Community Palliative Care Initiatives to Reduce End-of-Life Hospital Utilization and In-Hospital Deaths: A Population-Based Observational Study Evaluating Two Home Care Interventions.

CONTEXT: The end-of-life period is characterized by increased hospital utilization despite patients' preferences to receive care and die at home. OBJECTIVES: To evaluate the impact of interventions aimed at planning for a home death (Yellow Folder) and managing symptoms in the home (Symptom Response Kit) on place of death and hospital utilization among palliative home care patients. METHODS: This was an ecologic and retrospective cohort study of palliative home care patients in southeastern Ontario from April 2009 to March 2014. Linked health administrative and clinical databases were used to identify palliative home care patients and their receipt of the interventions, hospitalizations, emergency department visits, and place of death. Bivariable and multivariable regressions were used to evaluate outcomes according to patients' receipt of intervention(s). RESULTS: The proportion of patients who died in the community increased after implementation of the interventions, from 42.8% to 48.5% (P < 0.0001). Compared with patients who received neither intervention, patients who received the Yellow Folder or Symptom Response Kit had an increased likelihood of dying in the community, with the largest relative risk observed in patients who received both interventions (relative risk = 2.20, 95% confidence interval 2.05-2.36). Receipt of these interventions was only associated with reductions in hospitalization or emergency department visit rates in the six months before death. CONCLUSION: Patients who received the Yellow Folder or Symptom Response Kit were more likely remain at home at the end of life. This association was stronger when these interventions were used together.

Predictors of hospital stay and home care services use: a population-based, retrospective cohort study in stage IV gastric cancer.

BACKGROUND: Home care services use has been proposed as a means of reducing costs in palliative care by decreasing hospital stay without impacting quality of clinical care; however, little is known about utilization of these services in the time following a terminal cancer diagnosis. AIM: To examine disease, patient and healthcare system predictors of hospital stay, and home care services use in metastatic gastric cancer patients. DESIGN: This is a population-based, retrospective cohort study. Chart review and administrative data were linked, using a 26-month time horizon to collect health services data. PARTICIPANTS: All patients diagnosed with metastatic gastric cancer in the province of Ontario between 2005 and 2008 were included in the study (n = 1433). RESULTS: Age, comorbidity, tumor location, and burden of metastatic disease were identified as predictors of hospital stay and receipt of home care services. Individuals who received home care services spent fewer days in hospital than individuals who did not (relative risk: 0.44; 95% confidence interval: 0.38-0.51). Patients who interacted with a high-volume oncology specialist had shorter cumulative hospital stay (relative risk: 0.62; 95% confidence interval: 0.54-0.71) and were less likely to receive home care services (relative risk: 0.80; 95% confidence interval: 0.72-0.88) than those who did not. CONCLUSION: Examining how differences in hospital stay and home care services use impact clinical outcomes and how policies may reduce costs to the healthcare system is necessary.

Health system characteristics of quality care delivery: a comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada.

BACKGROUND: A number of palliative care delivery models have been proposed to address the structural and process gaps in this care. However, the specific elements required to form competent systems are often vaguely described. AIM: The purpose of this study was to explore whether a set of modifiable health system factors could be identified that are associated with population palliative care outcomes, including less acute care use and more home deaths. DESIGN: A comparative case study evaluation was conducted of 'palliative care' in four health regions in Ontario, Canada. Regions were selected as exemplars of high and low acute care utilization patterns, representing both urban and rural settings. A theory-based approach to data collection was taken using the System Competency Model, comprised of structural features known to be essential indicators of palliative care system performance. Key informants in each region completed study instruments. Data were summarized using qualitative techniques and an exploratory factor pattern analysis was completed. RESULTS: 43 participants (10+ from each region) were recruited, representing clinical and administrative perspectives. Pattern analysis revealed six factors that discriminated between regions: overall palliative care planning and needs assessment; a common chart; standardized patient assessments; 24/7 palliative care team access; advanced practice nursing presence; and designated roles for the provision of palliative care services. CONCLUSIONS: The four palliative care regional 'systems' examined using our model were found to be in different stages of development. This research further informs health system planners on important features to incorporate into evolving palliative care systems.

Effective palliation and quality of life outcomes in studies of surgery for advanced, non-curative gastric cancer: a systematic review.

