Providing regular relief; considerations for palliative care in the Netherlands]

Over the last few decades the attention devoted to the palliative aspects of medicine, particularly those in hospital care, has declined due to the emphasis on medical technology. In Anglo-Saxon countries a review of this development resulted in structured palliative care that benefited terminally ill patients with a progressive fatal disease, especially cancer patients. Due to increasing national and international criticism of both the practice of euthanasia (assumed to be too liberal) and the lack of attention devoted to structured palliative care in the Netherlands, the Dutch government decided to improve the structure of palliative care. The government's viewpoint is based on the assumption that good palliative care that includes adequate pain control benefits patient care and might eventually lead to fewer requests for euthanasia. The improvements to palliative care should be realised by means of improvements in the structure, training and knowledge. Six academic medical clusters have been designated as Centres for the Development of Palliative Care (Dutch acronym: COPZ) for a 5-year period. Each COPZ must develop the various aspects needed to improve palliative care within the region it serves and ensure that its activities are carefully coordinated with those in the other centres. Research will focus on measuring the efficacy of palliative care as well as ethical and epidemiological aspects. A government committee will assess the appropriateness of the activities undertaken by each of the centres.     

Economic aspects of day care after operations for hernia or varicose veins.

In a trial of 360 patients with hernia or varicose veins, day care surgery provided an economic alternative to the provision of surgical aftercare either in the surgical wards of a district hospital or in a convalescent hospital. There was only slightly more work for general practitioners. Most of the additional work for the community services was carried out by district nurses, with an average contact time in the postoperative period of 325 minutes for day care patients, compared with 186 minutes and 204 minutes respectively for patients admitted for 48 hours to the surgical or convalescent wards. Day care produced estimated savings of 30 pounds compared with the costs of a 48-hour stay in the surgical wards, and savings of 22 pounds compared with a 48-hour stay in the convalescent wards.     

Diabetes care.

Providing good quality diabetes care is complex but achievable. Many aspects of the care do not require high tech medicine but, rather, good organisation. Diabetes is a costly disease, consuming 1500 pounds per diabetic patient per year versus 500 pounds on average for a non-diabetic member of the population in health service costs. Investment now in good quality diabetes care is sound: patients will benefit from a better quality of life associated with a reduced incidence of the complications of diabetes and the direct costs to the health service in treating these complications and the indirect costs to employers will be reduced. Physical and clinical assessments--measurements of blood glucose and glycosylated haemoglobin concentrations, weight, and blood pressure and assessment of eyes, kidneys, feet, and heart--are clearly important, but quality must include consideration of people and their reactions to life and diabetes--a lifelong entanglement--for which much more support should be provided.     

Developing and financing a palliative care program

Although hospice care to assist the dying is widely available, palliative care, which focuses on living with chronic and life threatening illness and preparing the living for dying, is poorly understood. Only recently, palliative care has been mandated by the Joint Commission on Accreditation of Healthcare Organizations as a necessary intervention for facilities. Defining a palliative care model for the community hospital emphasizes total care for the patient beyond the traditional medical model. No specific Medicare reimbursement exists for palliative care in hospitals, and hospital administrators are generally not supportive of programs where no reimbursement exists. Developing a model palliative care program using a cost aversion financial model to quantify benefits of a palliative care programs is one strategy to address the reimbursement shortcomings.     

Kansas primary care weighs in: a pilot randomized trial of a chronic care model program for obesity in 3 rural Kansas primary care practices.

Context: Obesity is a chronic disease of epidemic proportions in the United States. Primary care providers are critical to timely diagnosis and treatment of obesity, and need better tools to deliver effective obesity care. PURPOSE: To conduct a pilot randomized trial of a chronic care model (CCM) program for obesity care in rural Kansas primary care. METHODS: We enrolled 107 participants to a 6-month, 2-armed, randomized trial comparing a CCM for obesity with usual care. The primary outcome was weight change at 90 days. The usual care arm received educational weight loss materials and outcome assessments at day 0, 90, and 180. The active arm received the same elements as the usual care arm plus a multicomponent obesity CCM. FINDINGS: The Day 90 mean +/- SD weight change for the active arm (n = 34) and control arm (n = 33), respectively, was -4.5 +/- 7.7 pounds and -2.4 +/- 8.1 pounds (P = .27 for difference). The Day 180 mean +/- SD weight change for the active (n = 27) and control (n = 27) arms, respectively, was -9.4 +/- 10.3 pounds and -2.1 +/- 10.7 pounds (P = .01 for difference). There was no significant change in physical activity, or fruit and vegetable intake at day 90 or day 180. CONCLUSIONS: Improving the recognition and treatment of obesity in primary care settings is a critical initiative. Rural populations suffer disproportionately with obesity, and better methods of delivering obesity care are needed for this population. Further research is needed to establish the effectiveness of a CCM approach for obesity care.     

