Interprofessional team building in the palliative home care setting: Use of a conceptual framework to inform a pilot evaluation

Home-based palliative care is increasingly dependent on interprofessional teams to deliver collaborative care that more adequately meets the needs of clients and families. The purpose of this pilot evaluation was to qualitatively explore the views of an interprofessional group of home care providers (occupational therapists, nurses, personal support work supervisors, community care coordinators, and a team coordinator) regarding a pilot project encouraging teamwork in interprofessional palliative home care services. We used qualitative methods, informed by an interprofessional conceptual framework, to analyse participants’ accounts and provide recommendations regarding strategies for interprofessional team building in palliative home health care. Findings suggest that encouraging practitioners to share past experiences and foster common goals for palliative care are important elements of team building in interprofessional palliative care. Also, establishing a team leader who emphasises sharing power among team members and addressing the need for mutual emotional support may help to maximise interprofessional teamwork in palliative home care. These findings may be used to develop and test more comprehensive efforts to promote stronger interprofessional teamwork in palliative home health care delivery.     

Changes in medical and nursing care in cancer patients transferred from a palliative care team to a palliative care unit

The primary aim of this study was to explore the changes in medical/nursing care in patients who transferred from a palliative care team (PCT) to a palliative care unit (PCU) in the same hospital, and to explore the reasons why new or modified interventions were required. This was a retrospective study of 50 consecutive patients who were transferred from PCT to PCU in a 750-bed general hospital. A trained nurse performed a chart review and recorded the changes in 1) medical/nursing care, 2) help with decision-making within 48 hours after PCU admission, and 3) documentation of family and psycho-existential care. Group discussions among PCT and PCU staff members explored the potential reasons for the changes. Five patients were excluded due to admission periods of shorter than 48 hours. The number of new/modified medical and nursing care interventions after PCU admission averaged 1.9 ± 1.5 and 1.5 ± 1.3 per patient, respectively. The most common medical treatments were: reduction in hydration volume, dose titration of opioids, change in opioid administration device, opioid rotation, and addition of NSAIDs and steroids. The most common nursing interventions were: allowing patient to take a bath, changing mattress, use of massage, and discontinuation of bronchial suctioning. In addition, PCU staff newly coordinated opportunities to discuss preferred end-of-life care with primary caregivers in 38% of the cases, family members other than primary caregivers in 16%, and patients in 6.7%. The chart documentation of family care and psycho-existential care increased considerably after PCU admission. The chief reasons for these changes were: under-recognition of the problems and unavailability of treatments (pharmacological treatments), no intention to intervene and recommendations not followed by primary physicians (rehydration therapy), no intention to intervene (nursing care), and no intention to intervene and under-recognition of the problems (help with decision-making). These data demonstrate that many patients under PCT consultation receive new or modified interventions after PCU admission. Potentially useful strategies to strengthen the PCT interventions are: modification of intervention structure to minimize under-recognition of symptoms and decision making problems (e.g., use of standardized assessment tools, regular conferences), changes in the health care system to allow unlicensed drugs, clinical studies to clarify the benefits of artificial hydration therapy, and greater efforts to intervene in the areas of nursing care, help with decision making, family care, and psycho-existential care.     

护士姑息护理态度及其影响因素的质性研究

目的 了解护士照顾中晚期患者的态度及其影响因素.方法 采用质性研究中现象学分析法对8例个案进行深度访谈.结果 护士照顾中晚期患者态度的影响因素主要有4个方面:护士的各种不良情绪;不完善的医疗制度;专业机构和专业标准的缺乏;护士的工作特点.结论 今后应加强护士应对不良情绪的培训、死亡教育及同理心的培育;尽力争取社会支持,改善医疗保险制度;制定与姑息护理相配套的规范和标准;多形式、多渠道建立姑息护理机构;减轻护士工作负担,逐步提高护士的福利待遇.     

