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Public Awareness and Perceptions of Palliative and Comfort Care

BackgroundFalls are the leading cause of hospitalisation and death due to injuries in Australia. Amongst hospitalised patients, falls are the most common safety incident and cause substantial concern among staff...

United States: Overview of Cancer Pain and Palliative Care

In order to estimate the prevalence of palliative care programs in academic hospitals in the United States, we surveyed a random sample of 100 hospitals in the Council of Teaching Hospitals and Health Systems directory. Sixty percent of hospitals provided information. At least 26% of hospitals had either a palliative care consultation service or inpatient unit and 7% had both. Eighteen percent of hospitals had a palliative care consultation service alone, 19% had an inpatient palliative care unit, 22% reported a hospice affiliation, and 17% had a hospice inpatient contract. Additionally, at least 20% of the remaining hospitals were planning a palliative care program. The consultation services had an average daily census of 6; the inpatient units had an average of 12 beds. Palliative care consultation programs were largely affiliated with departments of medicine or hematology/oncology, and were typically staffed by a physician and a nurse. Only half had a dedicated social worker, one third had a chaplain, one third had a pharmacist, and a few included a bereavement coordinator or volunteer director, suggesting that the hospice model of interdisciplinary care is not being adopted regularly in palliative care programs. In comparison, almost half of hospitals noted established pain services. In conclusion, palliative care programs, although found in a minority of surveyed hospitals, are becoming an established feature of academic medical centers in the United States. More detailed information is needed about the type and quality of care they provide.

BackgroundThe majority of palliative care patients express a preference for remaining at home for as long as possible. Despite progression of disease there is a strong desire to die at home. Nonetheless, there are transfers between care settings, demonstrating a discrepancy between desired and actual place of death.AimTo map the prevalence of patients near death undergoing specialized palliative home care and being transferred to inpatient care in Sweden.MethodsA national retrospective cross-sectional study based on data from the Swedish Register of Palliative Care. Patients ≥ 18 years of age enrolled in specialized palliative home care with dates of death between 1 November 2015 and 31 October 2022 were included (n = 39,698). Descriptive statistics were used.ResultsSeven thousand three hundred eighty-three patients (18.6%), approximately 1,000 per year, were transferred to inpatient care and died within seven days of arrival. A considerable proportion of these patients died within two days after admission. The majority (73.6%) were admitted to specialized palliative inpatient care units, 22.9% to non-specialized palliative inpatient care units and 3.5% to additional care units. Transferred patients had more frequent dyspnoea (30.9% vs. 23.2%, p < 0.001), anxiety (60.2% vs. 56.5%, p < 0.001) and presence of several simultaneous symptoms was significantly more common (27.0% vs. 24.8%, p 0.001).ConclusionThe results show that patients admitted to specialized palliative home care in Sweden are being transferred to inpatient care near death. A notable proportion of these patients dies within two days of admission. Common features, such as symptoms and symptom burden, can be observed in the patients transferred. The study highlights a phenomenon that may be experienced by patients, relatives and healthcare personnel as a significant event in a vulnerable situation. A deeper understanding of the underlying causes of these transfers is required to ascertain whether they are compatible with good palliative care and a dignified death.

In 1994, the Harry R. Horvitz Palliative Care Center opened as a dedicated inpatient palliative care unit within a comprehensive Palliative Care Program in the United States. The program is designated by the World Health Organization as a national and international demonstration project in the provision of palliative care. The mission of the program and the inpatient unit is to provide excellent care for patients with advanced cancer and their families throughout the illness and during bereavement. The need for the 23-bed inpatient unit was documented by the increasing number of cancer deaths each year and the complex physical and psychosocial problems patients and families experience throughout the course of their illness. Health care professionals specially trained in palliative care are an essential component of a dedicated program within a cancer center.