Is a target culture in health care always compatible with efficient use of resources? A cost-effectiveness analysis of an intervention to achieve thrombolysis targets

BACKGROUND: The UK government has attempted to improve the quality of health care in the National Health Service and minimize geographical variations in quality by imposing targets in certain areas of health care. The measures taken by local health economies to achieve these targets have not before been subjected to cost-effectiveness analysis. We have assessed the cost effectiveness of an intervention designed to achieve thrombolysis time targets. METHODS: In the setting of a single district general hospital in England, we audited local pain-to-needle (PTN) and door-to-needle (DTN) times, before and after a pounds 208,000 (Euro 310,000, dollar 370,000) annual expenditure to improve performance against government targets. The intervention included the recruitment of additional nursing time in the Accident & Emergency Department and the use of a single bolus thrombolytic agent for all patients with ST elevation myocardial infarction. An economic evaluation was performed, based on the expected number of additional lives saved, extrapolated from a meta-analysis of previous thrombolysis trials. RESULTS: The intervention reduced mean DTN time from 37.6 +/- 5.9 minutes (mean +/- SEM) to 27.6 +/- 3.6 minutes (p = 0.06). The cost per life saved was pounds 3,423 +/- 850 (Euro 5,100,000, dollar 6,100,000), the cost per life year gained was pounds 222,184 (Euro 330,000, dollar 390,000) and the cost per quality-adjusted life year (QALY) gained was pounds 246,871 (Euro 370,000, dollar 440,000). CONCLUSION: Although moderately successful at improving performance against government targets, this intervention to promote rapid thrombolysis proved to be an inefficient use of health-care resources. Strict government targets in health care may not always lead to efficient targeting of resources.     

Smoking. Baccy to front

The government is making 60m pounds available to develop smoking cessation services over three years. This year's funding is concentrated on health action zones where progress has been slow. The cost of nicotine replacement patches is significantly more than many smokers spend on cigarettes.     

An economic analysis of varicella vaccination for health care workers.

A simulation model was constructed to assess the relative costs and cost-effectiveness of different screening and vaccination strategies for dealing with hospital incidents of varicella exposure, compared with current policies, using data from published sources and a hospital survey. The mean number of incidents per hospital year was 3.9, and the mean annual cost of managing these incidents was pounds 5170. Vaccination of all staff would reduce annual incidents to 2.2 at a net cost of pounds 48,900 per incident averted. Screening all staff for previous varicella, testing those who are uncertain or report no previous varicella, and vaccinating those who test negative for VZV antibodies, reduces annual incidents to 2.3 and gives net savings of pounds 440 per incident averted. Sensitivity analyses do not greatly alter the ranking of the options. Some form of VZV vaccination strategy for health care workers may well prove a cost-effective use of health care resources.     

Development and validation of a core outcome measure for palliative care: the palliative care outcome scale. Palliative Care Core Audit Project Advisory Group.

OBJECTIVES: To develop an outcome measure for patients with advanced cancer and their families which would cover more than either physical symptoms or quality of life related questions. To validate the measure in various specialist and non-specialist palliative care settings throughout the UK. DESIGN: A systematic literature review of measures appropriate for use in palliative care settings was conducted. In conjunction with a multidisciplinary project advisory group, questions were chosen for inclusion into the scale based on whether they measured aspects of physical, psychological, or spiritual domains pertinent to palliative care, and whether similar items had shown to be valid as part of another measure. A staff completed version was developed to facilitate data collection on all patients throughout their care, and a patient completed version was designed to enable the patient to contribute to the assessment of their outcomes when possible. A full validation study was conducted to evaluate construct validity, internal consistency, responsiveness to change over time, and test-retest reliability. Assessments were timed. SETTING: Eight centres in England and Scotland providing palliative care, including inpatient care, outpatient care, day care, home care, and primary care. PATIENTS: A total of 450 patients entered care during the study period. Staff collected data routinely on patients in care long enough to be assessed (n = 337). Of these, 262 were eligible for patient participation; 148 (33%) went on to complete a questionnaire. MAIN MEASURES: The Palliative Care Outcome Scale (POS), the European Organisation for Research on Cancer Treatment, and the Support Team Assessment Schedule. RESULTS: The POS consists of two almost identical measures, one of which is completed by staff, the other by patients. Agreement between staff and patient ratings was found to be acceptable for eight out of 10 items at the first assessment. The measure demonstrated construct validity (Spearman rho = 0.43 to 0.80). Test/re-test reliability was acceptable for seven items. Internal consistency was good (Cronbach's alpha = 0.65 (patients), 0.70 (staff)). Change over time was shown, but did not reach statistical significance. The questionnaire did not take more than 10 minutes to complete by staff or patients. CONCLUSION: The POS has acceptable validity and reliability. It can be used to assess prospectively palliative care for patients with advanced cancer.     