护士姑息护理态度及其影响因素的质性研究

目的了解护士照顾中晚期患者的态度及其影响因素。方法采用质性研究中现象学分析法对8例个案进行深度访谈。结果护士照顾中晚期患者态度的影响因素主要有4个方面：护士的各种不良情绪;不完善的医疗制度;专业机构和专业标准的缺乏;护士的工作特点。结论今后应加强护士应对不良情绪的培训、死亡教育及同理心的培育;尽力争取社会支持,改善医疗保险制度;制定与姑息护理相配套的规范和标准;多形式、多渠道建立姑息护理机构;减轻护士工作负担,逐步提高护士的福利待遇。     

Evidence on home palliative care: Charting past,present, and future at the Cicely Saunders Institute – WHO Collaborating Centre for Palliative Care,Policy and Rehabilitation

Abstract

The need for home palliative care is increasing globally as the overall number of deaths rise and home remains where most people prefer to die and where most spend their last months of life. Research must accompany this growing demand and inform service developments. We highlight key findings by our team at the Cicely Saunders Institute that have informed policy in the UK, Europe, and beyond, influencing clinical practice and training. We also share the lessons learnt in the process of conducting research on aspects related to home palliative care over the last 15 years. We conclude by presenting priorities for future research, expressing our commitment as the WHO Collaborating Centre for Palliative Care, Policy and Rehabilitation to continue helping the development of quality, accessible, and cost-effective home palliative care for the generations to come.     

Effects of the hospital-based palliative care team on the care for cancer patients: An evaluation study

Background

The hospital-based palliative care team model has been implemented in most Western countries, but this model is new in Taiwan and there is little research to evaluate its outcomes.

Objectives

The purpose of this study was to evaluate the effects of the hospital-based palliative care team on the care for cancer patients.

Design

The design was a quasi-experimental study with a pretest–posttest design.

Setting

A medical center, National Taiwan University Hospital in Taipei, Taiwan.

Participants

Cancer patients were excluded after the hospital-based palliative care team visited if they were unable to give informed consent, were not well enough to finish the baseline assessment, were likely to die within 24 h or would be discharged within 24 h, or could not communicate in Mandarin or Taiwanese. A sample of 60 patients who consulted the hospital-based palliative care team was recruited.

Methods

Patients recruited to the study were divided to receive the usual care only (control group, n = 30) or the usual care plus visits from the hospital-based palliative care team (intervention group, n = 30). Data were collected using questionnaires including the Symptom Distress Scale, Hospital Anxiety and Depression Scale, Spiritual Well-Being Scale, and Social Support Scale at the initial assessment and one week later.

Results

Comparison between groups revealed that the degree change for edema, fatigue, dry mouth, abdominal distention, and spiritual well-being in the intervention group showed significant improvement compared to the control group (p < 0.05). However, there was no difference between groups on measures of anxiety, depression and feeling of social support. Within group analysis showed patients’ pain score, dyspnea, and dysphagia improved in both groups (p < 0.05). In addition, the average degree of constipation and insomnia in the control group declined from baseline (p < 0.05), while the degree of edema, fatigue, dry mouth, appetite loss, abdominal distention, and dizziness decreased significantly in the intervention group (p < 0.05).

Conclusion

The findings indicated the hospital-based palliative care team can improve the care for patients in relation to symptom management and spiritual well-being. The hospital-based palliative care team is a good care model for patients and worth implementing in clinical practice in Taiwan. The results also provide a general understanding about how the hospital-based palliative care team works in Taiwanese culture.     

Barriers to referral to inpatient palliative care units in Japan: a qualitative survey with content analysis

Objectives We investigated the barriers to referral to inpatient palliative care units (PCUs) through a qualitative study across various sources of information, including terminal cancer patients, their families, physicians, and nurses. Materials and methods There were 63 participants, including 13 advanced cancer patients, 10 family members, 20 physicians, and 20 nurses in palliative care and acute care cancer settings from five regional cancer institutes in Japan. Semi-structured interviews were conducted regarding barriers to referral to PCU, and data were analyzed by content analysis method. Results A total of 21 barriers were identified by content analysis. The leading barriers were (1) a negative image of PCUs by patients and families (n = 39), (2) delay of termination of anti-cancer treatment by physicians in the general wards (n = 24), (3) unwillingness to end anti-cancer treatment and denial of the fatal nature of the disease by patients and families (n = 22), (4) patient’s wish to receive care from familiar physicians and nurses (n = 20), and (5) insufficient knowledge of PCUs by medical staff in general wards (n = 17). Conclusions To correct these unfavorable images and misconceptions of PCUs, it is important to eliminate the negative image of PCUs from the general population, patients, families, and medical staffs. In addition, early introduction of palliative care options to patients and communication skills training regarding breaking bad news are relevant issues for a smooth transition from anti-cancer treatment to palliative care.     

