Burnout Prevalence and Associated Factors Among Palliative and Hospice Care Professionals During the COVID-19 Endemic: An Exploratory Survey.

BACKGROUND: Burnout is a significant issue for palliative and hospice professionals, exacerbated by the impact of Coronavirus Disease 2019 (COVID-19) on healthcare professionals. It is crucial to update our understanding of prevalence data, identify associated factors, and evaluate support resources during the COVID-19 pandemic. METHODS: We aimed to explore the prevalence of burnout among palliative and hospice care workers, 2 years into the COVID-19 pandemic by using the Maslach's Burnout Inventory; anxiety, using General Anxiety Disorder-7 (GAD-7), workload, risk perception of COVID-19, confidence in protective measures (personal, workplace, and government), and usage and perceived helpfulness of support resources. Univariate logistic regression analysis was conducted to analyse burnout against these factors. RESULTS: Of the 115 respondents encompassing doctors, nurses and social workers (76.5% female; average age 40.9), 48.7% experienced burnout. Burnout correlated with increased anxiety, higher COVID-19 risk perception, heavier workload, and reduced confidence in protective measures. Peer support, COVID information, and psychological programs were rated as the most effective for coping. CONCLUSION: The study indicates considerable levels of burnout among palliative and hospice care workers, linked to workload, anxiety, and perceived risk. Traditional mental health interventions had limited efficacy; respondents favoured peer support and organisational changes. The findings stress the need for a holistic approach, including diverse resources, workload management, and regular mental health assessments.

Comparing situational influences on differential healthcare utilization trajectories in patients on home palliative care: A qualitative study.

OBJECTIVES: Patients with terminal cancer receiving home palliative care present differential healthcare utilization trajectories before death. It remains unclear which situational elements influence these trajectories among disparate patient groups. The aim of this study was to compare situational influences on "persistently high" and "low stable" trajectories of healthcare utilization in patients who received palliative care support at home. METHODS: Bereaved family caregivers were recruited from our prior quantitative study investigating healthcare utilization trajectories in oncology patients on home-based palliative care. In-depth interviews were conducted with 30 family caregivers. Data were analyzed using thematic analysis. RESULTS: Analysis of data uncovered how the 2 utilization trajectories were influenced by the interplay of 1 or more of 4 situational elements. Perceived symptom control in patients, influenced by their determination to die at home, shapes the susceptibility to situational contingencies, resulting in differential utilization trajectories. Caregivers' mental readiness in dealing with unexpected circumstances has a significant impact on the overall manageability of care, ultimately affecting decisions related to healthcare utilization. The concordance between symptom needs and scope of homecare services in a given situation proves to be an important determinant. Lastly, perceived accessibility to informal support in times of need acts as a contextual reinforcement, either preventing or precipitating decisions regarding healthcare utilizations. SIGNIFICANCE OF RESULTS: Our findings hold important implications for the provision of homecare services, in particular, the need for comprehensive assessment of end-of-life wishes during homecare enrolment and strengthening psychological preparedness of caregivers. Expansion of home-based clinical interventions tailored to high utilizers, and funding for temporary in-home respite should be considered to optimally manage potentially preventable acute healthcare utilization.

"I don't know whether I will be alive or not" - An interpretative phenomenological analysis of young adult males with Duchenne Muscular Dystrophy making sense of self and life.

BACKGROUND: With ventilatory support, boys with Duchenne Muscular Dystrophy (DMD) now live longer. The emerging adulthood offers unanticipated opportunities for identity exploration. Existing literature has raised issues around transitions and implicit obligations within structural and sociological domains; intrinsic challenges are posed, while concurrently engendering possibilities in an uncertain future. OBJECTIVE: Reveal lived experience and meaning making among men with advanced DMD living outside the western context. METHODS: Secondary data, essentially transcripts of semi-structured interviews with five young men with DMD, age ranging from 23 to 37 years, conducted as part of a larger study were analysed iteratively in depth. Given their underlying vulnerability associated with significant physical dependencies, all respondents were receiving palliative care from the local hospice, and lived with family caregivers at home. RESULTS: Three themes encapsulated the essence of their lifeworld at this juncture. Each shared poignant stories of having survived adverse circumstances in the past, learning to live with themselves in the current state of disabilities and disconnection with peers. Yet, moments of yearning surface, to make new friends and find gainful employment like everyone else. Ambivalence notwithstanding, they navigated societal marginalization through digital media, or found meaning in family bonding and existential dimensions. Faced with uncertainty, most embraced the status quo in silent resignation, to minimise disappointment or as pragmatic responses to enduring systemic and personal barriers. CONCLUSIONS: Study findings expounded challenges men with advanced DMD grappled that ultimately shaped self-identity. Healthcare professionals could support this group of precarious survivors even better through individualised person-centred care.

Utilisation of after-hours telephone support in a home-based hospice service.