BACKGROUND: Relief of symptoms should be the primary focus of palliative treatment as defined by the World Health Organization. Evaluating the effectiveness of palliative interventions should incorporate this goal and include quality of life (QOL) outcome assessments. A systematic review of the surgical gastric cancer literature was performed to summarize the effectiveness of palliative surgical interventions in addressing QOL. METHODS: An electronic literature search of EMBASE, Medline, and the Cochrane Database of Controlled Trials was performed from January 1, 1985 to December 1, 2009. English language abstracts and articles were reviewed independently by two reviewers. A systematic approach to data abstraction and presentation was followed. RESULTS: No articles were identified as reporting true QOL outcomes using reliable, validated QOL instruments in surgically managed, advanced gastric cancer patients. Nine articles were identified as reporting outcomes measuring effectiveness of palliation. Commonly reported pre-procedure symptoms were weight loss, abdominal pain, vomiting, obstruction, and bleeding. Time to oral intake was reported in 5 of 9 studies, ranging from a mean of 2.9 days (laparoscopic gastrojejunostomy) to 8 days (surgical bypass). Length of postoperative inpatient stay ranged from a mean of 7 days (gastrojejunostomy) to 28 days (surgical bypass). Other measures of effective palliation included measures of clinical success, hospital re-admission rates, and post-procedure analgesic intake. CONCLUSION: A paucity of literature exists regarding the QOL of surgically managed gastric cancer patients. Prospectively designed studies using credible QOL measures are necessary to better inform the treatment decision-making process for these patients.

Inhaled fentanyl citrate improves exercise endurance during high-intensity constant work rate cycle exercise in chronic obstructive pulmonary disease.

CONTEXT: Activity limitation and dyspnea are the dominant symptoms of chronic obstructive pulmonary disease (COPD). Traditionally, efforts to alleviate these symptoms have focused on improving ventilatory mechanics, reducing ventilatory demand, or both of these in combination. Nevertheless, many patients with COPD remain incapacitated by dyspnea and exercise intolerance despite optimal therapy. OBJECTIVES: To determine the effect of single-dose inhalation of nebulized fentanyl citrate (a µ-opioid agonist drug) on exercise tolerance and dyspnea in COPD. METHODS: In a randomized, double-blind, placebo-controlled, crossover study, 12 stable patients with COPD (mean ± standard error of the mean post-ß(2)-agonist forced expiratory volume in one second [FEV(1)] and FEV(1) to forced vital capacity ratio of 69% ± 4% predicted and 49% ± 3%, respectively) received either nebulized fentanyl citrate (50 mcg) or placebo on two separate days. After each treatment, patients performed pulmonary function tests and a symptom-limited constant work rate cycle exercise test at 75% of their maximum incremental work rate. RESULTS: There were no significant postdose differences in spirometric parameters or plethysmographic lung volumes. Neither the intensity nor the unpleasantness of perceived dyspnea was, on average, significantly different at isotime (5.0 ± 0.6 minutes) or at peak exercise after treatment with fentanyl citrate vs. placebo. Compared with placebo, fentanyl citrate was associated with 1) increased exercise endurance time by 1.30 ± 0.43 minutes or 25% ± 8% (P=0.01); 2) small but consistent increases in dynamic inspiratory capacity by ∼0.10 L at isotime and at peak exercise (both P≤0.03); and 3) no concomitant change in ventilatory demand, breathing pattern, pulmonary gas exchange, and/or cardiometabolic function during exercise. The mean rate of increase in dyspnea intensity (1.2 ± 0.3 vs. 2.9 ± 0.8 Borg units/minute, P=0.03) and unpleasantness ratings (0.5 ± 0.2 vs. 2.9 ± 1.3 Borg units/minute, P=0.06) between isotime and peak exercise was less after treatment with fentanyl citrate vs. placebo. CONCLUSION: Single-dose inhalation of fentanyl citrate was associated with significant and potentially clinically important improvements in exercise tolerance in COPD. These improvements were accompanied by a delay in the onset of intolerable dyspnea during exercise near the limits of tolerance.

Resource use and costs of end-of-Life/palliative care: Ontario adult cancer patients dying during 2002 and 2003.

The objective of this study is to estimate the direct medical cost of end-of-life and palliative (EOL/PAL) care for cancer patients during the last six months of their lives--or, during the period from diagnosis to death, if briefer--in 2002 and 2003, in Ontario, Canada. A linkage of cancer registry and administrative data is used to determine the costs of health care resources used during the EOL/PAL care period. Costs are analyzed by cancer diagnosis, location of death, and type of service. The total Ontario Ministry of Health-funded cost of EOL/PAL care for cancer patients is estimated to be about CAD$544 million per year, with an average per patient cost of about $25,000 in 2002-2003. Our results suggest that acute care consumes 75 percent of EOL/PAL funding and that only a small proportion of health care services used by EOL/PAL care cancer patients is likely to be formal palliative care.