Characteristics of community palliative care patients requiring acute admission to hospital

Background: A substantial proportion of palliative care patients cared for in the community require acute hospital admission during their terminal illness. A greater understanding of the multifactorial reasons leading to acute admission to hospital may enable some potential hospital admissions to be avoided through provision of appropriate community palliative care support.

Aim: To identify the characteristics of community specialist palliative care team (CSPCT) patients requiring acute admission to hospital.

Methods: A retrospective audit of all patients known to the CSPCT who required acute admission to hospital over a five-month period between January and June 2016.

Results: A total of 97 hospital admissions occurred, involving 88 patients. The majority of patients had a malignant diagnosis (80%) with 31% still undergoing anti-neoplastic therapy. Of these admissions, 58% were to acute hospital facilities and 42% were to hospital-based palliative care units. The leading reasons for hospitalization were pain (27%), patient/relative distress (24%) and dyspnoea (16%).

Conclusion: This study described the characteristics of CSPCT patients who required acute admission to hospital. Further research is needed to understand the reasons patients seek acute hospital admission and to explore if interventions in the community can decrease the rate of acute hospital admissions.     

The problems experienced by patients with cancer and their needs for palliative care

Objectives To investigate the problems that patients experience and their met- and unmet needs for professional help. This information is necessary to tailor palliative care to patient needs.Patients and methods Patients (n=94) with disseminated cancer completed a validated checklist with 90 potential problems and needs for palliative care (PNPC questionnaire).Main results On average, patients experienced 37 problems (range 0–68) and required more professional attention for eight problems (range 0–71). The five most prevalent problems were: fatigue, heavy housework, coping with the unpredictability of the future, fear of metastases, and frustrations because I can do less than before. The five issues most in need of extra attention were: informational needs, coping with the unpredictability of the future, fear of metastases, fear of physical suffering, and difficulties remembering what was told (during consultations). Younger patients experienced more social, psychological, and financial problems. Some 10% of patients expressed a multitude of problems and needs.Conclusions While patients with metastasized cancer experienced a wide variety of problems, they asked for more support for only a few specific problems. Evidently, problems are not synonymous with unmet needs. Therefore, not only problems but also needs for care should be assessed. A structural need for support to cope with fears of suffering and loss of autonomy was found. Ten percent of patients expressed a multitude of problems and needs and might benefit either from psychological counseling or better palliative care.     

Cognitive assessment of palliative care patients

Cognitive impairment is prevalent among cancer patients receiving palliative care. It affects both clinical management and research with these patients. Cognitive impairments can often be reversed by appropriate therapeutic intervention, but many cases of cognitive impairment among palliative care patients will remain undetected by clinical staff unless formal assessment is conducted. Selection of an appropriate method of assessment should be guided by the goal for which assessment is undertaken, the ways in which the special characteristics of palliative care patients constrain the gathering of information, the type of information and the scale of measurement required, the validity, reliability and standardisation of the tests available, and the significance attached to test outcomes.

A wide variety of methods for assessing cognitive competence is available. They differ in the type of information provided, the scale of measurement, and the breadth of the skills assessed. Each is most suitable for particular purposes. The variety ensures that cognitive performance can be assessed in palliative care patients despite constraints imposed by budgets, limited relevant staff expertise, and patient characteristics.     

