Specialist Palliative Care within the Acute Hospital Setting

The hospital-based specialist palliative care service is the latest extension of the hospice movement in the UK, bringing the message of specialist palliative care back into the hospital setting. There are now over 200 palliative care services within the acute setting, including 76 specialist palliative care teams. The composition, advantages and disadvantages of such teams are described, and the challenge and importance of evaluating these services are discussed.     

A PALLIATIVE CARE EDUCATION MODEL FOR THE HOSPITAL SETTING

This paper describes an integrated, needs-led palliative care education model for qualified nurses, developed by collaboration between a hospital-based palliative care team of a large NHS Trust and a specialist palliative care unit, in order to serve its common healthcare users. The aim of this model was to develop the knowledge and skills gained through clinical practice and ongoing education in order to achieve a basic level of expertise, and to enhance communication and collaboration between the hospital and community-based nursing services throughout the geographical area for patients requiring palliative care.     

Palliative care needs in a District General Hospital: a survey of patients with cancer

Although sophisticated treatment of cancer requires the resources of specialist cancer treatment centres, most patients with cancer still undergo initial diagnostic investigation and treatment in district general hospitals (DGHs). The DGH frequently remains the principle site of referral for management of symptoms and terminal care. This survey was carried out at a DGH which has no palliative care services. It aimed to demonstrate the need for such services by collecting data on inpatients with cancer and interviewing members of the nursing staff. Of 63 patients studied, 76% were admitted as emergencies, 50% had newly diagnosed cancer and 27% died in hospital. The majority (85%) were cared for on general medical, surgical and care of the elderly wards. Assessment of patients' symptoms suggested thet 39 (62%) might have benefited from the services of a palliative care team. Interviews with nursing staff highlighted the need for improved communication between professionals, increased staff education and support, and highlighted the particular difficulties that exist in caring for patients with advanced cancer and their families on busy acute general hospital wards. Imaginative and flexible approaches to the design and delivery of palliative services are essential if patients with cancer in DGHs are to receive the highest standards of care at all stages of their illness.     

Role of the geriatrician,primary care practitioner,nurses, and collaboration with oncologists during cancer treatment delivery for older adults: A narrative review of the literature

Cancer is a disease that mostly affects older adults. With the aging of the population there will be a considerable increase in the number of older adults with cancer. Optimal care of the older adult with cancer requires the involvement of many types of health care providers, including oncologists, nurses, primary care practitioners, and geriatricians. In this narrative review, the literature for evidence relating to the roles of and collaboration between geriatricians, primary care practitioners, nurses, and the oncology team during cancer treatment delivery to older adults was examined. Relevant abstracts were reviewed by all team members. The full texts were reviewed to identify common themes related to roles and collaboration. The results showed that primary care practitioners felt underutilized and that the communication and collaboration between oncologists and primary care practitioners is challenging due to lack of clarity about roles and lack of timely communication/sharing of all relevant information. Furthermore, some of oncology staff, but not all, saw a need for greater collaboration between oncologists and geriatricians. The lack of availability of geriatricians limited the collaboration. Geriatric oncology nurses perceived themselves as having an important role in geriatric assessment and management, but there was no data on their collaboration with these medical specialists. There is a clear need for improvement of collaboration to improve patient outcomes. In conclusion, further research is needed to examine the impact of geriatric oncology team collaboration on the quality of cancer care, in particular, the role of nurses in supporting quality of care during treatment.     

Palliative care team at general hospital

Some three hundred thousand patients die from cancer in a year, most of whom end their lives at a general hospital. Considering this situation, the general hospital has to provide palliative care and make up interdisciplinary Palliative Care Team (PCT). Since April 2002, we established a PCT at Akita City Hospital. Our PCT educated doctors and nurses for palliative care medicine and established a system for palliative care. For example, the assessment sheet of cancer pain is useful for treatment of pain and to equally recognize the patient's condition by each team. The PCT provides support for doctors and nurses in the general unit. We general doctors must learn more about how to provide palliative care medicine for at least cancer pain as well as cancer treatment. A team approach is needed for all cancer patients.     