Prognosticating in palliative care: a survey of Canadian palliative care physicians.

OBJECTIVE: To determine how palliative care physicians view the accuracy and importance of prognostication, what information they consider, and what processes they use. METHODS: A questionnaire was sent to members of the Canadian Society of Palliative Care Physicians (CSPCP). Respondents recorded their perceptions about prognostication and the factors they considered when predicting survival. A patient scenario was described in which a prognosis was requested by two different people: a patient's daughter and a palliative care admissions coordinator. RESULTS: 90 responses were received from 219 CSPCP members (41.1 percent). There was moderate agreement between respondents' perceptions of their own accuracy and that of other physicians (K = 0.549). Of all the respondents, 89.9 percent believed that prognosticating was somewhat or very important. They considered clinical factors most commonly when prognosticating. A range of predictions was given for the scenario; often, the same physician gave different answers to the two people requesting a prognosis. CONCLUSION: Palliative care physicians believe that prognostication is important and use clinical factors to estimate survival. They often give different estimates to different information recipients.

Factors Associated with End-of-Life Health Service Use in Patients Dying of Cancer.

This study describes acute care hospital death, physician house calls and home care near the end of life among patients who died of cancer and the factors that are associated with these events and services. It is a population-based retrospective study that uses linked administrative healthcare data. The cohort includes all patients who died of cancer between 2000 and 2004 in Ontario, Canada.Fifty-five per cent of patients died in acute care hospital, 68% received home care in the last 6 months of life and 24% received at least one physician house call in the last 2 weeks of life. Increased age was associated with a decreased likelihood of each event or service. Women were less likely to die in acute care and more likely to receive home care. Residents in low-income neighbourhoods were less likely to receive house calls or home care. Patients who received home care or house calls were less likely to die in acute care.Our observations add to those in the literature, suggesting a need to increase the use of supportive care services at the end of life in hopes of decreasing the need for acute care. They also serve as a baseline for future comparison, which is of particular interest since new government policies directed at end-of-life care were recently introduced.

Palliative Care Integration Project (PCIP) quality improvement strategy evaluation.

This study evaluated the effectiveness of implementation of common assessment tools, collaborative care plans, and symptom management guidelines for cancer patients as a strategy to improve the quality, coordination, and integration of palliative care service across organizations and health care sectors. A pre-post design to measure the impact on symptom management, caregiver burden and satisfaction with care delivery, and service utilization was used. Two cohorts of eligible patients and caregivers completed Edmonton Symptom Assessment Scales, Caregiver Reaction Assessment and FAMCARE Scales and chart audits were conducted. Administrative data from each participating site were examined for utilization trends. Audits of 53 charts preimplementation and 63 postimplementation showed an increase in documentation of pain from 24.5% to 74.6% (P<0.001) of charts. Administrative data showed a decrease in the percentage of patients with at least one emergency room visit from 94.3% to 84.8% (P<0.001), in the percentage of patients with at least one admission to the acute care hospital (P<0.001), and deaths in acute care 43.1%-35.7% (P=0.133). There was minimal change in the intensity of symptoms (P=0.591), and no change in the burden on the caregiver (P=0.086) or caregiver satisfaction with care (P=0.942). This study showed that implementation of common assessment tools, collaborative care plans, and symptom management guidelines across health sectors can result in some increased documentation of symptoms and efficiencies in care. Future projects should consider imbedding a continuous quality improvement methodology and longer timelines into their projects to improve outcomes.

The management of dyspnea in cancer patients: a systematic review.

GOALS OF WORK: The goal of the study is to evaluate the effectiveness of four drug classes (opioids, phenothiazines, benzodiazepines, and systemic corticosteroids) for relieving dyspnea experienced by advanced cancer patients. MATERIALS AND METHODS: A systematic literature review was conducted to July 2006. Search sources included MEDLINE, EMBASE, HealthSTAR, CINAHL, and the Cochrane Library. Four reviewers selected evidence using predefined criteria: controlled trials not limited to cancer and involving the specified drug classes for dyspnea treatment. MAIN RESULTS: Three systematic reviews, one with meta-analysis, two practice guidelines, and 28 controlled trials were identified. Most examined the effect of opioids, generally morphine, on dyspnea. Although the results of individual trials were mixed, the systematic review with meta-analysis detected a significant benefit for dyspnea with systemic opioids; two small placebo-controlled trials in cancer patients found systemic morphine reduced dyspnea, and dihydrocodeine also significantly reduced dyspnea in four placebo-controlled trials. Nebulized morphine was not effective in controlling dyspnea in any study or the meta-analysis. No controlled trials examined systemic corticosteroids in the treatment of cancer patients, and of the other non-opioid drugs examined, only oral promethazine, a phenothiazine, showed some benefit in the relief of dyspnea. Studies varied in methodological quality. CONCLUSIONS: Systemic opioids, administered orally or parenterally, can be used to manage dyspnea in cancer patients. Oral promethazine may also be used, as a second-line agent if systemic opioids cannot be used or in addition to systemic opioids. Nebulized morphine, prochlorperazine, and benzodiazepines are not recommended for the treatment of dyspnea, and promethazine must not be used parenterally.

