to access hospice insurance benefits to be admitted to the unit. The home-hospice program has a median length of stay of 31 days and serves patients living within the city limits of Chicago. A total of 800 patients were referred to the program, and 370 patients died in the program in fiscal 1997. A total of 219 different physicians were attending physicians for patients in the program during a 3- year period. Revenue exceeded direct expenses by $1.48 million. Fee-for-service billing for physician services outside of those provided or billed under the Medicare Hospice Benefit are not included in these figures. The group practice that bills for the physicians collected an average of 50.5% of billed charges over 4 years. We conclude that a program of hospice and palliative care can be successful in a private teaching hospital in the United States.     

Prospective validation of the palliative prognostic index in patients with cancer

The Palliative Prognostic Index (PPI) was devised and validated in patients with cancer in a hospice inpatient unit in Japan. The aim of this study was to test its accuracy in a different population, in a range of care settings and in those receiving palliative chemotherapy and radiotherapy. The information required to calculate the PPI was recorded for patients referred to a hospital-based consultancy palliative care service, a hospice home care service, and a hospice inpatient unit. One hundred ninety-four patients were included in the study, 43% of whom were receiving chemotherapy /or radiotherapy or both. Use of the PPI split patients into three subgroups based on PPI score. Group 1 corresponded to patients with PPI4 and 6, median survival five days (95% CI 3, 11). Using the PPI, survival of less than three weeks was predicted with a positive predictive value of 86% and negative predictive value of 76%. Survival of less than six weeks was predicted with a positive predictive value of 91% and negative predictive value of 64%. The PPI is quick and easy to use, and can be applied to patients with cancer, in hospital, in hospice, and at home. It may be used by general physicians to achieve prognostic accuracy comparable, if not superior, to that of physicians experienced in oncology and palliative care, and by oncology and palliative care specialists, to improve the accuracy of their survival predictions.     

The impact of a palliative medicine consultation service in medical oncology

This prospective study of consecutive patients describes the palliative medicine consult service in a tertiary level cancer center and its impact on patient care. All inpatients/outpatients referred to the Palliative Medicine Program in a 4-month period were enrolled. Data were collected at the initial consultation using standardized forms with spaces for: reason for the consultation, referring service, demographics and history, ECOG performance status, symptoms, prognosis and diagnostic tests, treatment, and care plan. In all, 240 patients were seen: 79% were referred for symptom management; 53% were referred from medical oncology; and 50% were women. Median patient age was 67 years (range 18-96). Median performance status was 2 (1-4). Most (84%) of the patients had cancer. The cancer sites were: lung in 26% of cases, colorectal in 8%, and breast in 7%. Inpatients accounted for 53% and outpatients, for 47% of the study population. The median number of symptoms per patient was 13 (2-30). The estimated survival was <2 weeks in 15%, 2-8 weeks in 38%, 2-6 months in 37%, and >6 months in 10%. The patients' goals were: improve symptoms for 84%, return home for 55%, and no further admissions for 5%. The support systems named by patients were: family in 89%, friends in 13%, and the community in 5%. Hospice care was discussed at the consultation with 38% of the patients, would have been inappropriate for 31%, was not discussed with 22%, and had been discussed before with 9%. In response to questions about psychosocial care, a caregiver was identified by 78%, a spokesperson by 75%, and durable power of attorney was referred to by 21%. The DNR status was discussed on consult by 57%, had already been discussed with 30%, and was not discussed with 13%. Plan of care foresaw outpatient follow-up for 40%, inpatient follow-up for 32%, and transfer to palliative medicine for 27%. In 39% of cases the consults were considered late referrals. New medications suggested were opioids for 46% of patients, antiemetics for 28%, a bowel regimen for 24%, steroids for 15%, and others for 51%. (1) Palliative medicine consultation involves common complex medical, psychological, and social problems. (2) Complex symptomatology in this population is confirmed. (3) Multiple interventions were suggested even at the initial consultation. (4) Important issues such as DNR (do not resuscitate) status, support system, treatment goals, and eligibility for hospice care had often not been addressed.     

Specialist palliative care and patients with noncancer diagnoses: the experience of a service

This retrospective review was undertaken to identify the pattern of noncancer referrals to a specialist palliative care service, comprising a teaching hospital support team, home care, outpatients and inpatient hospice, over a 1-year period. Of 287 hospital ward referrals, 83 patients had a noncancer diagnosis (29%); they were referred predominantly for symptom control (92%), particularly of pain (84%). Of 130 outpatient referrals, 30 had a noncancer diagnosis (23%) and were also referred mainly for the management of pain (85%). Of 196 home care referrals, 18 had a noncancer diagnosis (9%); they tended to be referred for multiprofessional care of endstage disease. Of 421 hospice inpatient admissions, 17 were for patients with a noncancer diagnosis (4%) and were predominantly for respite care. These admissions accounted for 2% of occupied bed days. It is concluded that specialist palliative care skills are perceived to be transferable to patients with noncancer diagnoses. Resource implications focus on hospital and outpatient services, where shared care with medical teams is usual practice. Defining management goals at the outset is particularly important.     

