A multi-centre study on patients dying from COVID-19: communication between clinicians, patients and their families.

BACKGROUND: COVID-19 has led to challenges in providing effective and timely communication in healthcare. Services have been required to adapt and evolve as successful communication remains core to high-quality patient-centred care. AIM: To describe the communication between admitted patients, their families and clinicians (medical, nursing, allied health) during end-of-life care. METHODS: This retrospective review included all patients (n = 230) who died directly due to COVID-19 at five Melbourne hospitals between 1 January and 31 December 2020. Contacts and modality used (face to face, video, telephone) during the 8 days prior to death were recorded. RESULTS: Patients were predominantly elderly (median age 86 years) and from residential aged care facilities (62%; n = 141). Communication frequency increased the closer the patient was to death, where on day of death, contact between clinicians and patients was 93% (n = 213) clinicians and families 97% (n = 222) and between patients and families 50% (n = 115). Most contact between patients and families was facilitated by a clinician (91.3% (n = 105) day of death) with the most commonly used mode being video call (n = 30 day of death). CONCLUSION: This study is one of the first and largest Australian reports on how communication occurs at the end of life for patients dying of COVID-19. Contact rates were relatively low between patients and families, compared with other cohorts dying from non-COVID-19 related causes. The impact of this difference on bereavement outcomes requires surveillance and attention.

Palliative care facilitates the preparedness of caregivers for thoracic cancer patients.

OBJECTIVE: Palliative care improves outcomes for patients with thoracic cancer; however, limited evidence exists for the benefits of this approach for caregivers. This study aimed to advance understanding of the experiences of palliative care described by bereaved caregivers. METHODS: Fifteen adult caregivers completed semi-structured interviews following prior participation in a randomised controlled trial of early referral to palliative care versus discretionary referral to palliative care. Interviews explored caregiver experiences of palliative care delivery. Interview transcripts were thematically analysed. RESULTS: Four related themes about the experiences of palliative care were identified, each of which required sufficient time between palliative care first contact and death: 'relationship building'; 'clear communication and information'; 'access to practical support'; and 'access to psychosocial support'. The core category underpinning these themes was palliative care facilitates caregiver preparedness. Caregivers noted that palliative care played a critical role in preparing them for the future and described a sense of practical and emotional 'relief' associated with the support services made available to them. CONCLUSION: Our findings emphasise that palliative care can have a positive impact on caregivers' preparedness for providing the care needed by thoracic cancer patients and that this can improve the experiences of both caregivers and patients.

Working with palliative care physicians to prepare for voluntary assisted dying legislation.

OBJECTIVE: The Victorian Voluntary Assisted Dying Act 2017 (the Act) exposed a spectrum of opinions regarding euthanasia and physician-assisted suicide amongst Victorian palliative care physicians leading to sometimes acrimonious debate. The profession was unable to articulate a unified role in respect of VAD. METHOD: A collaboration between psychiatry and palliative care led to a series of group discussions in order to prepare for the Act and to re-establish professional cohesion. RESULTS: Although the meetings revealed a plurality of views regarding VAD amongst palliative care physicians, the majority were firmly against the Act. Early meetings revealed strong feelings of shock and an inability to proceed. Previous debates resurfaced between those in support and those not in support of VAD. Over time, there was increased acceptance of the need to adapt to the presence of the Act in order to limit its impact on the robust relationship with the patient central to the practice of palliative care. CONCLUSIONS: The implementation of VAD legislation requires an active process to address the challenges it represents for palliative care physicians. Collaborative facilitated meetings can help re-establish group cohesion through affirming the core principles of palliative care which remain independent of VAD.

Palliative care physicians' preparation and planning for the implementation of the Voluntary Assisted Dying Act in Victoria.