Stress and coping with advanced cancer.

OBJECTIVE: For people with advanced cancer, the months preceding death can be very stressful. Moreover, cancer-related stressors can arise within multiple dimensions. However, little research has examined how people cope differentially with different types of stressors. The goal of this study was to examine patterns of coping across different dimensions of stress. METHOD: Fifty-two patients who were receiving palliative care for cancer were asked to indicate their most significant stressors within social, physical, and existential dimensions. A structured interview was then conducted to describe how the participants coped with these stressors. RESULTS: Overall, stressor severity ratings were correlated significantly across the three dimensions, although physical symptoms received the highest mean rating. Participants generally used a range of coping strategies to deal with their stressors, but there were clear differences across dimensions in the relative use of problem-focused versus emotion-focused strategies. Problem-focused coping was less frequent for existential issues, whereas emotion-focused strategies were used less frequently for physical stressors. Coping efforts were not clearly related to psychological distress. SIGNIFICANCE OF RESULTS: Although coping is an important research theme within psycho-oncology, it may be overly broad to ask, "How do people cope with cancer"? In fact, different cancer-related stressors are coped with in very different ways. There is not necessarily any particular pattern of coping that is best for relieving psychological distress.

Parenteral ketamine as an analgesic adjuvant for severe pain: development and retrospective audit of a protocol for a palliative care unit.

BACKGROUND: Ketamine is an effective analgesic agent for treating a variety of neuropathic and cancer pain syndromes. Recent studies indicate that ketamine may have a particular role in the management of patients with neuropathic and/or pain syndromes that are poorly responsive to opioids. OBJECTIVE: To develop, implement, and subsequently assess a protocol designed to maximize the analgesic effect of ketamine while minimizing its side effects. DESIGN: A retrospective chart audit of 16 patients who had used the ketamine protocol over a 12-month period. Criteria for assessing the effectiveness of ketamine were defined. RESULTS: Ketamine was an effective, well-tolerated analgesic adjuvant for 11 of 16 patients with previously uncontrolled pain. Pain scores were reduced by at least 4 of 10 in 15 of the 16 patients. Median opioid dose reduction on starting ketamine was 25%. CONCLUSION: The audit confirmed the safety and effectiveness of ketamine as an analgesic adjuvant for patients with severe pain. Baseline opioid dose reduction and prophylactic use of haloperidol or benzodiazepine were effective in minimizing psychotomimetic side effects.

Structured interview assessment of symptoms and concerns in palliative care.

OBJECTIVE: Assessment in palliative care requires a multidimensional review of physical symptoms and psychosocial concerns in a format appropriate for patients with advanced illness. In this study, we describe the initial development and validation of a structured interview for assessing common symptoms and concerns faced by terminally ill individuals. METHOD: We constructed a 13-item Structured Interview for Symptoms and Concerns (SISC) based on a review of end-of-life issues and administered it to 69 patients receiving palliative care for advanced cancer. Along with the interview, each participant completed visual analog scales (VAS) addressing the same constructs. Test-retest and interrater reliability were determined, as was the concordance between interview ratings and VAS scores. RESULTS: Overall, the interview items had excellent interrater reliability (intraclass correlations were > 0.90) and at least moderate temporal stability (test-retest correlations ranged from 0.50 to 0.90). Concurrent validity was evident in the good concordance between interview items and VAS measures (correlations were > 0.70). The SISC was also sensitive to individual differences between subgroups of participants who did or did not meet diagnostic criteria for anxiety or depressive disorders. CONCLUSIONS: This study demonstrates that structured interviews provide a reliable and valid approach to assessment in palliative care and may be an appropriate alternative for some research applications.

Family caregiver burden: results of a longitudinal study of breast cancer patients and their principal caregivers.