Working with a palliative care team

The interdisciplinary team is fundamental to the successful delivery of quality palliative care. Ideally, the oncologist is an integral part of either the palliative care or hospice team and serves to maintain continuity of care through the end of life. In the United States, barriers can complicate the oncologist's easy integration into the hospice team as patients often remain at home. Also, there may be philosophical or clinical practice differences between oncology and palliative care at first glance. This article focuses on ways to overcome these potential obstacles and use differences in training to strengthen the team's impact. A significant part of oncology practice includes managing difficult symptoms, mitigating suffering, and discussing priorities of care--all elements of palliative medicine that oncologists perform daily. Participating on a palliative care team may be natural for oncologists, and some might elect to provide integrated palliative cancer care for patients throughout the course of their disease and at the end of life. Thus, there is a need to enrich the general oncologist's knowledge of specialized palliative medicine, as recommended by the major cancer organizations, including the American Society of Clinical Oncology and the European Society of Medical Oncology.It is important to know when to incorporate a palliative or hospice care team into the routine management of a cancer patient and what benefits these referrals can provide. Oncologists have an obligation to provide high-quality palliative care to all patients in an integrated fashion, including patients with advanced cancer enrolled in clinical trials for early therapeutics.     

Bereavement referrals to a psychiatric service: an audit

The majority of people who are bereaved will work through their grief with support from family and friends. Over 30%, however, may require professional support, and studies have shown that most people contact their General Practitioner and primary health-care team for counselling/support. Effective support and counselling can also be given by voluntary agencies.
It was decided to audit the referrals made to a bereavement service for bereavement counselling to ascertain the level of support given prior to the referral and whether information had been given to the bereaved regarding the services available to them in the voluntary sector.
Twelve referrals were received in the allotted time period, 10 of which were made within the first year of bereavement. Only one referral had been offered counselling by the primary health-care team and one other had been informed of voluntary bereavement support/counselling agencies. Two referrals had abnormal grief reactions requiring psychiatric intervention.
Conclusions include raising the awareness of general practitioners and primary health-care teams of the normal grieving process, and increasing the provision of support for the bereaved. It is also suggested that the bereaved are made more aware of the services that voluntary agencies can provide.     

The development of hospice/palliative care in Russia: a nurse-education programme

This article describes some of the on-going hospice and palliative-care initiatives in Russia and, in particular, focuses on a pilot nursing education programme on palliative care, implemented in Moscow during the summer of 1991. The programme was designed to prepare a group of nurses from seven different towns in Russia, where future developments of hospice/palliative-care services are planned. Seven experienced hospice nurses implemented the programme, and the three leaders, experienced nurse teachers, will be taking the Moscow initiative forward.     

Referrals to a voluntary sector cancer day care centre: a descriptive study

In the UK, recent guidance on supportive and palliative care has acknowledged the contribution of voluntary organizations, including their role in palliative day care. Similarly, research has tended to focus exclusively on palliative day care as opposed to comparable care for people with cancer, regardless of prognosis. This paper describes a case record review study conducted at a nurse-led voluntary sector cancer day care centre. The study focused on referrals over a one-year period in terms of user demographics, referral sources/reasons and subsequent care given. It was found that 220 referrals (including 106 self-referrals) were made during the year. Of these, 70.9% were people with cancer and the remainder were carers/bereaved people. Those referred broadly reflected national statistics on age, gender and cancer diagnosis. Carers were rarely referred by professionals, few lived in inner-city neighbourhoods and some had no informal support. Non-specific referral reasons, such as 'support', tended to be translated into specific therapies, such as complementary therapies and counselling, at initial assessment. Care offered at the centre appeared to supplement and complement that provided by local statutory services. The study raised issues for practice and further research that may be relevant to those working in similar centres.     

What value is given to quality of life assessment by health professionals considering response to palliative chemotherapy for advanced cancer?

A study was designed to obtain information on the importance of quality of life assessment (QL) during palliative chemotherapy. A questionnaire was answered by 542 health professionals (392 general practitioners, 20 specialist oncologists, and 130 oncology nurses). In both simulated patient situations and multiple-choice questions, all groups rated QL higher than other standard methods of assessment. General practitioners and oncologists appeared to weight the assessment criteria more equally than nurses who gave strong emphasis to QL. In the simulated patient situation, there was a small degree of interaction between QL and other assessment criteria. However, the analysis showed that QL was regarded as an independent variable and was considered to be the most important objective of palliative chemotherapy for advanced cancer.     

