Changing characteristics of patients with palliative care needs in acute hospitals.

BACKGROUND: Palliative care services drastically changed over the course of the COVID-19 pandemic between the years 2020 to 2022. AIM: To report on the changes in a specialist palliative care hospital liaison service (SPCHLS) during the COVID-19 pandemic, and consider the impact of this for longer term service modelling. METHODS: A retrospective analysis of patients admitted via the emergency department (ED) in January 2020 and 2021, who were given a palliative care 'code' at the end of their episode of care. Data were collected using electronic records and descriptive statistics were used. FINDINGS: The total number of patients seen in the ED increased by 30%, with a 185% increase in death as an outcome of admission. A total of 50% of patients were seen by a member of the SPCHLS in the ED in 2021, compared to just 28% in 2020. There was a 46% increase in the number of patients transferred to a Specialist Palliative Care Unit. CONCLUSIONS: Delayed diagnoses, long waiting times and changing community services lead to increased pressure and a requirement to meet palliative care needs in acute hospitals. There is a growing need for acute palliative care services to meet the needs of the population.

GIST-related malignant ascites with large-volume paracentesis complicated by myocardial infarction and tumour rupture.

This paper describes a patient with an inoperable gastrointestinal stromal tumour with moderate volume malignant ascites. A large-volume paracentesis caused haemodynamic instability and a myocardial infarction. An indwelling right-sided peritoneal catheter was inserted following further ascites build-up. The patient experienced spontaneous acute rupture of tumour and subsequent loculated ascites. An additional second catheter was inserted to the left side of the abdomen following reaccumulation of ascites following liquefaction of cyst contents and successful one-off drainage on the left side of abdomen. This is the first case report of a patient with two indwelling catheters: we describe learning points pertaining to those as well as the rupture of gastrointestinal stromal tumours. Haemodynamic instability after paracentesis in malignant-related ascites has also not been described.

Palliative care inpatients favour research participation irrespective of prognosis, performance or socioeconomic status: multicentre cohort study.

OBJECTIVES: Palliative care needs to embrace research to guide service development and effective symptom management. Healthcare professionals often feel research is too burdensome for patients who have poor performance status or are near the end of life. Many studies exclude these groups from participating.We aimed to identify whether specialist palliative care inpatients would wish to take part in research and whether preference varies according to study design, demographics, diagnosis, performance status and prognosis. METHODS: 100 inpatients in two National Health Service specialist palliative care units and one independent hospice in the Northeast of England completed a short questionnaire about preferences for involvement in research. RESULTS: 92% of participants stated they were interested in being involved in research. This was mostly unaffected by age, diagnosis, prognosis, performance and socioeconomic status. Three-quarters were within the last 3 months of life. Simple questions or interviews were the preferred methodology, whereas only half of patients would want further investigations or additional medications and fewer still wanted to participate in online activities, lifestyle change or group activities. CONCLUSIONS: Palliative care inpatients welcome the opportunity to be involved in research and should not be excluded on the grounds of advanced disease, poor prognosis and low performance status.

Clinical frailty and performance scale translation in palliative care: scoping review.

BACKGROUND: Frailty is associated with advancing age and increases the risk of adverse outcomes and death. Routine assessment of frailty is becoming more common in a number of healthcare settings, but not in palliative care, where performance scales (eg, the Australia-modified Karnofsky Performance Status Scale (AKPS)) are more commonly employed. A shared understanding of performance and frailty measures could aid interspecialty collaboration in both end-of-life care research and clinical practice. AIMS: To identify and synthesise evidence comparing measures of performance routinely collected in palliative care with the Clinical Frailty Scale (CFS), and create a conversion chart to support interspecialty communication. METHODS: A scoping literature review with comprehensive searches of PubMed, Web of Science, Ovid SP, the Cochrane Library and reference lists. Eligible articles compared the CFS with the AKPS, Palliative Performance Scale (PPS), Karnofsky Performance Scale or Eastern Cooperative Oncology Group Performance Status or compared these performance scales, in patients aged >18 in any setting. RESULTS: Searches retrieved 3124 articles. Two articles directly compared CFS to the PPS. Thirteen studies translated between different performance scores, facilitating subsequent conversion to CFS, specifically: AKPS/PPS 10/20=very severe frailty, AKPS/PPS 30=severe frailty, AKPS/PPS 40/50=moderate frailty, AKPS/PPS60=mild frailty. CONCLUSION: We present a tool for converting between the CFS and performance measures commonly used in palliative care. A small number of studies provided evidence for the direct translation between CFS and the PPS. Therefore, more primary evidence is needed from a wider range of population settings, and performance measures to support this conversion.