BACKGROUND: In November 2017, the Victorian Voluntary Assisted Dying (VAD) Act was passed enabling people with a progressive terminal illness to end their life voluntarily. Heated debate abounded including, to some extent within palliative care, which was also challenged with developing processes around the legislation enactment. AIM: In response, the lead author convened a series of meetings of palliative care physicians to: (i) share ideas about preparations being undertaken within services; and (ii) re-establish professional cohesion following the divide that the legislation had presented. METHODS: A series of three closed meetings were held between the legislation passage and its implementation, with all Victorian palliative care physicians invited to attend. Meetings were facilitated by an experienced psychiatrist from outside the field. RESULTS: These meetings proved very valuable as physicians collectively sought to define and respond to challenges, simultaneously reflecting on the personal and professional implications for individuals and the field. Key areas raised including gauging institutional 'readiness' for the legislation through staff surveys; the educational role of palliative care staff of the legislation implications; communication skills training; the role (if any) of palliative care in the processes of VAD; and the perceptions of palliative care itself in health services and the community. It was during the processes of discussing challenges and sharing solutions that the attendees appeared to reaffirm their professional interconnections. CONCLUSION: A description of the key elements of these discussions may be useful to others who may yet face similar circumstances with the introduction of VAD legislation.

Cancer patients' perceptions of palliative care.

PURPOSE: Despite clear benefits of early integration of palliative care (PC) and oncology, concerns remain about negative perceptions of PC. Our aim was to explore current knowledge and perceptions of PC in cancer patients. METHODS: We conducted a prospective, cross-sectional survey. A 16-item questionnaire was distributed to all cancer patients (N = 103) upon admission to the oncology ward of an Australian tertiary academic hospital. Chi-squared test was used to examine for significant factors related to patients' perceptions. RESULTS: Ninety-six patients (93%) completed the questionnaire; 76% had metastatic cancer. We explored the following domains:Experience and knowledge: 76% had heard of PC; 21% had received PC. Self-rated PC knowledge was varied. Forty-five percent believed that PC was only associated with EOLC; those more likely to disagree had received PC services (p = 0.039).Integration of PC and oncology: Majority believed that they could receive oncology care (86%) and anti-cancer treatment (81%) whilst receiving PC. Those who had heard of PC and with better self-rated knowledge were more likely to believe that they could receive concurrent anti-cancer treatment (p = 0.005, p = 0.045, respectively).Feelings: 77% felt comforted with PC involvement; this was significantly associated with older age (p = 0.047) and understanding that oncology (p < 0.005) and anti-cancer treatment (p = 0.013) could continue. However, some felt frightened (40%) and hopeless (29%) about referral to PC. Fifty percent felt more comfortable with referral to 'supportive care' services (versus PC). CONCLUSIONS: Our survey demonstrates reasonable understanding and relatively positive feelings about PC, associated with experience and knowledge. Nonetheless, there is ongoing need for better patient and public education about PC.

Exploring disparities in receipt of adjuvant chemotherapy in culturally and linguistically diverse groups: an Australian centre's experience.

BACKGROUND: Globally, racial and ethnic disparities exist in treatments and outcomes for cancer patients. In Australia, there are few published data related to cancer patients from culturally and linguistically diverse (CALD) backgrounds. AIM: To explore disparities in adjuvant chemotherapy utilisation in cancer patients from CALD groups. METHODS: Retrospective analysis of patients who were recommended adjuvant chemotherapy for early stage breast cancer or early stage colorectal cancer between July 2011 and October 2014 was performed. Rates of adjuvant chemotherapy uptake were analysed between those who identified English as their first-preferred language, versus those who did not, as well as between patients who were born in a country where English is the main language (non-CALD), versus those born in a country where English is not the main language (CALD). RESULTS: Two hundred and eleven patients were identified. One hundred and forty-three (67.7%) patients had early stage breast cancer and 68 (32.2%) patients had early stage colorectal cancer. No difference was detected in the acceptance of adjuvant chemotherapy between non-CALD (80.9%) and CALD patients (81.3%, P = 0.984) or between patients who identified English as their first-preferred language (80.8%) and those who did not (81.8%, P = 0.870). There was no difference in the rate of chemotherapy completion, with 75.6% completion in the non-English-speaking group and 81.1% in the English-speaking group (P = 0.426). CONCLUSION: No difference was observed in adjuvant chemotherapy utilisation in patients who identified English as their first-preferred language compared to those who did not, as well as between non-CALD and CALD groups. This is the first study to assess these differences in Australia.