Changing perspectives on palliative care

In the United States, hospice and palliative care are two distinct expressions of the hospice interdisciplinary team approach to end-of-life care, which originated in Great Britain in the 1960s. The hospice movement developed largely as a home-care program and alternative to conventional care. Hospice regulations and reimbursement allowances limit services to patients who are expected to die within 6 months and who forego many common oncologic treatments. On the other hand, palliative care is a more recent academic, medically mainstream discipline that attempts to integrate the hospice approach into oncology and other areas of clinical medicine from the earliest phases of diagnosis and treatment. Palliative care entertains all appropriate forms of care at any phase of an illness. In this review, we describe the key goals of palliative care, which include excellent pain and symptom control, psychosocial and spiritual support for the patient and family, informed decision-making, and coordinated services across the continuum of care. We focus on selected recent developments that are important to oncology practice: the role of artificial nutrition; management of malignant small bowel obstruction; communication tasks, such as information sharing, recognition of patient preferences, advanced-care planning, and bereavement care; and ethical principles related to the hastening of death.     

Completing the continuum of cancer care: integrating life-prolongation and palliation

Cancer care extends from diagnosis through the late stages of advanced illness as patients confront dying and their families cope with caregiving and grief. Palliative care is a rapidly developing area of clinical focus that offers valuable services to patients in terms of symptom management and adjustment to illness, including issues of life completion and life closure. It is often appropriate to offer certain elements of palliative care early in the course of illness. As disease progresses, physical comfort and enhancing quality of life increasingly become primary goals of cancer care. Specialized palliative care programs, epitomized by hospice, are invaluable resources for patients with far-advanced illness and their families. Current regulations and prevailing payment structures limit access to and the scope of hospice services and highlight the need for innovative models of delivering and financing palliative care.     

Improving cancer patients' pain: the impact of the hospital specialist palliative care team

Pain is reported to occur in the majority of patients with advanced cancer and is one of the main reasons for referral to a hospital specialist palliative care team. Yet despite this, there is a paucity of research into the impact the hospital specialist palliative care team has on pain control in patients. A non-equivalent control group design using a quota sample investigated 100 cancer patients who had been admitted to hospital for symptom control. Fifty patients received specialist hospital palliative care team intervention compared with 50 patients receiving traditional care. Outcome was assessed using the Palliative Care Assessment (PACA) tool on three occasions. There was no difference between the groups on the initial assessment and the results indicated that all cancer patients admitted to hospital had a significant improvement in their pain control. However, the patients who had the additional input of the palliative care team demonstrated a statistically significant greater improvement than the control group (P<0.001). Potential explanations are made for the results including the enhanced knowledge and skills of the hospital specialist palliative care team.     

Providing cancer services to remote and rural areas: consensus study

There is controversy about how cancer care should be provided to patients in remote and rural areas. The aim of this project was to measure consensus among health professionals who treat rural patients with cancer about priorities for cancer care. A modified Delphi process was used. Of 78 health professionals in Grampian, 62 responded (79%). Of 49 items suggested, there was agreement on 26 (53%), encompassing fast access to diagnosis, high-quality specialist treatment, and well-coordinated delivery of care with good and fast communication and effective team working between all health professionals involved. Specialist oncology nurses in local hospitals were considered a priority along with good facilities, accommodation, and transport for patients. There was no agreement on the best location for chemotherapy (local or central). The only large difference of opinion between participants based in primary and secondary care concerned chemotherapy provision at local community hospitals (primary care was in favour, hospital practitioners against, P&<0.001). In making their decisions, participants took problems of access into account, but were also concerned with quality of care and feasibility in the current health service. Our findings show that more evidence is needed regarding the balance of risks and benefits of local chemotherapy provision. Overall, however, there is agreement on many principles for cancer care that could be translated into practice.     