Palliative care: the public health strategy

There is the knowledge to improve the Quality of Life, Dying and Death of cancer sufferers, other patients dying of chronic diseases, HIV/AIDS and the children and elderly terminally ill and their caring family members, an estimated 100 million people globally, if palliative care and pain relief would be available. Tragically however, palliative care is only reaching a lucky few. Two third of those in need of palliative care are in the low or middle income countries.The World Health Organization (WHO) has pioneered a public health strategy to integrate palliative care into existing healthcare systems as this offers the best approach for translating new knowledge and skills into evidence-based, cost-effective interventions that can reach everyone in the population, when incorporated by governments into all levels of their healthcare systems and owned by the community. The WHO Strategy starts by establishing four foundation measures, key components that are: 1) appropriate policies, 2) adequate drug availability, 3) education of the public, policymakers and the public and 4) implementation.The WHO Model has shown that it provides an effective strategy for countries to establish palliative care. The Open Society Institute has actively supported countries to establish National Palliative Care Programs according to these principles. Combined with a community strategy that involves the society through collective and social action"Palliative Care for All" indeed could become a reality.     

Pregnancy care: an apprenticeship for palliative care?

The American Board of Medical Specialties has recently recognized palliative medicine as a new subspecialty. Family Medicine was one of 10 specialty boards cosponsoring this certification process. The role of the family physician has many parallels in the care of pregnant and dying patients. The family physician that has provided maternity care can apply his or her experiences to their care of the dying. The reader is invited to consider this possibility as part of an intentional transition to palliative medicine.     

Palliative care, care for life: a study of the specificity of residential palliative care

In this study, the authors describe the concept of palliative care as applied in a palliative care unit. They conducted in-depth interviews with 8 patients, 9 relatives, and 24 caregivers from two residential palliative care units. Observation of the care and of team meetings and analysis of patient records provided additional data. Palliative care involves a specific concept of care, the central focus of which is life. This is realized by two strategies. The first is to create space to live by diverting attention from the sick body, moving the illness into the background. The second is to fill the space as meaningfully as possible, so that patients can enjoy life even in the face of death. The quality of the caregiving process in palliative care is determined by a range of conditions and processes that reflect its complexity.     

Progress in palliative care in Israel: comparative mapping and next steps

ABSTRACT: Palliative care was established rapidly in some countries, while in other countries its establishment has taken a different trajectory. This paper identifies core steps in developing a medical specialty and examines those taken by Israel as compared with the US and England for palliative care. It considers the next steps Israel may take.Palliative care aims to provide quality of life for those with serious illnesses by attending to the illness-prompted physical, mental, social, and spiritual needs of patients and their families. It has ancient roots in medicine; its modern iteration began against the backdrop of new cures and life-sustaining technology which challenged conceptions of how to respect the sanctity of life.The first modern hospice was created by Saunders; it provided proof that palliative care works, and this has occurred in Israel as well (the first step). Another key step is usually skills development among clinicians; in Israel, few education and training opportunities exist so far. Specialty recognition also has not yet occurred in Israel. Service development remains limited and a major shortage of services exists, compared to the US. Research capacity in Israel is also limited. Policy to develop and sustain palliative care in Israel is underway; in 2009, the Ministry of Health established policy for implementing palliative care. However, it still lacks a financially viable infrastructure.We conclude that palliative care in Israel is emerging but has far to go. Adequate resource allocation, educational guidelines, credentialed manpower and specialty leadership are the key factors that palliative care development in Israel needs.     

Palliative care in a psychiatric-somatic care unit

Patients with severe psychiatric and somatic disorders may require admission to a combined psychiatric-somatic care unit. These units provide specialised psychiatric and somatic care as well as palliative care. This is illustrated by two case reports. A 51-year-old man with a malignant brain tumour was admitted to our psychiatric-somatic care unit after threatening his wife and children. He was aggressive and confused. Seizures were suspected and palliative care was needed. Within a few weeks his condition deteriorated. He died 1 day after terminal sedation had been initiated. A 78-year-old woman was admitted to receive daily electroconvulsive treatment (ECT) for depression with catatonia. The ECT had to be interrupted repeatedly due to comorbid infections and complications. She died 3 days after palliative care was initiated.     