Is the Patient’s Voice Under-Heard in Family Conferences in Palliative Care? A Question From Sydney, Australia

Communication: Communication best practices (e.g., teaching goals of care conversations/

ASCO and IOM recommend palliative care (PC) across health care settings for patients with serious illnesses, including cancer. This study provides an overview of the current availability, structure, and basic quality of PC services within NCCN Member Institutions. A PC survey was developed by NCCN staff and a working group of PC experts from 11 NCCN Member Institutions under the auspices of the NCCN Best Practices Committee. The survey was piloted and refined by 3 working group members and sent electronically to all 26 NCCN Member Institutions. NCCN staff and working group leaders analyzed the survey data. A total of 22 of 26 institutions responded (85%). All respondents (100%) reported an inpatient PC consult service (staffed by an average of 6.8 full-time equivalents [FTEs], seeing 1,031 consults/year with an average length of stay [LOS] of 10 days). A total of 91% of respondents had clinic-based PC (with an average of 469 consults/year, staffed by an average of 6.8 FTEs, and a 17-day wait time). For clinics, a comanagement care delivery model was more common than strict consultation. Home-based PC (23%) and inpatient PC units (32%) were less prevalent. Notably, 80% of institutions reported insufficient PC capacity compared with demand. Across PC settings, referrals for patients with solid tumors were more common than for hematologic malignancies. Automatic or "triggered" referrals were rare. The most common services provided were symptom management (100%) and advance care planning (96%). Most programs were funded through fee-for-service billing and institutional support. Partnerships with accountable care organizations and bundled payment arrangements were infrequent. PC program data collection and institutional funding for PC research were variable across institutions. Despite the prevalence of PC inpatient and clinic services among participating NCCN Member Institutions, PC demand still exceeds capacity. Opportunities exist for expansion of home-based PC and inpatient PC units, optimizing referrals, research, and payer collaborations.

24 Background: Palliative care (PC) improves outcomes for patients with advanced cancer, and current ASCO guidelines recommend early outpatient referral. However, recent data show that PC teams at many cancer centers see more inpatient consults than outpatient visits; the comparative impact of inpatient versus outpatient PC is not well-described. For this reason, we conducted a retrospective cohort study of hospitalized cancer patients to quantify exposure to inpatient/outpatient PC, and to describe associations between PC exposure and end-of-life (EOL) quality measures including hospice utilization, advance care planning (ACP), and intensity of care. Methods: We identified all patients admitted to one cancer center’s inpatient oncology unit during one fiscal year (10/1/2017-9/30/2018). Demographics, admission statistics, inpatient/outpatient PC visits, and EOL outcomes were abstracted from the electronic medical record. Decedents were identified through chart review and public obituaries. Results were summarized by descriptive statistics, and standard statistical tests were used to evaluate associations between PC exposure and EOL outcomes. Results: 842 patients were hospitalized in one year. 522 patients died by the study end-date of 10/1/2020 and were included in analysis. 50% of decedents had any PC exposure prior to death, but only 21% had an outpatient PC visit. Patients seen by PC were younger at time of death, (median: 67 vs 72 years; p &lt;.001) and more likely to be female (52% vs 42%; p =.03). Compared to patients never seen by PC, patients with any PC exposure were significantly more likely to enroll in hospice (78% vs 44%; p &lt;.0001), have do-not-resuscitate status (87% vs 55%; p &lt;.0001), have scanned ACP documents (53% vs 31%; p &lt;.0001), and die at home or inpatient hospice instead of in the hospital (67% vs 40%; p &lt;.01). PC exposure was not associated with differences in 30-day re-admissions, systemic cancer therapy in the last 14 days of life, or intensive care (ICU) utilization in the last 30 days of life. Notably, PC exposure was associated with longer hospital length-of-stay (LOS) (8.4 vs 7.2 days), but this association was reversed for patients seen by outpatient PC versus all others (6.3 vs 8.2 days; p &lt;.01). Patients seen by outpatient PC also had longer hospice LOS (46.5 vs 27.1 days; p &lt;.01) and less EOL ICU use (6% vs 15%; p &lt;.05) compared to all others. Conclusions: In this large retrospective study of hospitalized patients with cancer, PC exposure was associated with significant improvements in multiple EOL quality measures. The subset of patients seen by outpatient PC experienced additional benefits, including shorter hospital LOS, longer hospice LOS, and less EOL ICU utilization. These findings point to differential effects between inpatient and outpatient PC, underscoring the importance of early, longitudinal PC involvement.

