Palliative care Needs Rounds in rural residential aged care: A mixed-methods study exploring experiences and perceptions of staff and general practitioners

New approaches are needed to assist residential aged care (RAC) staff increase their skills and confidence in identifying when residents are nearing the dying phase and managing symptoms. One new evidence-based approach to improve palliative and end-of-life care in RAC is outreach Specialist Palliative Care Needs Rounds (monthly triage and risk stratification meetings – hereafter Needs Rounds); as yet untried in rural settings which may face unique enablers or challenges. Needs Rounds were introduced into two RAC facilities in the rural Snowy Monaro region of New South Wales, Australia. This study explored staff and general practitioners’(GPs’) experiences and perceptions of palliative and end-of-life care in rural RAC, and staff confidence and capability in providing such care, prior to, and after the introduction of Needs Rounds. A mixed-methods, pre- and post-intervention approach was taken, utilizing a Likert-scale written questionnaire and face-to-face semi-structured interviews. Between March and November 2018, 61 questionnaires were completed by 48 RAC staff (33 pre-, 28 post-intervention); eight staff and three GPs were interviewed. Despite system and site-specific barriers, staff self-reported that Needs Rounds increased their capability in providing end-of-life care (p?=?0.04; 95% CI 0.20–7.66), and improved staff: (1) awareness of end of life, reflective practice, and critical thinking; (2) end-of-life decision making and planning; and (3) pain management. Needs Rounds are acceptable and feasible in rural RAC. Palliative and end-of-life care for residents may be improved through education, collaboration, communication, and planning. Further studies should explore running Needs Rounds via telehealth and/or utilizing a multidisciplinary approach.     

The Impact of Embedding a Palliative Care Advance Practice Provider on a Neuroscience Intensive Care Unit Service

Palliative care is a service that works together with the patient’s primary team in an inpatient setting to provide additional guidance, support, and symptom management to patients dealing with a serious illness. Neuroscience intensive care unit patients are both complex and acute and often require multiple collaborating services to provide efficient and proper care. A palliative care nurse practitioner was embedded on the neuroscience ICU team; in doing so, the number of consults, family meetings, and follow-up visits increased. Multidisciplinary staff members had a better understanding of the role of palliative care. There were many benefits from the addition of a palliative care nurse practitioner.     

The Impact of COVID-19 Surge on Clinical Palliative Care: A Descriptive Study From a New York Hospital System

ContextIn spring 2020, New York experienced a surge of patients hospitalized with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) disease, as part of a global pandemic. There are limited data on populations of COVID-19–infected patients seen by palliative care services.ObjectiveTo describe a palliative care population at one New York hospital system during the initial pandemic surge.MethodsThis repeated cross-sectional, observational study collected data on palliative care patients in a large health system seen during the COVID-19 outbreak and compared it with pre-COVID data.ResultsPalliative service volume surged from 678 (4% of total admissions) before COVID-19 to 1071 (10% of total admissions) during the COVID-19 outbreak. During the outbreak, 695 (64.9%) of the total palliative patients tested positive for the virus. Compared with a preoutbreak group, this COVID-19–positive group had higher rates of male (60.7% vs. 48.6%, P < 0.01) and Latino (21.3% vs. 13.3%; P < 0.01) patients and less white patients (21.3% vs. 13.3%; P < 0.01). Our patients with COVID-19 also had greater prevalence of obesity and diabetes and lower rates of end-stage organ disease and cancers. The COVID-19–positive group had a higher rate of intensive care unit admissions (58.9% vs. 33.9%; P < 0.01) and in-hospital mortality rate (57.4% vs. 13.1%; P < 0.01) than the preoutbreak group. There was increased odds of mortality in palliative care patients who were COVID-19 positive (odds ratio = 3.21; 95% confidence interval = 2.43–4.24) and those admitted to the intensive care unit (odds ratio = 1.45; 95% confidence interval = 1.11–1.9).ConclusionDuring the initial surge of the COVID-19 pandemic in New York, palliative care services experienced a large surge of patients who tended to be healthier at baseline and more acutely ill at the time of admission than pre–COVID-19 palliative patients.     

An Interventional Study for the Early Identification of Patients With Palliative Care Needs and the Promotion of Advance Care Planning and Advance Directives

ContextPrograms identifying patients needing palliative care and promoting advance care planning (ACP) are rare in Asia.ObjectivesThis interventional cohort study aimed to identify hospitalized patients with palliative care needs using a validated palliative care screening tool (PCST), examine the ability of the PCST to predict mortality, and explore effects of a pragmatic ACP program targeted by PCST on the utilization of life-sustaining treatment during the last three months of life.MethodsIn this prospective study, we used PCST to evaluate patients' palliative care needs between 2015 and 2016 and followed patients for three months. ACP with advance directives (ADs) was systematically offered to all patients with PCST score ≥4.ResultsOf 47,153 hospitalized patients, 10.4% had PCST score ≥4. During follow-up, 2121 individuals died within three months of palliative care screening: 1225 (25.0%) with PCST score ≥4 and 896 (2.1%) with PCST score <4. After controlling for covariates, PCST score ≥4 was significantly associated with a higher mortality within three months of screening (adjusted odds ratio [AOR] 6.86; 95% CI 6.16–7.63). Moreover, ACP consultation (AOR 0.78; 95% CI 0.66–0.92) and AD completion (AOR 0.49; 95% CI 0.36–0.65) were associated with a lower likelihood of receiving life-sustaining treatments during the last three months of life.ConclusionWe demonstrated the feasibility of implementing a comprehensive palliative care program to identify patients with palliative care needs and promote ACP and AD in Eastern Asia. ACP consultation and AD completion were associated with reduced utilization of life-sustaining treatments during the last three months of life.     