BACKGROUND: After-hours support from hospice providers is instrumental to patients with serious illness who choose to remain at home, particularly at end of life. Utilisation of out-of-hours support has been much characterised in terms of frequency and nature of calls, but more needs to be known to inform service customisation and resource allocation to optimise care. To this end, we stratify reasons for using the after-hours helpline according to time sensitivity, and to explore disease and person factors associated with urgent calls. METHOD: Electronic medical records for incoming calls from external parties outside workhours within a large home hospice in Singapore were analysed inductively, to identify patterns and associations along study objectives. Individual code books for caller type and call reasons were created and tested in vivo, and later administered to extracted data. Patients that accessed the helpline were tracked for different outcomes, including hospital admissions and on-call home visits. Logistic regression modelling was performed to categorise call reasons by urgency and to identify disease and person factors associated with time sensitive calls. RESULTS: More than 5,000 calls to the helpline were made over a two-year period (2019-2020), predominantly by family caregivers (88.4%). These were in relation to 2,303 unique patients (38.9% of total patients served). After-hours calls were made an average of 2.3 times by patients across various lengths of service. Only 11.9% of calls were deemed time sensitive or urgent, requiring home visits by on-call staff (4%) or resulting in admission to hospital (7.9%). The majority were managed by primary care teams on the next workday (65.1%) and the remainder sorted during the after-hours call itself (22.3%). Call reasons or presenting issues were classified into two groups according to urgency. Calls in the year 2020, from the younger patient, preferred place of death outside the home, and caller types other than patient or healthcare worker were significantly associated with urgent calls. CONCLUSION: Deeper characterisation of after-hours calls offers possibilities: service redesign for optimal resourcing and customised training for better care. Ultimately, planners, providers, and patients all stand to benefit.

Longitudinal patterns and predictors of healthcare utilization among cancer patients on home-based palliative care in Singapore: a group-based multi-trajectory analysis.

BACKGROUND: Home-based palliative care (HPC) is considered to moderate the problem of rising healthcare utilization of cancer patients at end-of-life. Reports however suggest a proportion of HPC patients continue to experience high care intensity. Little is known about differential trajectories of healthcare utilization in patients on HPC. Thus, we aimed to uncover the heterogeneity of healthcare utilization trajectories in HPC patients and identify predictors of each utilization pattern. METHODS: This is a cohort study of adult cancer patients referred by Singapore Health Services to HCA Hospice Service who died between 1st January 2018 and 31st March 2020. We used patient-level data to capture predisposing, enabling, and need factors for healthcare utilization. Group-based multi-trajectory modelling was applied to identify trajectories for healthcare utilization based on the composite outcome of emergency department (ED) visits, hospitalization, and outpatient visits. RESULTS: A total of 1572 cancer patients received HPC (median age, 71 years; interquartile range, 62-80 years; 51.1% female). We found three distinct trajectory groups: group 1 (31.9% of cohort) with persistently low frequencies of healthcare utilization, group 2 (44.1%) with persistently high frequencies, and group 3 (24.0%) that begin with moderate frequencies, which dropped over the next 9 months before increasing in the last 3 months. Predisposing (age, advance care plan completion, and care preferences), enabling (no medical subsidy, primary decision maker), and need factors (cancer type, comorbidity burden and performance status) were significantly associated with group membership. High symptom needs increased ED visits and hospitalizations in all three groups (ED visits, group 1-3: incidence rate ratio [IRR] 1.74-6.85; hospitalizations, group 1-3: IRR 1.69-6.60). High home visit intensity reduced outpatient visits in all three groups (group 1-3 IRR 0.54-0.84), while it contributed to reduction of ED visits (IRR 0.40; 95% CI 0.25-0.62) and hospitalizations (IRR 0.37; 95% CI 0.24-0.58) in group 2. CONCLUSIONS: This study on HPC patients highlights three healthcare utilization trajectories with implications for targeted interventions. Future efforts could include improving advance care plan completion, supporting care preferences in the community, proactive interventions among symptomatic high-risk patients, and stratification of home visit intensity.

Communicating with young children who have a parent dying of a life-limiting illness: a qualitative systematic review of the experiences and impact on healthcare, social and spiritual care professionals.

BACKGROUND: Healthcare professionals play a key role in interacting with children who have a parent with a life-limiting illness. While playing such a role can be challenging, not much is known about how such interactions impact these professionals and affect their ability to render support. METHODS: Four databases were searched with the intention to conduct a qualitative systematic review. Articles were selected based on pre-determined inclusion and exclusion criteria. Their quality was assessed using the tool "Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields". Findings were analysed using thematic analysis techniques outlined by Thomas and Harden as well as Sandelowski and Barroso. Review was registered with the Review Registry database. RESULTS: Three themes emerged - healthcare professionals' discomfort; their assumptions and actions; and potentiating workplace factors. The discomfort had several dimensions: fear of making a situation worse, concern of not being able to cope with emotionally charged situations, and internal conflict that arose when their values clashed with family dynamics. CONCLUSION: Healthcare professionals' sense of discomfort was very pronounced. This discomfort, together with their assumptions, could impact their ability to support children. The organisation played an important role, which was reflected in the work culture, workflow and ability to collaborate with other agencies involved in supporting children. The discomfort was mitigated by having more professional experience, workplace support systems and training on communicating with children. It was apparent that the individual professional did not work alone when supporting children but alongside others within an organisation. As such, issues raised in this review will benefit from multi-faceted solutions.