BackgroundThe use of virtual reality (VR) for symptom management in palliative care has grown over the last five years; most of the studies have been of its use in hospice...

Practice Problem: At a small community hospital in Virginia, there is an absence of standardized screening processes for identifying intensive care unit (ICU) patients with unmet palliative care needs, contributing to delayed and unequitable access to palliative care consultations. PICOT: The PICOT question that guided this project was “In adult ICU patients, how does implementing a palliative care screening tool upon ICU admission, as compared to standard ICU admission protocol, affect palliative care consultations within an 8-week time frame?" Evidence: This project was guided by consensus reports from the World Health Organization and the Centers to Advance Palliative Care, systematic reviews, and retrospective cohort studies evaluating the use of palliative care screening tools in the acute care setting. Intervention: In a 6-bed ICU, a validated palliative care screening tool was implemented over an 8-week period to screen all ICU patients within 24 hours of admission. Pre and post-implementation data were collected from the electronic medical record to analyze the number of ICU patients screened, patients with positive screenings, and palliative care consultations placed. Outcome: Overall screening compliance was 71 percent for all ICU patients, with 66 percent screened within 24 hours of admission. Although there was not a significant increase in palliative care consultations, the time from ICU admission to consultation decreased by 2.88 days and the ICU mortality rate for patients with consultations decreased by 83 percent. Conclusion: The palliative care screening tool did not generate more palliative care consultations; however, this tool facilitated identification and consultation for patients earlier in the ICU stay. More work is needed to overcome barriers to consultation and expand access to palliative care services throughout all inpatient units.

&lt;sec&gt;&lt;st&gt;Background&lt;/st&gt; Traditionally hospices are seen as providing care and comfort at the end of life. However, many people with a terminal illness have rehabilitation needs – to maintain or improve function, independence and quality of life. This is increasingly the case as benefits of palliative care are being seen as relevant for a widening population with a range of terminal illnesses, and at different stages in their disease. Rehabilitative palliative care aims to empower patients to achieve realistic goals to optimise function and independence within the limitations of their illness, and is increasingly recognised as an essential part of holistic palliative care. However, this approach can seem confusing and at odds with caring for the dying, and may be misunderstood by patients, families and health professionals. This misunderstanding may reduce opportunities for patients to optimise their final weeks and months, and may be especially challenging on the hospice inpatient unit. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Aims&lt;/st&gt; To explore the views and experiences of inpatient unit staff about rehabilitative palliative care, and how these influence models of care and practice. To identify barriers and practices that are helpful, and to begin a conversation about ways to widen opportunities for a rehabilitative approach. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Methods&lt;/st&gt; • qualitative semi-structured interviews • 18 inpatient unit staff • range of health care professions • interviews taped and transcribed verbatim. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Results&lt;/st&gt; Five themes emerged: • perceptions of hospice and palliative care • understanding of ‘palliative rehabilitation’ • patient psychology • staff priorities and experiences • opportunities and barriers. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Conclusions&lt;/st&gt; There are many examples of good rehabilitative practice on the inpatient unit, although these are not often named as such. Barriers to this approach may be rooted in perceptions and misunderstandings at public and organisational levels as well as at the bedside. Opportunities for further developing a rehabilitative approach were seen to depend on time and resources, communication and continuity, teamwork, leadership and identifying ‘champions’. &lt;/sec&gt;

