Cost effectiveness in palliative care setting

Public Awareness and Perceptions of Palliative and Comfort Care

Few studies have evaluated the role of a clinical pharmacist in hospice and palliative care in oncology. We aimed to describe the intervention of a clinical pharmacist in hospice and palliative care at a comprehensive oncology center in Jordan. A retrospective descriptive study at a comprehensive oncology center in Jordan between 2006 and 2019. Quantifi® pharmacy documentation system was used to retrieve the clinical pharmacists' interventions in three hospice and palliative care settings, inpatient hospice and palliative care, outpatient hospice and palliative care clinics and home health care. Where clinical pharmacists document their interventions, significance and acceptance of the interventions by the physician is done using Quantifi®. Over 13 years, 27,720 documented interventions were retrieved in the three settings of hospice and palliative care: inpatient hospice and palliative care, outpatient hospice and palliative care clinics and home health care setting. The most common reported interventions were drug therapy recommendation/discontinuation (41%), followed by medication reconciliation (21.7%) and patient counseling (16.8%). The medication classes most commonly associated with the hospice and palliative care clinical pharmacist interventions were analgesics (20.9%), antibiotics (19.7%), followed by medications for the nervous system (12.4%). The acceptance rate of the interventions by physicians was around (90%) and 100% of the interventions were considered significant. Our study showed the high impact of the hospice and palliative care clinical pharmacist in oncology providing the high number of clinical pharmacists' interventions.

Although palliative and hospice care are essential for individuals with life-limiting illnesses, academic inpatient hospices, which combine care with research and education, remain rare. This study explores the experiences, perceptions, and expectations of patients and their relatives regarding palliative and hospice care with the aim of informing the development of an academic inpatient hospice. Semi-structured individual and dyadic interviews were conducted with patients and relatives who had experience with palliative and hospice care services in an academic setting in Germany. The data were analyzed using qualitative content analysis. A total of 14 interviews were conducted with 17 participants (10 patients, 7 relatives). Participants reported initial uncertainty and skepticism regarding palliative and hospice care; however, direct experiences led to more positive attitudes. Key aspects valued included psychosocial support, effective symptom management, and a non-clinical atmosphere. The preservation of autonomy and dignity, meaningful personal interactions, and the active involvement of relatives were considered essential. The transition from a hospital-based palliative care unit to an inpatient hospice was often perceived as abrupt and emotionally challenging, creating a risk of losing established familiarity. Participants responded positively to the idea of an academic inpatient hospice. They highlighted the potential benefits of integrating palliative and hospice services within a unified and familiar environment, including smoother transitions and continuity of care. An academic inpatient hospice offersopportunitiesto address end-of-life care needs by strengthening existing structures and ensuring continuity and comprehensiveness of care. It can support patient-centered care, provide a platform for education and research, and promote greater public awareness and understanding of palliative and hospice care.

Abstracts from theCenter to Advance Palliative Care National Seminar Pathways to Quality Palliative Care<i>November 13–15, 2014</i><i>Orlando, Florida</i>

Antibiotics are commonly prescribed medications in the hospice and palliative care setting, as well as in many other healthcare settings. The overuse or negligent use of antibiotics is associated with the harmful consequence of fostering the development of antibiotic-resistant pathogens. Thus, there is an urgent need to critically examine and audit antibiotic use in all aspects of healthcare. In the status quo, there is a lack of consistent standards and guidelines surrounding the use of antibiotics in hospice and palliative care settings, leading to significant variations in how antibiotics are prescribed and administered in end-of-life care. It is apparent that greater thought needs to go into antibiotic decisions for patients receiving hospice or palliative care, especially considering the harmful consequences of the overprescription of antibiotics. The literature suggests that many clinicians prescribe antibiotics inappropriately for patients who would not benefit from their use or prescribe them without adequate documentation. Clinicians should be deliberate about when they prescribe antibiotics and adhere to the appropriate documentation standards and procedures within their institution or community. Future research should seek to generate generalizable knowledge about which patients will benefit most from antibiotic therapy during end-of-life care.