Education in palliative care: a qualitative evaluation of the present state and the needs of general practitioners and community nurses

A questionnaire survey was carried out of all general practitioners, community hospital nurses and community nurses working in Worcester Health District in the west of England, to assess the present state and future needs of their education in palliative care.
The overall response rate of the survey was 72%. The respondents were an experienced group of doctors and nurses. They felt that their undergraduate or basic training did not prepare them to care for dying patients in the community.
Educational needs were identified: control of symptoms other than pain and bereavement care were priorities for doctors. Community hospital nurses rated pain control education as a major need. Alternative medicine and caring for dying children were additional areas for further education for the general practitioner and community nurses.
Ninety per cent of general practitioners, 84% of community hospital nurses and 95% of community nurses felt that multi-disciplinary teaching sessions would be helpful. Analysis of their responses revealed that these would be most likely to succeed it they were arranged in the middle of the day during lunch or in the evenings.
The doctors felt that they lacked protected learning time. Nurses also felt this, but in addition, identified lack of finance as a limiting factor in their post-basic education. There was evidence that existing educational resources in the district are under-utilized.     

Recommendations for Palliative and Hospice Care in NCCN Guidelines for Treatment of Cancer

BackgroundIntegration of specialist palliative care into routine oncologic care improves patients’ quality of life and survival. National Comprehensive Cancer Network (NCCN) cancer treatment guidelines are instrumental in standardizing cancer care, yet it is unclear how palliative and hospice care are integrated in these guidelines. In this study, we examined the frequency of occurrence of “palliative care” and “hospice care” in NCCN guidelines and compared between solid tumor and hematologic malignancy guidelines.Materials and MethodsWe reviewed all 53 updated NCCN Guidelines for Treatment of Cancer. We documented the frequency of occurrence of “palliative care” and “hospice care,” the definitions for these terms if available, and the recommended timing for these services.ResultsWe identified a total of 37 solid tumor and 16 hematologic malignancy guidelines. Palliative care was mentioned in 30 (57%) guidelines (24 solid tumor, 6 hematologic). Palliative care was mentioned more frequently in solid tumor than hematologic guidelines (median, 2 vs. 0; p = .04). Among the guidelines that included palliative care in the treatment recommendation, 25 (83%) only referred to NCCN palliative care guideline. Specialist palliative care referral was specifically mentioned in 5 of 30 (17%) guidelines. Only 14 of 24 (58%) solid tumor guidelines and 2 of 6 (33%) hematologic guidelines recommended palliative care in the front line setting for advanced malignancy. Few guidelines (n = 3/53, 6%) mentioned hospice care.Conclusion“Palliative care” was absent in almost half of NCCN cancer treatment guidelines and was rarely discussed in guidelines for hematologic malignancies. Our findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.Implications for PracticeIntegration of specialist palliative care into routine oncologic care is associated with improved patient outcomes. National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines in Oncology have an important role to standardize palliative care involvement for cancer patients. It is unclear how often palliative care referral is recommended in these guidelines. In this study involving 53 NCCN Guidelines for Treatment of Cancer, the researchers found that palliative care was not mentioned in over 40% of NCCN guidelines and was rarely discussed in guidelines for hematologic malignancies. These findings underscored opportunities to standardize timely palliative care access across NCCN guidelines.     