Association between symptom distress and survival in outpatients seen in a palliative care cancer center

Clinical observation and preliminary reports suggest that higher scores for symptoms such as pain may be associated with shorter survival. We undertook a survival analysis to determine whether symptom expression in outpatients with complex cancer is related to the duration of their survival. Participants were 225 outpatients with cancer evaluated in our comprehensive cancer center for pain management or palliative care over a 10-week period ending June 2000. In addition to age and other clinical and demographic information, the patients completed the Anderson Symptom Assessment System (ASAS), which assesses pain, fatigue, nausea, depression, anxiety, drowsiness, shortness of breath (dyspnea), appetite, sleep, and feeling of well-being on a 0–10 scale. Univariate analyses showed that higher symptoms of dyspnea, drowsiness, problems with appetite, and nausea were significantly associated with shorter survival whereas pain, depression and other ASAS items were not. In multivariate analyses, only higher levels of dyspnea and drowsiness showed a significant association (P = 0.01 and P = 0.02, respectively) with shorter survival. Knowledge about these symptoms may be important in formulating adaptive randomization techniques for clinical trials and for research concerning estimates of survival.     

The impact of the palliative care mobile team on symptom assessment and medication profiles in patients admitted to a comprehensive cancer center

Goals of work In recent years, tertiary care hospitals and cancer centers have shown great interest in forming palliative care consultation teams. Thus, these centers may be interested in the types of care that such teams give, which could help the other centers put together their own teams. However, the availability of such information is limited. The purpose of our study was therefore to describe the experience of a palliative care team at our comprehensive cancer center. Materials and methods We reviewed the medical records of 100 consecutive patients who were referred to our palliative care mobile team between November 2004 and January 2005; we then analyzed the primary interventions of this team. Results The median patient age was 61 years; 57 patients were female. The most frequent symptoms were fatigue in 78% and pain in 62% of patients. The main interventions by the palliative team were changes in medication types (opioids, antiemetics, neuroleptics, and laxatives) and in medication doses. Conclusions Palliative care mobile teams make multiple changes in previous medications and provide almost universal counseling services to patients and families. The length of involvement with the patient and family is short; therefore, rapid stabilization and counseling are required. Our findings regarding medication changes could be helpful to tertiary care hospitals and cancer centers considering palliative care consultation teams.     

Capturing activity,costs, and outcomes: The challenges to be overcome for successful economic evaluation in palliative care

Abstract

Palliative care, as with other health care services, is faced with the difficulty of competing for limited health care resources. Health care decision makers seek to maximize ‘value for money’ when selecting services to fund. The challenges for the palliative care community are to (a) demonstrate the cost effectiveness of its interventions in comparison to other health services and (b) provide evidence that the resources currently allocated are being used efficiently. Health economic evaluation can be conducted to support this. In this paper different economic approaches to evaluating health care services are introduced. Providing examples from (home based) palliative care we consider the opportunities to progress this work. We also describe the related challenges of capturing activity, costs, and outcomes. Although the very nature of this area of care presents unique methodological challenges that will need to be overcome, appropriate analyses will allow comparisons across the wider health sector and strengthen the argument for palliative care services.     

ICU病人亲属家庭需要的调查研究

应用Molter“急危重病人家庭需要量表”对 5 0例ICU病人亲属进行调查 ,以了解当病人在ICU接受监护时 ,其亲属对病人家庭需要的认识。结果显示ICU病人亲属认为能够保证病人的安全 ,了解病人的治疗与预后 ,了解病人护理的需要最重要 ,而与病人亲属身心相关的需求重要性得分则较低。某些需要在男女病人亲属之间存在显著性差异 ,部分需要与病人亲属的年龄、教育水平和家庭收入分别有显著相关。提示ICU护士必须正确认识病人家庭需要 ,并根据病人亲属的性别、年龄、教育水平和家庭收入等因素满足病人家庭需要 ,以帮助病人家庭应对病人病重时的危机状态 ,维持病人及亲属的身心健康     

Specialized palliative care services are associated with improved short- and long-term caregiver outcomes