Perspectives of cancer treatment providers regarding voluntary assisted dying in Victoria.

A survey of cancer treatment providers at our institution exploring their perspectives regarding voluntary assisted dying in Victoria and the imminent legislation showed that while almost all were aware of the Bill (92%), reported knowledge and understanding of it was much less (38%). As many clinicians supported the Bill as opposed it (28%); 44% were uncertain of their stance. Most were unwilling to directly provide voluntary assisted dying; if they did, would refer to palliative care services for ongoing support.

Completion of Limitation of Medical Treatment forms by junior doctors for patients with dementia: clinical, medicolegal and education perspectives.

Objective Limitation of Medical Treatment (LMT) forms are an essential element of end-of-life care. Decision making around LMT is complex and often involves patients with dementia. Despite the complexity, junior doctors frequently play a central role in completing LMT forms. The present study sought perspectives from a range of stakeholders (hospital clinicians, medical education personnel, legal and advocacy staff) about junior doctors' roles in completing LMT forms in general and for patients with dementia. Methods Qualitative data were gathered in semi-structured interviews (SSI) and theoretical concepts were explored in roundtable discussion (RD). Participants were recruited through purposive and convenience sampling drawing on healthcare and legal personnel employed in the public hospital and aged care systems, selected from major metropolitan hospitals, healthcare and legal professional bodies and advocacy organisations in Victoria, Australia. The contents of the SSIs and RD were subject to thematic analysis using a framework approach. Data were indexed according to the topics established in the study aim; categories were systematically scrutinised, from which key themes were distilled. Results Stakeholders reported that completing LMT forms was difficult for junior doctors because of a lack of medical and legal knowledge, as well as clinical inexperience and inadequate training. Healthcare organisations (HCOs) either lacked policies about the role of junior doctors or had practices that were discordant with policy. In this process, there were substantial gaps pertaining to patients with dementia. Recommendations made by the study participants included the provision of supervised clinical exposure and additional training for junior doctors, strengthening HCO policies and explicit consideration of the needs of patients with dementia. Conclusions LMT forms should be designed for clarity and consistency across HCOs. Enhancing patient care requires appropriate and sensitive completion of LMT. Relevant HCO policy and clinical practice changes are discussed herein, and recommendations are made for junior doctors in this arena, specifically in the context of patients with dementia. What is known about the topic? Junior doctors continue to play a central role in LMT orders, a highly complex decision-making task that they are poorly prepared to complete. LMT decision making in Australia's aging population and for people with dementia is especially challenging. What does this paper add? A broad range of stakeholders, including hospital clinicians, medical education personnel and legal and advocacy staff, identified ongoing substantial gaps in education and training of junior doctors (despite what is already known in the literature). Furthermore, LMT decision making for patients with dementia is not explicitly considered in policy of practice. What are the implications for practitioners? Current policy and practice are not at the desired level to deliver appropriate end-of-life care with regard to LMT orders, especially for patients with dementia. Greater involvement of executives and senior clinicians is required to improve both practice at the bed side and the training and support of junior doctors, as well as creating more robust policy.

Percutaneous Sacroplasty for Painful Bone Metastases: A Case Report.

INTRODUCTION: The occurrence of bone metastases is common in patients with advanced cancer. The literature supports percutaneous vertebroplasty and kyphoplasty as minimally invasive procedures to relieve pain and improve quality of life for selected patients with disabling pain from pathological vertebral fractures secondary to bone metastases. CASE: We describe a case of a 71-year-old patient with castrate-resistant metastatic prostate cancer who underwent sacroplasty for painful sacral metastases. The patient had previously been treated with maximally tolerated analgesics and anticancer therapies including systemic anticancer treatments and local radiotherapy. After sacroplasty, he experienced significant pain reduction and improvement in mobility and function. CONCLUSION: This case and recent literature demonstrate positive outcomes of sacroplasty in terms of pain reduction and improved mobility. Further research is warranted to establish the role of such minimally invasive percutaneous procedures for pain management in cancer patients.

Impact of Visitor Restrictions on the Pain and Psychological Wellbeing of Palliative Care Patients: A Cohort Study.