Virtual Reality (VR) is a safe and effective adjunctive care option with multiple clinical applications. An interdisciplinary VR program aimed at improving quality of life for veterans receiving inpatient hospice and palliative care was implemented at the VA Bedford Health Care System. Principles from the 4Ms of Geriatrics (Mentation, Mobility, Medications, and Matters Most) guided evaluation and outcomes. Implementation involved decision-making around hardware and software, learning about processes at other facilities, financing, and creating policies and procedures. Project development began in 2021 and data collection began in March 2023. Veteran residents enrolled in inpatient hospice and palliative care were invited to participate. As of August 2023, 22 VR visits were conducted with 13 veterans. Preliminary data suggests VR can be used with a wide range of individuals receiving hospice and palliative care. Analysis of pre-post measures indicate improvement in mood (62%) and overall day (81%), and reduced pain. Barriers to engagement include staffing (e.g., availability), technology (e.g., VR technical issues), hospital procedures/policies (e.g., infection control, COVID-19), and patient factors (e.g., interest, symptoms). Facilitators include hospital support, interdisciplinary collaboration, and understanding of the setting and patient preferences/ needs. Although conception to implementation took two years, a VR program to improve quality of life for veterans enrolled in hospice and palliative care appears to be feasible and clinically beneficial. Experience has shown that flexibility, adaptability, and an individualized approach facilitate engagement. Best practices in the application of VR within the hospice and palliative care setting will continue to be evaluated and honed.

Previous main body of research on end-life-care in South Korea has focused on developing services quality in hospital settings or service payment system in National Health Insurance Program. The delivery system of hospice and palliative care services has evolved in diverse ways but there is little research on reviewing the past history of development and whole picture of them so far. So, the aim of this study is to review the old hospice and palliative care system and also to introduce the current one supported by the National Health Insurance Program in South Korea. The palliative care or hospice services in South Korea have been available in diverse settings and provided by different organizations (i.e. catholic hospitals or charity organizations). Finally, it was set up in 2004 that the hospice team or official Palliative Care Units (PCUs) was established in hospitals, in order to meet the end-of-life care for the patients with terminal cancer under the Cancer Control Act. The current hospice and palliative care services such as pain management, bereavement services, and counselling can be reimbursed by National Health Insurance program since 2008. Nevertheless hospice and palliative care services are available to dying patients, yet the utilization rate of hospice and palliative care services or the length of stay in the palliative care unit (PCU) is still relatively short compared to other country systems. South Korea is undergoing several efforts to expand the services in PCU along with the development of quality indicators for PCU. Hospice and palliative care services are still new in the health care system and unfamiliar to the public so it requires raising awareness for medical professionals and the public as well as further research.

Background:Current Respiratory Therapy programs incorporate minimal palliative and hospice care education in their curriculum; palliative and hospice care is not included in the respiratory care department orientation process; participation in the Main Line Health (MLH) Palliative Care Fellowship highlighted the need to determine baseline RT knowledge and attitudes towards Palliative and Hospice Care and evaluate potential education and engagement opportunities. Literature Review: Much of the literature obtained focused on terminal extubation and end of life care in the critical care setting; Michaud-Young (2009) noted that patients with chronic lung disease require care by clinicians who will be in a position to support them as they approach end of life; an editorial in the September 2017 Lancet journal remarked that palliative care in chronic lung disease is an important and often neglected part of clinical practice. Methods:Respiratory therapists at MLH were invited via email and department posted flyers to participate in a palliative and hospice care pre/post education survey; all RTs who completed the pre survey were sent a link to view a short palliative and hospice care video in-service; as well as, complete a post survey. Results:44 of 126 RTs (35%) invited to participate completed the pre-survey, while 32 of 44 RTs (73%) who completed the pre-survey viewed the video in-service and completed the post survey; 91% (40/44) of RTs believe there was not adequate Palliative and Hospice Care education provided during their student training; 98% (43/44) of RTs believe palliative and hospice care should be part of the department orientation process. Post survey/in-service data displayed in chart below. Conclusions:Simple education initiatives related to palliative and hospice care may address RT knowledge gaps; as well as, positively impact attitudes related to this topic; incorporating palliative and hospice care into our department orientation process is warranted; with an aging chronic lung disease population there is opportunity for Respiratory Therapists to increase engagement in MLH Palliative and Hospice Care initiatives. Disclosures: None