Current status of hospice cancer deaths both in-unit and at home (1995-2000), and prospects of home care services in Japan

In Japan, the first government-approved hospice (GAH) and palliative care unit was established and commenced operations in 1990, and hospice medical care was made eligible for health insurance coverage. By 31 December 2000, the number of GAH institutions had increased to 86 (1,590 beds). The ratio of hospices to population in Japan is currently approximately 1:1.5 million, with an average of one hospice bed for approximately every 80,000 people. This study of institutions reports a survey conducted to determine the number of deaths (hospice unit and home) of GAH cancer patients, and to determine the servicing status of hospice home care for the period 1995 through 2000. The place of death of the patients cared for by GAHs in 2000 were: hospice units 97.7% and home 2.3%. GAH patient deaths (both inpatient and at home) in 2000 was 2.6% of the total number of cancer patients' deaths, an increase of 3.8-fold since 1995. Of the total number of GAH institutions, 62% are engaged in home care services and 91 % offer hospice care by hospice-assigned doctors. In addition, 72% offer team care with nurses based at Home Care Agencies. In order for the hospice (including home care service) to become established in a way most appropriate to each region of Japan, GAH institutions must assume significant promotional roles in their respective regions. One of the goals and assignments of establishing medical service with hospice home care in Japan is to develop the systematic care programs of GAH institutions, which include home care service in addition to the already established hospice unit and outpatient services.     

Acute care palliative medicine: psychosocial assessment of patients and primary caregivers

This paper describes the application of an empirically-derived psychosocial assessment for use in advanced cancer. The patient population selected for this study was those patients no longer pursuing aggressive antitumour treatment, and the focus of care was on management of major symptoms and complications, and psychosocial support of the patient and family. The physical, cognitive, social and emotional dimensions were the framework for the assessment of both patient and caregiver functioning. Through this assessment of all patients admitted to our inpatient palliative medicine unit, care needs were identified and psychosocial interventions planned. The results of 150 assessments are reported, as well as observations of the process, implications for psychosocial care and modifications of the assessment based on this experience.     

Activities of counsellors in a hospice/palliative care environment

This study examined activities related to the provision of psychosocial care by counsellors in the hospice/palliative care setting. A qualitative design using written reports was used in an urban Canadian hospice/palliative care program. A convenient sample of 13 counsellors indicated the activities they typically performed in their work with patients and families. Thematic analysis of the activities directly related to patient and family care was performed and then validated by presenting these activities back to the counsellors in a group setting. Seven themes resulted: 1) companioning; 2) psychosocial assessment, planning, and evaluation; 3) counselling interventions; 4) facilitation and advocacy; 5) patient and family education; 6) consultation and reporting; and 7) team support. These thematic findings confirmed those of previous studies and also highlighted two additional findings. Team support was seen as an activity that directly affected client care, and there was a strong emphasis on the activity of companioning the dying and their families. Also discussed are implications of these results, as well as suggestions for further research.     

Ambulatory hospice training in family medicine residency

End-of-life care has become an important competency for primary care physicians, and yet many family physicians feel unprepared in the areas of hospice and/or palliative medicine. In preparation for designing an ambulatory geriatrics rotation within a family medicine residency training program, a needs assessment revealed gaps in hospice training specific to the philosophy of hospice and the common settings in which it is practiced. A hospice-focused core curriculum unit was developed, using a community-based hospice experience and formal seminars. The resident's community-based experiences included home visits and nursing home contacts as part of a multispecialty hospice team. End-of-rotation resident assessments and rotations evaluations revealed enhanced resident understanding of hospice philosophy and venues, increased knowledge of the criteria for hospice admission and medical management of the dying patient and an increased intention to refer patients to a hospice program, although follow-up audits of referral patterns were inconclusive to date.     

Development of a rural palliative care program in the Calgary Zone of Alberta Health Services

Specialized rural models of palliative care are greatly needed to address the challenges rural communities face in providing palliative care services and to ensure that their unique strengths and needs are considered. In late 2005, a Rural Palliative Care Program was developed to support primary care providers in delivering palliative care to patients in rural communities outside of Calgary, Alberta, Canada. The program was grounded in the needs of individual communities, incorporated integral roles for local champions, and adopted pre-existing, accepted rural structures and processes. Needs and gaps in rural palliative care service delivery were identified and prioritized. The following actions were taken to address the top six priorities: 1) more accessible palliative care education opportunities with a rural focus were provided to health care professionals; 2) linkages with rural and urban resources were strengthened and access to specialists and procedures was improved; 3) strategies were implemented to improve psychosocial support for patients and families; 4) resources were developed to facilitate rural home deaths; 5) opportunities were expanded for education and utilization of volunteers; and 6) a mobile specialist consultation team was developed to support rural health care professionals and their patients in their rural communities. In its first four years, the team consulted on 640 patients, nearly three-quarters of whom died in their rural communities. Rather than imposing an urban outreach strategy, the development of a rural-based program through respectful engagement of local providers has proven to be crucial to the success of this rural palliative care program.     