Aim: Palliative care patients with advanced or life-threatening illnesses in hospital during the COVID-19 pandemic are likely to be affected by visitor restrictions (VR). We aimed to explore the impact of VR on patients' levels of physical pain and psychological distress. Design: Retrospective cohort study comparing two cohorts of patients admitted to a palliative care unit in a major metropolitan hospital in Australia; the first cohort from 1 April to 30 June 2019 (pre-pandemic; n = 96), and the second from 1 April to 30 June 2020 (during pandemic; n = 95). Methods: Patient-rated pain scores (using the Symptom Assessment Scale; SAS) and clinician-rated pain and psychological/spiritual severity scores (using the Palliative Care Problem Severity Score; PCPSS) on admission and on discharge or death were compared between pre-pandemic and pandemic cohorts. Discharge pain scores and change in scores from admission to discharge were also assessed via multivariable analyses. Results: Case-mix of patients in both cohorts were similar. After adjusting for demographics and functional status, pain scores in the pandemic cohort were higher for patients deceased on discharge, compared to the pre-pandemic cohort (SAS: coefficient = 0.86, 95%CI: 0.09 to 1.64, P = 0.029; PCPSS: coefficient = 0.24, 95%CI: -0.07 to 0.86, P = 0.131, respectively). Differences in SAS and PCPSS pain and psychological/spiritual scores for those discharged alive were not statistically significant. Conclusion: Among palliative care inpatients affected by VR, we observed higher pain scores for patients discharged deceased; suggesting that VR may have impacted the physical wellbeing (pain) of these patients.

Palliative care nursing during the COVID-19 pandemic: reflections from Melbourne, Australia.

BACKGROUND: Nurses played a critical role in providing care for patients throughout the COVID-19 pandemic. AIM: This study aimed to explore perspectives of Australian palliative care nurses regarding the impact of COVID-19 on the provision of care for patients with advanced illness, or at the end of life. METHODS: The authors conducted a survey of palliative care nurses in ward- and consultation-based roles at a metropolitan health service in Victoria, Australia. FINDINGS: A total of 24 out of 39 nurses completed the survey. Responses included strong themes of fear of COVID-19 and sadness about separating dying patients from their families. CONCLUSION: Delivery of palliative care changed at an individual and service level. Importantly, there were strong themes of adapting to change and 'soldiering on' with the core business of palliative care.

Interstitial lung disease in a patient treated with oxaliplatin, 5-fluorouracil and leucovorin (FOLFOX) for metastatic colorectal cancer.

BACKGROUND: Oxaliplatin in combination with 5-fluorouracil (5-FU) and leucovorin (FOLFOX) is a common chemotherapeutic regimen for advanced colorectal cancer. Here, we present a case of interstitial lung disease associated with FOLFOX therapy. CASE REPORT: A 74-year-old man with a history of metastatic colorectal cancer was admitted with a four week history of progressive dyspnoea and evidence of severe respiratory failure. He had recently completed six cycles of FOLFOX chemotherapy in the months prior to presentation. Investigations did not reveal convincing evidence of infection or pulmonary embolism. CT chest demonstrated widespread pulmonary infiltrates and interlobular septal thickening. The patient was commenced on both broad spectrum antibiotic therapy and high dose corticosteroid treatment however his respiratory failure continued to progress. The patient died four days after admission due to progressive respiratory failure. Subsequent post-mortem examination demonstrated evidence of diffuse alveolar damage without evidence of tumour infiltration, infection or pulmonary embolism. CONCLUSIONS: Although infrequent, pulmonary toxicity can occur in association with FOLFOX therapy. Cessation of therapy and prompt initiation of corticosteroids may improve outcomes.

A Multi-Centre COVID-19 Study Examining Symptoms and Medication Use in the Final Week of Life.

