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.     

Sheltered housing compared to independent housing in the community

Background:  With elderly people desiring to live independently as long as possible, traditional homes for the elderly are increasingly being transformed into sheltered accommodations. In order to assess the importance of housing for frail elderly people, elderly people at risk for institutionalization were studied in two living conditions: sheltered accommodation and living independently in the community.
Methods:  A total of 317 elderly people at risk for institutionalization [91 men and 240 women, mean age = 83.3 (SD = 6.0)] were interviewed using a structured questionnaire with questions regarding home care and social service use, quality of life, subjective well-being, life satisfaction, autonomy, functional status, feelings of insecurity and loneliness.
Results:  Exactly 56.5% of the respondents were living in sheltered accommodation (n = 179) and 43.5% (n = 138) were living in regular houses. Although both groups were similar in demographic details and functional status, those in sheltered accommodation had a higher perceived autonomy, sense of security and quality of life. No differences were found with regard to subjective well-being or feelings of loneliness. Elderly people in regular houses needed more hours of housekeeping assistance. Those in sheltered accommodation participated more frequently in services like social activities and social restaurants, but made less use of day care facilities.
Conclusions:  Affordable, decent and suitable noninstitutional housing with service provision play a vital role in the lives of elderly people. Compared with independent living in the community, sheltered accommodations provide added value. Sheltered housing should therefore be an integral part of long-term care policy.     

The challenges in adopting care pathways for the dying for use in care homes

An increasing number of older people are requiring palliative care within the care home setting. There are currently a number of initiatives that are generally gaining approval and being implemented within health care in general with the goal of improving standards of palliative care. These are the Integrated Care Pathway for the dying person, the Gold Standards Framework and the Preferred Place of Care document. The Liverpool Care Pathway is being used across a wide range of care settings to improve care in the last 24–48 hours of life and is being implemented in care homes as part of a national rollout programme. This article aims to explore some of the issues associated with the use of the care pathways in care homes, particularly without the input of additional resources and support for the care homes. It also questions the appropriateness of the pathway in its current format without further work on the specific palliative care needs of the residents dying in care homes.     

Is integrated nursing home care cheaper than traditional care? A cost comparison

Background

It is generally assumed that integrated care has a cost-saving potential in comparison with traditional care. However, there is little evidence on this potential with respect to integrated nursing home care.

Aims and objectives

• • 

  To portray the costs of traditional and integrated nursing home care.

• • 

  To explore the cost-saving potential of integrated care.

Design/methods/settings/participants

Between 1999 and 2003, formal and informal caregivers of different nursing homes in the Netherlands recorded activities performed for residents with somatic or psycho-social problems. In total, 23,380 lists were analysed to determine the average costs of formal and informal care per activity, per type of resident and per nursing home care type. For formal care activities, the total personnel costs per minute (in Euro) were calculated. For informal care costs, two shadow prices were used.

Results

Compared to traditional care, integrated care had lower informal direct care costs per resident and per activity and lower average costs per direct activity (for a set of activities performed by formal caregivers). The total average costs per resident per day and the costs of formal direct care per resident, however, were higher as were the costs of delivering a set of indirect activities to residents with somatic problems.

Conclusions

The general assumption that integrated care has a cost-saving potential (per resident or per individual activity) was only partially supported by our research. Our study also raised issues which should be investigated in future research on integrated nursing home care.     

Pediatric palliative care

Progress in pediatric palliative care has gained momentum, but there remain significant barriers to the appropriate provision of palliative care to ill and dying children, including the lack of properly trained health care professionals, resources to finance such care, and scientific research, as well as a continued cultural denial of death in children. This article reviews the epidemiology of pediatric palliative care, special communication concerns, decision making, ethical and legal considerations, symptom assessment and management, psychosocial issues, provision of care across settings, end-of-life care, and bereavement. Educational and supportive resources for health care practitioners and families, respectively, are included.     

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.     