Bereavement support services are recognised as an integral part of hospices and palliative care services. Exploratory surveys on the nature of such services have been conducted in recent years in several countries, including the USA, UK and Australia. The purpose of this paper is to compare the main findings of these surveys and to offer preliminary suggestions on how to improve this component of care both within and across these three countries. Through this comparison, a number of common aspects of service delivery were highlighted. Common difficulties were also found, including low numbers of paid staff, variations in specialist training, insufficient levels of funding, and the lack of the use of validated bereavement assessment tools. Bereavement support is an important aspect of hospice and palliative care service delivery. In all countries, further research and policy development is required to address the common difficulties.

BackgroundThe diversity of the population is associated with different needs and expectations towards palliative and hospice care. Current approaches available in Germany generally fall short in addressing the role of diversity and intersectionality in this health care setting and healthcare facilities struggle with organizational difficulties and missing information on how to implement corresponding diversity-sensitive measures. The present study aims to develop a hands-on manual that enables providers of hospice and palliative care to implement measures and strategies for diversity-sensitive care, while taking into account the perspective of healthcare users and explicitly including vulnerable and minority patient groups.MethodsA participatory approach is used to co-create the aforementioned manual using an explanatory sequential mixed-methods design. First, based on a systematic analysis of existing measures, an initial draft of the manual will be developed. Subsequently, an online survey will be conducted among all hospice and palliative care providers in Germany (n = 2,823). Based on the results of the survey, 12 to 15 qualitative problem-centered interviews will be conducted with employees of selected providers who took part in the survey. Results of the survey and the qualitative interviews will be integrated and analyzed. In parallel to the development and research process, a comprehensive dissemination strategy will be developed.DiscussionThe manual will assist providers of palliative and hospice care in determining goals, needs, and available resources in order to utilize patient-centered and diversity-sensitive measures to meet a wide range of expectations. It can also be informative for providers in other countries. The participatory co-development approach ensures the practical relevance of the manual, while the mixed-methods design allows for targeted input on the manual’s usability, acceptance, and viability as a supportive tool.

Background: Despite NCCN Guidelines and clear definition of palliative care, patients often carry misperceptions about palliative care and how it can be beneficially integrated into a patient’s care plan. In order to better understand the misinformation about palliative and hospice care, this study aims to assess patient-healthcare provider (HCP) communication regarding treatment decisions. Methods: An online survey was conducted with individuals who have had a diagnosis of cancer (n=1,517) to better understand their healthcare experiences as well as the impact their cancer diagnosis had on their quality of life. Measures included agreement scale questions assessing patient information needs surrounding treatment decision making. Open-ended questions where respondents were prompted to provide a written response allowed researchers to further assess patients’ understanding of palliative and hospice care. Responses to agreement-scale questions were evaluated using descriptive statistics. Openended question responses were analyzed using Dedoose qualitative data analysis software. Results: Among patients with a diagnosis of cancer, there were a broad range of patient misperceptions regarding palliative care, hospice care, and how they are used in cancer care. The majority of respondents (81%) stated that their HCP played a role when deciding on their treatment plan. Despite this, only 46% were confident they knew about the treatment’s impact on their daily life, 56% were confident they knew about the potential side effects of treatment, and 57% felt they had all of the information they needed. Themes identified through qualitative analysis include: patient conflation of palliative and hospice care, belief that palliative and hospice care are only relevant to end-of-life decision-making, and uncertainty about whether quality of life can actually be improved. Conclusions: Institutions and HCPs are recommended to integrate palliative care into cancer care. However, as this research shows, oncology patients are often misinformed about the benefits of palliative care. This follows a parallel concern of patients making treatment decisions without optimal information. A potential factor behind this unmet need may be lack of effective communication between patient and HCP. Palliative care may be mentioned by the HCP, but not discussed with enough empathy or depth, leading to patient misunderstanding and lack of inclusion in treatment plans.