Hospice and palliative care programs.

Hospice and palliative care programs have grown rapidly in the United States over the last 25 years. Relief of suffering and maximization of quality of life including symptom control, psychosocial health, and spiritual care are the primary goals of hospice and palliative care. This article reviews the development, philosophy, and practice of hospice and palliative care, and describes barriers to and suggestions for integrating this approach into mainstream medicine.     

Impact of availability of an inpatient hospice unit on the parent hospital's quality of palliative care for Taiwanese cancer decedents, 2001-2006

Context

Hospice care has increasingly been shown to affect quality of palliative care at both the individual and institutional levels. However, an institutional effect has only been addressed in single comprehensive cancer centers/selected community hospitals.

Objectives

To investigate the impact of an inpatient hospice unit on the parent hospital’s quality of palliative care.

Methods

This was a retrospective cohort study using administrative data from the entire population of 204,850 Taiwanese pediatric and adult cancer patients who died in 2001–2006. Outcome variables were adjusted by multivariate logistic regression for five groups of confounding variables: 1) patient demographics and disease characteristics, 2) primary hospital characteristics, 3) primary physician specialty, 4) health care resources at the hospital and regional levels, and 5) historical trend.

Results

Taiwanese cancer patients who received primary care in a hospital with an inpatient hospice unit (whether or not they received hospice care) were significantly less likely to be intubated (adjusted odds ratio [AOR]: 0.71; 95% confidence interval [CI]: 0.58, 0.86) and use mechanical ventilation support (AOR: 0.70; 95% CI: 0.56, 0.87) in their last month of life. They also were more likely to use hospice care before death (AOR: 3.51; 95% CI: 1.57, 7.86). Furthermore, if they used hospice care, they tended to be referred earlier than cancer patients being cared for in a hospital without an inpatient hospice unit.

Conclusion

Integrating both acute care and palliative care approaches to caring for terminally ill cancer patients in the same hospital may influence the quality of palliative care throughout the hospital as evidenced by our findings that these patients have lower likelihood of being intubated with mechanical ventilation support in the last month of life, greater propensity to receive hospice care in the last year of life, and a trend toward earlier referral to hospice care. The generalizability of these results may be limited to patients who died of a noncancer cause and by the two groups not being exactly matched for patients’ characteristics.     

安宁缓和医疗中的心理及社会评估

心理社会评估是安宁疗护工作的核心内容之一.本文以北京市海淀医院安宁疗护病房开展心理社会评估的经验体会为基础,阐述了心理社会评估的意义以及有效开展评估工作的相关要点,供开展安宁缓和医疗的医护人员参考.     

No place like the hospital

The gold standard for end-of-life care is home hospice. A case is presented in which a patient dying of irreversible small bowel obstruction from metastatic cancer insisted on remaining in the acute care hospital for care when alternative sites of care, including a skilled nursing facility and residential hospice, were available to her and covered by her health insurance plan. The ethical issues raised by this case are discussed from the perspective of the patient, the clinical team, the hospital, and the insurance company. Over the past decade, hospital-based palliative care consultation and general inpatient hospice care have sought to improve the quality of dying in the hospital. To the extent that such efforts have been successful, they may result in increasing demand for the hospital as the site for terminal care in the future.     

The Cleveland Clinic Foundation Harry R. Horvitz Palliative Care Center

In 1994, the Harry R. Horvitz Palliative Care Center opened as a dedicated inpatient palliative care unit within a comprehensive Palliative Care Program in the United States. The program is designated by the World Health Organization as a national and international demonstration project in the provision of palliative care. The mission of the program and the inpatient unit is to provide excellent care for patients with advanced cancer and their families throughout the illness and during bereavement. The need for the 23-bed inpatient unit was documented by the increasing number of cancer deaths each year and the complex physical and psychosocial problems patients and families experience throughout the course of their illness. Health care professionals specially trained in palliative care are an essential component of a dedicated program within a cancer center.     

Providing pediatric palliative care through a pediatric supportive care team

We expect children to live to adulthood; however, children do die. Some die from diseases they are born with, others from accidents or illnesses. The devastating effects associated with the death of a child can be lessened by providing palliative, hospice, and bereavement care. At St. John Hospital (SJH) in Detroit, MI, the services that provide care for children chartered the Pediatric Palliative Care Committee. The committee brought together staff from the inpatient pediatric unit, cancer center, home care, and hospice care services within the St. John Health System. Utilizing established staff and services, this group began to provide care for children with potentially life limiting illnesses in a coordinated, multidisciplinary team approach. The positive outcomes of this approach include an overall increase in patient and family satisfaction with care, a decrease in the number of emergency room visits and inpatient hospital stays, and an increase in patient and family informed decision making and goal setting. Positive outcomes for the staff include support in caring for children with life limiting illnesses and an increase in satisfaction with the care they provide.