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.     

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.     

End of Life Care and Decision Making: How Far We Have Come,How Far We Have to Go

While enormous progress has been made in improving the quality of care and the decision-making process for patients at the end of life, as a society we still have far to go to ensure that dying patients and their families have a comfortable and dignified death. In particular, reexamination and reconfiguration of our current decision framework is essential as our elderly population with chronic disease and slowly fatal conditions expands. With less certain disease paths and more complex and ambiguous choices, the growth of this geriatric population challenges us to develop a broader conceptualization of end of life care planning, so that end of life considerations are integrated into a larger anticipatory framework addressing options and needs as patients gradually decline. Within this framework hospice becomes a natural, integrated option along a continuum of care planning, rather than an abrupt alternative at a late stage of illness. End of life care planning must positively anticipate a robust array of needs and concerns well beyond the dramatic decisions to withhold or withdraw life-prolonging technologies usually found in advance directives. To embrace this broader framework it is critical that primary care physicians as well as disease specialists receive training in fundamental aspects of both geriatric and palliative care. Professionals from both of these disciplines must share expertise with each other, and should collaborate in advocacy efforts to effectuate changes in the clinical, policy and legislative arenas. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-342-9678. E-mail address: getinfo@haworthpressinc.com <Website: http://www.haworthpressinc.com>]     

Negotiations about helpfulness--the relationship between formal and informal care in home care arrangements

Scand J Caring Sci; 2011; 25; 706–715 Negotiations about helpfulness – the relationship between formal and informal care in home care arrangements Background: Informal caregiving by family members is the most common way of caring for sick people at home. However, the number of care arrangements, in which both formal (nurses) and informal (family members) caregivers are involved, is considerable and increasing. Despite implicit assumptions in research that the involvement of nurses in home care arrangements is inherently beneficial, there is evidence that their involvement may have a destabilising effect. Aims: The purpose of this study was to investigate the relationship between nurses and family caregivers and its impact on the actual care that is provided. Method: Eighty‐eight interviews with family caregivers (n = 57) and nurses (n = 31) were conducted in Germany and analysed according to the Grounded Theory methodology. Findings: The relationship between formal and informal care is an encounter of two quite different perspectives that is focused on a negotiation process about caregiving work and the helpfulness of the actions taken and the interventions used. For family caregivers, it is determined by the goal of facilitating work and care for their sick family member. The nurses’ work is characterised by a process of shaping different realities in different homes. The results reveal the processes that lead to the involvement of nurses into home care arrangements and offer a deeper understanding of the negotiation processes between formal and informal caregivers. Conclusions: To provide sufficient support in home care, nurses need the ability to engage in negotiation processes that take the whole home care arrangement into account. Developmental work is needed to design services that are helpful for family caregivers.     

Intensive care performance: How should we monitor performance in the future?

Intensive care faces economic challenges. Therefore, evidence proving both effectiveness and efficiency, i.e., cost-effectiveness, of delivered care is needed. Today, the quality of care is an important issue in the health care debate. How do we measure quality of care and how accurate and representative is this measurement? In the following report, several topics which are used for the evaluation of intensive care unit (ICU) performance are discussed: (1) The use of general outcome prediction models to determine the risk of patients who are admitted to ICUs in an increasing variety of case mix for the different intensive care units, together with three major limitations; (2) As critical care outcomes research becomes a more established entity, mortality is now only one of many endpoints that are relevant. Mortality is a limited outcome when assessing critical care performance, while patient interest in quality of life outcomes is relevant; and (3) The Quality Indicators Committee of the Society of Critical Care Medicine recommended that short-term readmission is a major performance indicator of the quality of intensive care medicine.     

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.     

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。     

手术患者非手术时间段的安全对策及护理

护理安全是护理管理的重点,也是护理质量的重要标志之一.手术室工作具有环节多、操作多、技术性强、服务要求高、时间连续性强等特点[1].     

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.