An open-label clinical trial of oral transmucosal haloperidol and oral transmucosal olanzapine in the treatment of terminal delirium at home.

BACKGROUND: The phenomenon of restlessness, agitation, or cognitive disturbances experienced by dying patients is well-known in palliative care; more than half of these patients will experience delirium symptoms at end-of-life. When not identified early and effectively managed, delirium symptoms could lead to caregiver and patient distress and harm. METHODS: Eighty patients with a prognosis of 7 days or less will be recruited for an open-label randomised control trial. The two arms compare oral-transmucosal haloperidol 2.5 mg vs olanzapine 5 mg over 72 h. The severity of agitation, delirium and toxicities of treatments will be compared at the 24th, 48th and 72nd hour after drug administration. DISCUSSION: This trial is the first to compare anti-psychotics in the management of delirium at the dying stage in the home hospice setting using the oral transmucosal route. Ethical considerations, as well as recruitment procedures, are discussed. TRIAL REGISTRATION: This study was registered in ClinicalTrials.gov - identifier NCT04750395.

Parenteral Lidocaine for Complex Cancer Pain in the Home or Inpatient Hospice Setting: A Review and Synthesis of the Evidence.

Background: Cancer pain can remain refractory despite escalating opioids and adjuvants. Systemic Lidocaine is an option, but current approaches are hospital centered. While advantageous in advanced cancer, evidence is lacking for parenteral Lidocaine use in community-based care. Objectives: Review evidence for parenteral lidocaine in complex cancer pain outside the hospital setting. Design: Systematic review of peer-reviewed articles of any study design, including reviews. Search in four databases used keyword variations of "cancer," "pain," "Lidocaine," and "parenteral." Search was extended through reference lists of full texts assessed. Abstracted data from articles screened and selected were synthesized narratively by a palliative care clinician in Singapore. Results: Eight hundred eighty-three articles identified were screened by title and abstract. Twenty-eight full texts were assessed. Seven articles fulfilled criteria for synthesis of findings. A total of 73 patients received parenteral Lidocaine for mixed pains, reported collectively in 1 retrospective chart review, 3 practice guidelines, 2 case series, and 1 case study. Intravenous or subcutaneous Lidocaine was commenced in hospital or hospice and continued at home. Dosages and administration schedules varied, involving slow bolus with continuous infusion or the latter alone, for up to 240 days. All produced positive outcomes, with no severe adverse events. Monitoring included routine vital signs and conscious levels; electrocardiogram, liver, and renal function tests were uncommon. Lidocaine levels were not consistently assessed. Conclusion: Parenteral Lidocaine can be effective and safe in the community setting. More empirical studies are needed to inform patient selection and treatment protocol, and to validate expected outcomes.

Who needs and continues to need paediatric palliative care? An evaluation of utility and feasibility of the Paediatric Palliative Screening scale (PaPaS).

BACKGROUND: While the populations of children who can benefit from paediatric palliative care (PPC) have been broadly defined, identifying individual patients to receive PPC has been problematic in practice. The Paediatric Palliative Screening scale (PaPaS) is a multi-dimensional tool that assesses palliative care needs in children and families to facilitate timely referrals. This study evaluates its use to manage new referrals and ongoing review of patients receiving home-based PPC in Singapore. METHODS: Using a retrospective cohort study design, 199 patients admitted to receive PPC via clinician screening were scored using PaPaS. Eighty-four patients in two groups were scored again at one of two following milestones: one-year service continuation mark or point of discharge before a year. Accuracy measures were compared against clinical assessment. RESULTS: 96.98% of patients scored 15 and above on admission (indicating need for PPC). Patients assessed at following milestones were effectively stratified; those who continued to receive service after 1 year scored significantly higher (M = 19.23) compared to those who were discharged within a year (M = 7.86). Sensitivity and specificity for PaPaS were calculated at 82.54 and 100% respectively. Overall congruence with clinician-based decisions supports the utility of PaPaS as a screening tool in PPC. Recommendations to improve the scale further are proposed. CONCLUSION: The PaPaS is a practical screening tool that signposts PPC needs within the clinical setting. This facilitates early referrals to PPC, without having to specify individual prognoses that are often uncertain. Other benefits include optimised continuity of care and implications for resource allocation.