CONTEXT: Guidelines exist to direct end-of-life symptom management in COVID-19 patients. However, the real-world symptom patterns, and degree of concordance with guidelines on medication use, and palliative care involvement has received limited attention. OBJECTIVES: To describe the evolution of COVID-19 symptoms, medication used to alleviate these, and degree of palliative care involvement in the final week of life. METHODS: This retrospective study reviewed all COVID-19 inpatient deaths across five metropolitan hospitals in Australia from January 1 to December 31, 2020. Outcome measures were collected at day of death, and days one, two, five and seven before death. These were COVID-19 symptom severity (measured by the Palliative Care Outcome Scale), and use of supportive pharmacological and non-pharmacological therapies. Palliative care referral timepoint was also collected. RESULTS: Within the sample of 230 patients, commonest symptoms were breathlessness, agitation, pain, and respiratory secretions. On day of death, 79% (n = 181) experienced at least one symptom, and 30% (n = 68) experienced severe/extreme symptoms. The use of midazolam, glycopyrrolate, and infusions for symptom management occurred late, less frequently, and at lower doses than suggested in guidelines and other studies. Palliative care referrals were made late, at median three days before death (IQR 1-6 days), and for only half of people dying from COVID-19 (51%; n = 118). CONCLUSION: Symptoms peaked in final three days of life. Earlier use of in fusional and breakthrough medications should be considered in anticipation of symptoms given high likelihood of dying in discomfort. Earlier palliative care referral for high-risk patients should be considered at hospital admission.

Principles of cancer pain management: An overview and focus on pharmacological and interventional strategies

BACKGROUND: Pain remains one of the most significant symptoms of cancer. Impeccable assessment and understanding of the cause and mechanism of pain, pragmatic prescribing (including avoiding dogmatic opioid dose increments) and consideration of all modalities of interventions are central to optimal treatment. OBJECTIVES: This paper outlines aspects of cancer pain assessment, provides a mechanistic framework to facilitate analysis and guide treatment, and emphasises the need for ongoing assessment of treatment efficacy and toxicities. We discuss pharmacological and interventional treatment options and some cancer pain syndromes. DISCUSSION: Management of cancer pain should be proactive and driven by an understanding of pain mechanisms, cancer behaviour and trajectories. It should include optimal use of multimodality interventions alongside directed anti-cancer therapies as appropriate, in consultation with pain or palliative medicine physicians.

Geriatric assessment of older patients with cancer in Australia--a multicentre audit.

OBJECTIVE: The aim of this study is to determine the frequency of geriatric assessment in patients aged over 70 years in Australian medical oncology clinics. MATERIAL AND METHODS: This was a multicentre audit in two parts: a retrospective file review of initial consultations with an oncologist and prospective audit of case presentations at multidisciplinary meetings (MDMs). Patients aged over 70 years presenting to a medical oncology clinic or being discussed at an MDM were eligible. Data was collected at six oncology centres in Victoria, NSW and Canberra from October 2009 to March 2010. RESULTS: Data was collected from 251 file reviews and 108 MDM discussions in a total of 304 patients. Median age was 76 years (range 70-95). The geriatric assessment (GA) domains most frequently assessed during an initial consultation were the presence of comorbidities (92%), social situation-living alone or with someone (80%), social supports (63%), any mention of at least one Activity of Daily Living (ADL) (50%) and performance status (49%). Less frequently assessed were any Instrumental Activity of Daily Living (IADL) (26%), presence of a geriatric syndrome (24%), polypharmacy (29%) and creatinine clearance (11%). Only one patient had all components of ADLs and IADLs assessed. During MDMs all the geriatric domains were comparatively less frequently assessed. No patients had all ADL and IADL components discussed formally in an MDM. CONCLUSION: This is the first multicentre audit that reveals the low rates of GA in Australian medical oncology practice and describes the GA domains considered important by oncology clinicians.

Investigating trends in discharge destinations and impact on allied health service utilization in an Australian hospice.

Australia's population is aging and increasing. The palliative care needs of the population are also increasing in parallel, with more patients being referred to services for a broad range of reasons including symptom management, psychosocial support, and end-of-life care. Our study looks at how this manifests at on inpatient hospice in Melbourne, Australia, in terms of discharge destinations and allied health service utilization. We noted a trend in more discharges to residential care facilities, which appeared more likely for those patients who were admitted for assessment or had longer length of stay. Patients who were admitted for assessment also appeared in overall to utilize allied health services more than those admitted for end-of-life care. This information will help tailor resource allocation according to the current trends.