The reduced activity of the growth hormone (GH)-insulin-like growth factor I (IGF-I) axis in aging may contribute to changes in body composition. As this GH insufficiency is due to hypothalamic pathogenesis, the availability of GH-releasing peptides (GHRPs), such as GHRP-6 (His-D-Trp-Ala-Trp-D-Phe-Lys-NH2) which is active even after oral administration, might be useful to restore it. The aim of our study was to verify the effectiveness of oral administration of GHRP-6 in normal elderly subjects and to investigate whether its GH-releasing activity is maintained or vanishes after short-term oral treatment. Seven normal elderly women (aged 65-82 years) were studied. The effect of oral administration of 300 micrograms/kg GHRP-6 on GH secretion was investigated before and after 4 days of treatment with the hexapeptide given twice daily. The GH response to the maximal effective dose of GHRH (1 microgram/kg i.v.) also was studied. Before treatment, oral administration of 300 micrograms/kg GHRP-6 elicited a clear GH rise (peak 10.7 +/- 3.3 micrograms/l; AUC 353.1 +/- 90.6 micrograms.l-1.h-1), which was significantly higher (p < 0.01) than that induced by intravenous GHRH (peak 5.1 +/- 1.5 micrograms/l; AUC 106.5 +/- 43.9 micrograms.l-1.h-1). After 4 days of treatment with GHRP-6, the GH response to the hexapeptide was maintained, with a trend towards an increase (peak 16.8 +/- 2.9 micrograms/l; AUC 499.8 +/- 107.2 micrograms.l-1.h-1). The IGF-I levels were not increased significantly after treatment (77.1 +/- 8.4 vs 84.1 +/- 12.2 micrograms/l).(ABSTRACT TRUNCATED AT 250 WORDS)

The current investigation aimed to assess the antioxidant, antidiabetic and antilipidemic effects of the aqueous extract of aerial part of Cotula cinerea (C. cinerea). Cotula cinerea (Del). which belongs to the Asteraceae family is commonly used traditionally for the treatment of diabetes. The objective of the study was to study the effect of the aqueous C. cinerea extract on glucose and lipid metabolism in normal and streptozotocin-induced diabetic rats using a single and repeated oral administration. A preliminary phytochemical screening and the quantification of phenolic and flavonoid contents as well as the antioxidant activity using three methods (DPPH, FRAP and ABTS) were carried out. The effect of a single and repeated (15 days of treatment) oral administration of the aqueous extract of aerial part of Cotula cinerea (AEAPCC) at a dose of 20 mg/kg on glucose and lipid profile was examined in normal and streptozotocin-induced diabetic rats. Additionally, histopathological examination of the pancreas and liver was carried out according to the Hematoxylin-Eosin method. AEAPCC (20 mg/kg) showed a significant blood glucose-lowering activity in both normal and diabetic rats after a single and repeated oral administration during 15 days. The aqueous extract was also able to decrease the plasma triglycerides levels in both normal and diabetic rats after 15 days of oral treatment at a dose of 20 mg/Kg while no effect was observed on plasma cholesterol levels. In addition, the results show that AEAPCC exhibits an in vitro antioxidant activity using different tests. Histopathological analysis of the pancreas and liver of AEAPCC-treated diabetic rats has revealed that AEAPCC had a beneficial effect on the architecture of these organs while no improvement of glucose tolerance was noticed using the glucose tolerance test. Furthermore, the results showed that the extract is rich in several phytochemical compounds and exhibited an important antioxidant activity. The phytochemical screening revealed that AEAPCC contains polyphenolic compounds, flavonoids, tannins, alkaloids, saponins, quinones, sterols, terpenoids, anthroquinones and reducing sugars. Whereas, it is free from glycosides. In conclusion, this study demonstrates that Cotula cinerea possesses a beneficial effect on diabetes. Further investigations are required to study the mechanism of action of the antidiabetic effect of this plant.