BACKGROUND: The vital role played by family caregivers in supporting dying cancer patients is well recognized, but the burden and economic impact on caregivers is poorly understood. We prospectively examined the psychosocial, occupational and economic impact of caring for a person with a terminal illness. METHODS: We studied 89 caregivers of women with advanced breast cancer receiving care at either the Ottawa or Hamilton regional cancer centres in Ontario. Patients were followed until their death or study completion at 3 years. Patients identified a principal caregiver to participate in the study. The Karnofsky Performance Status (KPS) index, the Medical Outcomes Study 36-item Short Form (SF-36), the Hospital Anxiety and Depression Scale, the Zarit Burden Inventory, FAMCARE and the Medical Outcomes Study Social Support Survey were administered during follow-up. Economic data were collected by means of a questionnaire administered by an interviewer. Assessments were conducted every 3 months during the palliative period (KPS score > 50) and every 2 weeks during the terminal period (KPS score < or = 50). RESULTS: Over half of the caregivers were male (55%) and the patient's spouse or partner (52%), with a mean age of 53 years. At the start of the palliative period, the caregivers' mean physical functioning score was better than the patients' (51.3 v. 35.1, 95% confidence interval [CI] 13.3-20.0); there were similar mean mental functioning scores (46.6 and 47.1 respectively); similar proportions were depressed (11% and 12%); and significantly more caregivers than patients were anxious (35% v. 19%, p = 0.009). More caregivers were depressed (30% v. 9%, p = 0.02) and had a higher level of perceived burden (26.2 v. 19.4, p = 0.02) at the start of the terminal period than at the start of the palliative period. Burden was the most important predictor of both anxiety and depression. Of employed caregivers, 69% reported some form of adverse impact on work. In the terminal period 77% reported missing work because of caregiving responsibilities. Prescription drugs were the most important component of financial burden. INTERPRETATION: Caregivers' depression and perceived burden increase as patients' functional status declines. Strategies are needed to help reduce the psychosocial, occupational and economic burden associated with caregiving.

Women's decision-making needs regarding place of care at end of life.

Little is known about the decision-making needs of terminally ill women who are considering options for place of care at the end of life. A pilot study was conducted with a sample of 20 terminally ill women with advanced cancer to identify factors taken into consideration in making this decision. Participants were interviewed using a semistructured questionnaire incorporating the domains of quality of end-of-life care and based on the Ottawa Decision Support Framework. Results suggested a gap between the preferred (home, n = 13) and the actual (palliative care unit, n = 16) place of care. Discrepancies about place of care may be related to conflicting subjective factors such as being a burden to family versus having the opportunity to strengthen relationships with family and friends. Participants who were actively engaged in making the decision scored the highest levels of decisional conflict. Previous studies have shown an association between high decisional conflict scores and decision delay. Although findings from this small study are preliminary, they suggest that the decision regarding place of terminal care is complex with multiple competing factors being considered.

Should meta-analysts search Embase in addition to Medline?

It is widely accepted that meta-analysts should search multiple databases. The selection of databases is ideally based on the potential contribution of each database to the project or on the potential for bias if a database is excluded, as supported by research evidence. We explore whether searching Embase yields additional trials that influence a meta-analysis. We identified meta-analyses that searched Medline and Embase. A random-effects weighted mean method was used to estimate the intervention effect in articles indexed only in Embase compared with those indexed elsewhere. On average, Embase-unique trials yielded significantly smaller estimates by 29% (ratio of odds ratio [ROR] 0.71, 95% confidence interval [CI] 0.56-0.90) but influenced the pooled estimate by an average of only 6% (ROR 0.94, 95% CI 0.88-0.99). Searching Medline but not Embase risks biasing a meta-analysis by finding studies that show larger estimates, but their prevalence seems low enough that the risk may be slight, provided the rest of the search is comprehensive.

Low dose ketamine as an analgesic adjuvant in difficult pain syndromes: a strategy for conversion from parenteral to oral ketamine.

Ketamine is a non-competitive N-methyl D-aspartate (NMDA) receptor antagonist with analgesic and dissociative anesthetic properties. Low dose or sub-anesthetic doses of ketamine have been used effectively as either a primary analgesic or analgesic adjuvant in a variety of pain syndromes. In this paper, three patients with difficult to treat, predominantly neuropathic pain syndromes will be described. Their pain syndromes were initially managed successfully with the addition of low dose parenteral ketamine as an analgesic adjuvant. The strategy of concurrently starting ketamine at a low dose, i.e., 40-60 mg over 24 hours, with a benzodiazepine proved effective in preventing psychotomimetic side effects. An unavoidable shortage of ketamine prompted a literature search, which suggested that the equianalgesic dose of oral ketamine could be lower than the parenteral dose. Subsequently the patients were converted to oral ketamine at doses 30 to 40% of the previous parenteral dose. Their pain syndromes remained controlled on the lower dose of oral ketamine with remarkably few side effects. The implications of this warrant further discussion and study.