Transition of Nurse Practitioner Faculty Practice and Student Clinicals to Telehealth: Response to the COVID-19 Pandemic

The COVID-19 pandemic forced the US health care system to evaluate alternative care delivery strategies to reduce the risk of coronavirus transmission to patients and health care providers. Telehealth modalities are a safe and effective alternative to face-to-face visits for primary and psychiatric care. Federal policy makers approved changes to telehealth reimbursement coverage and allowed flexibility of location for patients and providers. This article describes the transition of patient visits to telehealth by nurse practitioner faculty at an academic medical center to maintain continuity of care of underserved patient populations. This pivot facilitated resumption of clinical learning experiences for nurse practitioner students.     

Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study

ContextHome care programs in Italy.ObjectivesThe aim of this study was to assess a protocol for palliative sedation (PS) performed at home.MethodsA total of 219 patients were prospectively assessed to evaluate a PS protocol in patients with advanced cancer followed at home by two home care programs with different territorial facilities. The protocol was based on stepwise administration of midazolam.ResultsA total of 176 of the patients died at home, and PS was performed in 24 of these patients (13.6%). Younger patients received the procedure more frequently than older patients (P = 0.012). The principal reasons to start PS were agitated delirium (n = 20) and dyspnea (n = 4). Mean duration of PS was 42.2 ± 30.4 hours, and the mean doses of midazolam were 23–58 mg/day. Both the home care team and the patients' relatives expressed optimal or good levels of satisfaction with the procedure in all but one case, respectively.ConclusionThis protocol for PS was feasible and effective in minimizing distress for a subgroup of patients who died at home. The characteristics of patients who may be effectively sedated at home should be better explored in future studies.     

Improving Hospice and Palliative Care Through Nurse Practitioner Engagement in a Community Paramedicine Program

More than 80% of Americans would prefer to die at home, but only 20% do. Paramedics have a role in caring for terminally ill patients, especially when involved in a community setting. A knowledge gap was noted with community paramedics (CPs) regarding end-of-life questions and palliative care for paramedics. This evidence-based quality improvement project aimed to provide structured, evidence-based palliative and hospice education to CPs. Nurse practitioners can provide education and training on palliative and hospice care to CPs and help patients remain at home.     

Symptom Burden and Palliative Care Needs Among High-Risk Veterans With Multimorbidity

Context

Palliative care research has focused on patients with disease-specific conditions. However, older patients with multimorbidity may have unmet palliative care needs.

The Role of Palliative Care in Burns: A Scoping Review

ContextPatients with severe burns may face distressing symptoms with a high risk of mortality as a result of their injury. The role of palliative care in burns management remains unclear.ObjectiveTo appraise the literature on the role of palliative care in burns management.MethodsWe used scoping review with searches in 12 databases from their inception to August 2019. The citation retrieval and retention are reported in a PRISMA statement.Findings39 papers comprising of 30 primary studies (26 from high-income and four from middle-income countries), four reviews, two editorials, two guidelines, and one expert board review document were retained in the review. Palliative care is used synonymously with comfort and end-of-life care in burns literature. Comfort care is mostly initiated when active treatment is withheld (early deaths) or withdrawn (late deaths), limiting its overall benefits to burn patients, their families, and health care professionals. Futility decisions are usually complex and challenging, particularly for patients in the late death category, and it is unclear if these decisions result in timely commencement of comfort care measures. Three comfort care pathways were identified, but it remained unclear how these pathways evaluated “good death” or supported the family which creates the need for the development of other evidence-based guidelines.ConclusionPalliative care is applicable in burns management, but its current role is mostly confined to the end-of-life period, suggesting that it is not been fully integrated in the management process. Evidence-based guidelines are needed to support the integration and delivery of palliative care in the burn patient population.     

Use of the Palliative Performance Scale (PPS) for End-of-Life Prognostication in a Palliative Medicine Consultation Service

This study examines the use of the Palliative Performance Scale (PPS) in end-of-life prognostication within a regional palliative care program in a Canadian province. The analysis was done on a prospective cohort of 513 patients assessed by a palliative care consult team as part of an initial community/hospital-based consult. The variables used were initial PPS score, age, gender, diagnosis, cancer type, and survival time. The findings revealed initial PPS to be a significant predictor of survival, along with age, diagnosis, cancer type and site, but not gender. The survival curves were distinct for PPS 10%, 20%, and 30% individually, and for 40%–60% and ≥70% as bands. This is consistent with earlier findings of the ambiguity and difficulty when assessing patients at higher PPS levels because of the subjective nature of the tool. We advocate the use of median survival and survival rates based on a local cohort where feasible, when reporting individual survival estimates.     

Unmet Palliative Care Needs Among Patients With End-Stage Kidney Disease: A National Registry Study About the Last Week of Life

Context

End-stage kidney disease (ESKD) is characterized by high physical and psychological burden, and therefore, more knowledge about the palliative care provided close to death is needed.

Latent Class Analysis of Specialized Palliative Care Needs in Adult Intensive Care Units From a Single Academic Medical Center

Context

In the intensive care unit (ICU), 14% of patients meet criteria for specialized palliative care, but whether subgroups of patients differ in their palliative care needs is unknown.

COVID-19 on New Primary Care Nurse Practitioners: A Qualitative Exploration

New nurse practitioners (NPs) struggle with the transition to practice and feelings of uncertainty concerning roles and responsibilities. COVID-19 has added a new layer of stress. This pilot study used a qualitative case study design featuring semistructured interviews of 10 newly graduated primary care NPs. Data analysis revealed 2 main themes: (1) emotional burden, and (2) coping and support. Emerging themes highlight the resiliency of NPs, who cope and seek support when faced with emotional burdens. This study informs educators and employers on the needs of new NPs during a global pandemic in order to better support the future workforce.