GOALS OF WORK: The goal of this study was to evaluate, at a population level, the association between specialized palliative care services (SPCS) and short- and long-term caregiver outcomes. PATIENTS AND METHODS: The Health Omnibus Survey, a face-to-face survey conducted annually in South Australia since 1991, collects health-related data from a rigorously derived, representative sample of 4,400 households. This study included piloted questions in the 2001, 2002, and 2003 Health Omnibus Survey on the impact of SPCS. Sample size was 9,088 individuals. "Unmet needs," a short-term outcome relevant to the caregiving period during a life-limiting illness, were tallied. "Moving on," a long-term caregiver-defined outcome reflecting the caregiver's adaptation and return to a new equilibrium after the death, was assessed with and without SPCS. RESULTS: Thirty-seven percent (3,341) indicated that someone close to them had died of a terminal illness in the preceding 5 years, of whom 949 (29%) reported that they provided care. SPCS were involved in caring for 60% of deceased patients. Day-to-day caregivers indicated fewer unmet needs when SPCS were involved (p = 0.0028). More caregivers were able to "move on" with their lives when SPCS were involved than when SPCS were not involved (86 vs 77%, p = 0.0016); this effect was greatest in the first 2 years after the loved one's death. CONCLUSION: At a population level, SPCS were associated with meaningful improvements in short-term ("unmet needs") and long-term ("moving on") caregiver-defined outcomes.     

Nutritional support and risk status among cancer patients in palliative home care services

Goal of work  The aim of this study was to investigate the nutritional risk status and use of nutritional support among cancer patients enrolled in palliative home care services. Differences in the use of nutritional support in relation to nutritional, social and clinical factors, as well as survival were also investigated. Patients and methods  Structured telephone interviews were conducted with cancer patients enrolled in all 21 palliative home care services in the Stockholm region. An interview guide was designed to investigate topics related to the patient’s nutritional situation. Main results  Interviews with 621 patients were analysed. Sixty-eight percent of the patients were scored as at nutritional risk according on a modified version of NRS-2002. Nutritional support was used by 55% of the patients, with oral nutritional supplements most common and 14% using artificial nutrition. Use of nutritional support was related to low BMI and severe weight loss and was more common in patients with shorter survival times. Conclusions  These findings demonstrate that nutritional support is used to treat already malnourished patients with shorter survival time, rather than to prevent malnutrition. A more structured approach to nutritional issues for patients in palliative phases, which considers life expectancy and psycho-social aspects of nutritional issues, could help identify potential candidates for nutritional support.     

Embedding of the spiritual dimension in palliative consultation services in the Netherlands: inventory,evaluation, and recommendations

Abstract

Caregivers in the Netherlands can ask for advisory support from Palliative Consultation Teams (PCTs). It is largely unclear, though, how consultants of these teams deal with spiritual questions. This article explores in what way the spiritual dimension of palliative care is embedded in the PCTs. The coordinators of the teams were asked to fill out a questionnaire concerning the team mission statement with regard to spiritual care, their expertise in the spiritual domain, and their plans for developing this expertise. The answers to yes-or-no questions were statistically analysed by frequency counts, the answers to the open questions were analysed by peer debriefing. This study shows that the spiritual dimension is only embedded to a limited extent in the PCTs. Most respondents are of the opinion that their team lacks expertise in spiritual care, the majority of the consultants do not receive regular training in dealing with the spiritual dimension, and many plans for education and training are in a preliminary stage. These limitations, however, go together with a clear desire for education and training in dealing with the spiritual dimension. Although most teams do not clearly distinguish between psychological, social and spiritual competences, the healthcare chaplain is most often mentioned as the expert in the field of spiritual care. On the basis of the results of this study and in keeping with the quality standards for palliative care consultants, recommendations are made for the further professionalization of PCTs regarding the spiritual dimension of palliative care.     

Relationship of nurses' assessment of organizational culture, job satisfaction, and patient satisfaction with nursing care.

This exploratory study investigated the relationship among staff nurses' assessment of organizational culture, job satisfaction, inpatient satisfaction with information about home care and follow-up, and general inpatient satisfaction with nursing care. A conceptual path model was tested using a secondary data analysis research design. Staff nurses and inpatients were sampled from inpatient units. The unit of analysis was patient care units. Pearson correlation and regression analyses were used. We found that strength of organizational culture predicted job satisfaction well and positively; job satisfaction predicted inpatient satisfaction significantly and positively; and inpatient satisfaction predicted general inpatient satisfaction well and positively. Methodological challenges of this study are discussed.