American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care

PURPOSE: An American Society of Clinical Oncology (ASCO) provisional clinical opinion (PCO) offers timely clinical direction to ASCO's membership following publication or presentation of potentially practice-changing data from major studies. This PCO addresses the integration of palliative care services into standard oncology practice at the time a person is diagnosed with metastatic or advanced cancer. CLINICAL CONTEXT: Palliative care is frequently misconstrued as synonymous with end-of-life care. Palliative care is focused on the relief of suffering, in all of its dimensions, throughout the course of a patient's illness. Although the use of hospice and other palliative care services at the end of life has increased, many patients are enrolled in hospice less than 3 weeks before their death, which limits the benefit they may gain from these services. By potentially improving quality of life (QOL), cost of care, and even survival in patients with metastatic cancer, palliative care has increasing relevance for the care of patients with cancer. Until recently, data from randomized controlled trials (RCTs) demonstrating the benefits of palliative care in patients with metastatic cancer who are also receiving standard oncology care have not been available. RECENT DATA: Seven published RCTs form the basis of this PCO. PROVISIONAL CLINICAL OPINION: Based on strong evidence from a phase III RCT, patients with metastatic non-small-cell lung cancer should be offered concurrent palliative care and standard oncologic care at initial diagnosis. While a survival benefit from early involvement of palliative care has not yet been demonstrated in other oncology settings, substantial evidence demonstrates that palliative care-when combined with standard cancer care or as the main focus of care-leads to better patient and caregiver outcomes. These include improvement in symptoms, QOL, and patient satisfaction, with reduced caregiver burden. Earlier involvement of palliative care also leads to more appropriate referral to and use of hospice, and reduced use of futile intensive care. While evidence clarifying optimal delivery of palliative care to improve patient outcomes is evolving, no trials to date have demonstrated harm to patients and caregivers, or excessive costs, from early involvement of palliative care. Therefore, it is the Panel's expert consensus that combined standard oncology care and palliative care should be considered early in the course of illness for any patient with metastatic cancer and/or high symptom burden. Strategies to optimize concurrent palliative care and standard oncology care, with evaluation of its impact on important patient and caregiver outcomes (eg, QOL, survival, health care services utilization, and costs) and on society, should be an area of intense research. NOTE: ASCO's provisional clinical opinions (PCOs) reflect expert consensus based on clinical evidence and literature available at the time they are written and are intended to assist physicians in clinical decision making and identify questions and settings for further research. Because of the rapid flow of scientific information in oncology, new evidence may have emerged since the time a PCO was submitted for publication. PCOs are not continually updated and may not reflect the most recent evidence. PCOs cannot account for individual variation among patients and cannot be considered inclusive of all proper methods of care or exclusive of other treatments. It is the responsibility of the treating physician or other health care provider, relying on independent experience and knowledge of the patient, to determine the best course of treatment for the patient. Accordingly, adherence to any PCO is voluntary, with the ultimate determination regarding its application to be made by the physician in light of each patient's individual circumstances. ASCO PCOs describe the use of procedures and therapies in clinical trials and cannot be assumed to apply to the use of these interventions in the context of clinical practice. ASCO assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of ASCO's PCOs, or for any errors or omissions.     

Identifying the palliative care needs of patients living with cerebral tumors and metastases: a retrospective analysis

Primary tumors and metastatic involvement of the central nervous system (CNS) lead to a multitude of symptoms and care needs. Patients and caregivers struggle with physical and psychological impairments, a shortened life expectancy and diverse palliative care needs. This study assesses the symptom burden and palliative care needs of patients with primary brain tumors and with metastatic brain tumors requiring inpatient hospital care. It is a retrospective analysis of patients with primary CNS tumors or cerebral metastases over a 6 month period. The data analysed included physical symptom burden and end of life care decisions such as health care proxy, transition to hospice and do-not-resuscitate orders. Hundred and sixty eight patients were included. The most common symptoms were gait impairment (65.5 %), cognitive/personality change (61.9 %), motor deficits (58.3 %), seizures (57.1 %) and delirium (27.4 %). Of the patients that died, 79 % had an appointed health care proxy, 79 % had hospice discussions, 70 % had a do-not-resuscitate order and 24 % received cancer directed therapy in the last month of life. There is a role for more aggressive palliative care support in patients living with primary or metastatic brain tumors.     

Early Palliative Care for Patients with Hematologic Malignancies: Is It Really so Difficult to Achieve?

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.     

A curriculum in palliative care for internal medicine housestaff: a pilot project

Despite dramatic growth in the number of hospice programs over the past 15 years, palliative care skills and principles receive minimal attention in medical schools and residency training programs. Northwestern University Medical School and Northwestern Memorial Hospital have developed a program in palliative care education for internal medicine housestaff. Residents, working with a multidisciplinary team of hospice staff, have primary responsibility for the care of terminally ill patients in the home. An inpatient unit is available for acute care when needed. A formal lecture series on symptom management, accompanied by a bibliography and defined learning objectives, provides a guide to the clinical experience. Participating residents also attend seminars focusing on physicians' coping skills and attitudes toward death and dying. Evaluation of the program in its first year shows a definite perception of educational benefit by residents, and enthusiasm for continued involvement in palliative care.