Palliative medicine trainees be should learn about frailty: meta-synthesis and Delphi study to establish curriculum content.

OBJECTIVES: Frailty is common and highly associated with morbidity and mortality, a fact that has been highlighted by COVID-19. Understanding how to provide palliative care for frail individuals is an international priority, despite receiving limited mention in Palliative Medicine curricula or examinations worldwide. This study aimed to synthesise evidence and establish expert consensus on what should be included in a Palliative-Medicine Specialist Training Curriculum for frailty. METHODS: Literature Meta-synthesis conducted by palliative medicine, frailty and education experts produced a draft curriculum with Bologna based Learning-Outcomes. A Delphi study asked experts to rate the importance of Learning-Outcomes for specialist-training completion and propose additional Learning-Outcomes. This process was repeated until 70% consensus was achieved for over 90% of Learning-Outcomes. Experts divided Learning-Outcomes into specific (for inclusion in a frailty subsection) or generic (applicable to other palliative conditions). The Delphi panel was Subject Matter Experts: Palliative-Medicine Consultants (n=14) and Trainees (n=10), representing hospital, community, hospice and care home services and including committee members of key national training organisations. A final reviewing panel of Geriatric Medicine Specialists including experts in research methodology, national training requirements and frailty were selected. RESULTS: The meta-synthesis produced 114 Learning-Outcomes. The Delphi Study and Review by Geriatric Medicine experts resulted in 46 essential and 33 desirable Learning-Outcomes. CONCLUSIONS: This frailty curriculum is applicable internationally and highlights the complex and unique palliative needs of frail patients. Future research is required to inform implementation, educational delivery and service provision.

Multicenter Evaluation of 434 Hospital Deaths From COVID-19: How Can We Improve End-of-Life Care During a Pandemic?

CONTEXT: The pandemic has substantially increased the workload of hospital palliative care providers, requiring them to be responsive and innovative despite limited information on the specific end of life care needs of patients with COVID-19. Multi-site data detailing clinical characteristics of patient deaths from large populations, managed by specialist and generalist palliative care providers are lacking. OBJECTIVES: To conduct a large multicenter study examining characteristics of COVID-19 hospital deaths and implications for care. METHODS: A multi-center retrospective evaluation examined 434 COVID-19 deaths in 5 hospital trusts over the period March 23, 2020 to May 10, 2020. RESULTS: Eighty three percent of patients were over 70%-32% were admitted from care homes. Diagnostic timing indicated over 90% of those who died contracted the virus in the community. Dying was recognized in over 90% of patients, with the possibility of dying being identified less than 48 hours from admission for a third. In over a quarter, death occurred less than 24 hours later. Patients who were recognized to be dying more than 72 hours prior to death are most likely to have access to medication for symptom control. CONCLUSION: This large multicenter study comprehensively describes COVID-19 deaths throughout the hospital setting. Clinicians are alert to and diagnose dying appropriately in most patients. Outcomes could be improved by advance care planning to establish preferences, including whether hospital admission is desirable, and alongside this, support the prompt use of anticipatory subcutaneous medications and syringe drivers if needed. Finally, rapid discharges and direct hospice admissions could better utilize hospice beds and improve care.