Inclusion of essential components of the World Health Organization palliative care development model in national palliative care plans: A documentary analysis in 31 countries

ContextThe World Health Organization has proposed a new model for the development of palliative care. Whether the current national palliative care plans of Member States are aligned or need to be reformed to meet the new model is unknown.MethodsWe conducted a documentary analysis of national palliative care plans based on an analytic framework structured with the elements recommended by the World Health Organization: (a) building a plan, (b) plan components, and (c) plan implementation. We conducted a categorical analysis of national plans by subgroups according to income and development level of palliative care.FindingsWe identified 112 countries with a palliative care plan, of which 31 were included in the analysis. Of these 31 plans, only 8 had the six components proposed by the World Health Organization, 29 reported an implementation strategy, 23 were aligned with the country's national public health plan, and 15 allocated financial resources for plan implementation. All the national plans assessed included the component provision of palliative care in integrated health services; 93%, education and training; 83%, research; 80%, empowered people and communities; 54%, health policies related to palliative care, and 48% use of essential medicines.ConclusionsNational palliative care plans include the two new development components, but few are fully aligned with the 2021 World Health Organization's model.     

Partners in pediatric palliative care: a program to enhance collaboration between hospital and community palliative care services

The provision of high-quality palliative care services to dying children and their families often requires extensive collaboration between hospital-based and community-based care teams. This article describes the origins and development of the Partners in Pediatric Palliative Care program, which has provided pediatric-specific educational offerings and fostered joint endeavors between a palliative care service located in a tertiary care children's hospital and a wide range of hospice and home care agencies in 5 states. The Partners in Pediatric Palliative Care program is evaluated in terms of the favorable ratings that attendees have given the educational components, the relatively modest direct costs of mounting the regional meetings, and the expanded capacity to provide home-based palliative services to children and families who desire them. The Partners in Pediatric Palliative Care program provides another feasible means for hospitals and community agencies to work together to improve pediatric palliative care.     

Community hospitals: an under-recognized resource for palliative care

In the UK there are concerns that, in certain groups of dying patients such as the old, those with non-cancer diagnoses and those in rural areas, the quality of care is unacceptably variable. There has been no systematic survey of the extent to which community hospitals provide general palliative care for such patients. Therefore, by means of a structured questionnaire we asked senior nurses/managers at all 478 community hospitals in the UK for information on staff expertise, facilities and specialist equipment, liaison arrangements with specialist palliative care providers, priorities, practice and policy in end-of-life care. Of the 346 hospitals (72%) that responded, only 28 were in urban areas. 73% of hospitals employed at least one nurse with additional training in palliative care, 72% had access to 24-hour specialist palliative care advice and 51% had separate overnight accommodation for relatives, but only 22% had designated palliative care beds. Most hospitals did not have written policies or guidelines for patient assessment or symptom control. These findings add to evidence that community hospitals represent an important resource to improve access to palliative care for groups that are currently under-served.     

Societal costs of home and hospital end‐of‐life care for palliative care patients in Ontario,Canada

In Canada, health system restructuring has led to a greater focus on home‐based palliative care as an alternative to institutionalised palliative care. However, little is known about the effect of this change on end‐of‐life care costs and the extent to which the financial burden of care has shifted from the acute care public sector to families. The purpose of this study was to assess the societal costs of end‐of‐life care associated with two places of death (hospital and home) using a prospective cohort design in a home‐based palliative care programme. Societal cost includes all costs incurred during the course of palliative care irrespective of payer (e.g. health system, out‐of‐pocket, informal care‐giving costs, etc.). Primary caregivers of terminal cancer patients were recruited from the Temmy Latner Centre for Palliative Care in Toronto, Canada. Demographic, service utilisation, care‐giving time, health and functional status, and death data were collected by telephone interviews with primary caregivers over the course of patients' palliative trajectory. Logistic regression was conducted to model an individual's propensity for home death. Total societal costs of end‐of‐life care and component costs were compared between home and hospital death using propensity score stratification. Costs were presented in 2012 Canadian dollars ($1.00CDN = $1.00USD). The estimated total societal cost of end‐of‐life care was $34,197.73 per patient over the entire palliative trajectory (4 months on average). Results showed no significant difference (P > 0.05) in total societal costs between home and hospital death patients. Higher hospitalisation costs for hospital death patients were replaced by higher unpaid caregiver time and outpatient service costs for home death patients. Thus, from a societal cost perspective, alternative sites of death, while not associated with a significant change in total societal cost of end‐of‐life care, resulted in changes in the distribution of costs borne by different stakeholders.