Methadone Boot Camp Revisited (319)

Overcoming barriers in hospice and palliative care research is a multifaceted challenge for researchers conducting intervention studies. The complexity and variations of these barriers are abundant and serious in nature and can threaten the success of intervention research for the hospice and palliative care patient population. This article explores how challenges and barriers to intervention research can be mitigated by nurses caring for patients in hospice and palliative care settings.

In the context of the current regulatory environment, patients may be discharged from hospice if their condition stabilizes or improves over time and the certifying physician is unable to provide a conscientious recertification of the six-month prognosis. Little is known about the characteristics or outcomes of patients who are determined by physicians to no longer be eligible for hospice care. This retrospective study was designed to characterize the rates and predictors of live hospice discharge using data from the 1996 and 1998. National Home and Hospice Care Survey (NHHCS). We compare records of live hospice discharge with hospice discharges due to death from the discharge patient files of the 1996 and the 1998 NHHCS. Of the 807,733 patients in the combined 1996 and 1998 NHHCS discharge patient file who met study inclusion criteria, 761,858 (94 percent) were deceased and 45,875 (6 percent) were discharged alive. Those who were discharged alive were more likely to be female, have received hospice care for more than 60 days, and to have had a noncancer diagnosis, particularly advanced cardiopulmonary or neurologic disease. Mean age and total number of assistive medical devices used did not differ significantly between patients who were discharged alive and those who died in hospice care. Factors most associated with live hospice discharge, using bivariate analyses, were length of service greater than 60 days (OR, 6.60; 95 percent CI, 6.47-6.73), cardiopulmonary diagnosis (OR, 3.24; 95 percent CI, 3.19-3.30), and neurologic diagnosis (OR, 2.73; 95 percent CI, 2.67-2.79). Multivariate logistic regression identified length of service greater than 60 days, cardiopulmonary diagnosis, neurologic diagnosis, female gender, worse functional status, and living in an institutional setting as being independently associated with live hospice discharge. We found that patients who were discharged alive from hospice care were more likely to have longer lengths of service, noncancer diagnoses, and better functional status than those who died while receiving hospice care. Age was not associated with discharge disposition. Given the demonstrated differences between these patients and those who died while receiving hospice care, these data provide further impetus for careful study of the appropriateness of current hospice eligibility criteria, the determinants of hospice discharge and, most important, the outcomes of patients who are discharged alive from hospice and the impact of hospice discharge on patients and their families.

The goals of this paper are to (1) provide a brief overview of palliative care, including its purpose and philosophy and how hospice care fits under the larger palliative care umbrella; (2) introduce pain assessment in patients with life-limiting illnesses; and (3) review pain management strategies in palliative care, with a focus on pharmacotherapy. Palliative care is a specialized field of medicine focused on providing patient- and family-centered care for those with life-limiting illnesses at any stage of their disease trajectory. When patients approach their end of life and the focus of care becomes comfort and quality of life, the decision may be made to enter hospice care. Pain management is an essential aspect of palliative and hospice care. An effective pain assessment should help elucidate the cause and type of pain, guiding selection of therapy. Options for treating pain may include nonpharmacological approaches such as physical therapy, interventions such as nerve blocks, and pharmacotherapy. Opioids are the mainstay of pain pharmacotherapy in palliative care, although, depending on patient-specific factors, nonopioids or adjuvant agents may be used instead of or in addition to opioids. Safe and effective pain medication use in serious illness requires careful consideration of which agents should be most effective and well tolerated; clinicians should also be prepared to anticipate and respond to medication adverse effects. Because of the outsized importance of safe and effective medication management to treat pain in patients with life-limiting illnesses, pharmacists are particularly well suited to intervene and help guide appropriate therapy.