Participatory knowledge exchange to support palliative care in Chile: lessons learned through global health research.

The authors designed a participatory qualitative research study to develop a collaborative partnership between palliative care practitioners in Canada and in Chile. The research goal was to support the provision of palliative care in vulnerable settings through a participatory knowledge exchange process using qualitative and participatory methodologies. The study involved an interprofessional palliative care team from a primary health care centre in Chile and 5 adults receiving palliative care and their relatives. It also involved the participation of registered nurses and allied health professionals from a palliative home care team in Canada. Participatory knowledge exchange activities included teamwork with the primary health care team in Chile and a process of participatory knowledge exchange with palliative care clinicians in Chile and Canada. The study produced qualitative evidence on the efficacy of a process of participatory knowledge exchange with palliative care practitioners from 2 diverse settings.

Evaluation of the Palliative Prognostic Score (PaP) and routinely collected clinical data in prognostication of survival for patients referred to a palliative care consultation service in an acute care hospital.

CONTEXT: Patients, caregivers, and clinicians require high levels of information regarding prognosis when conditions are incurable. OBJECTIVES: 1) To validate the Palliative Prognostic Score (PaP) and 2) to evaluate prognostic capacity of used clinical tools and the diagnosis of delirium, in a population referred to a palliative care consultation service at a Canadian acute care hospital. METHODS: This was a prospective observational cohort study on survival prediction based on the PaP and routinely collected clinical data, including the Palliative Performance Scale (PPS) and the Folstein Mini-Mental State Examination (MMSE). Kaplan-Meier survival curves, log-rank tests for significant differences between survival curves, and the Cox proportional hazards model were used to identify the relationship between the hazard ratio for death and the above variables. RESULTS: Nine hundred fifty-eight cases underwent final analysis, of which 181 (19%) had a noncancer diagnosis. Median and mean survival were 35 and 131 days, respectively. The three groups, divided based on different ranges of PaP, had significantly different survival curves, with 30-day-survival rates of 78%, 55%, and 11%. Age, PPS, and PaP remained significantly associated with survival, whereas diagnosis group, MMSE, and delirium became insignificant, despite lower hazard of death for cancer vs. noncancer and higher hazard for abnormal vs. normal MMSE and presence vs. absence of delirium. CONCLUSION: The PaP was successfully validated in a population with characteristics that extend beyond those of the population in which it was originally developed. This is the largest sample in which the PaP has been validated to date.

Hydration management at the end of life.

The management of parenteral hydration at the end of life remains controversial. The debate centers on whether and/or how often patients should be hydrated, the volume of hydration received, and the benefit verses side effects of parenteral hydration. In order to clarify the routine practice of physicians involved in the end-of-life care in Edmonton, Alberta, Canada, we investigated the routine management of hydration by attending physicians caring for patients dying in a palliative care unit (PCU) at Norwood Capital Care, and in acute care wards at the Royal Alexandra Hospital (RAH) both while receiving and while not receiving consult advice from the Palliative Care Program. We conducted a retrospective chart review of 50 consecutive patients who died in each of the 3 sites included in the study. Data from the last 7 days prior to and including the date of death (day 0) was recorded. The majority of patients at all sites received hydration. The volume of hydration ordered in the Norwood PCU site was significantly different compared to both RAH groups on all days studied (p < 0.005). The RAH palliative care group showed a trend for lower hydration volumes compared to the RAH acute care group with significant differences on days 1 and 2 (p < 0.05). Throughout the week, for all of the hydrated patients in the Norwood PCU site, hypodermoclysis (HDC) was ordered; for nearly all of the hydrated patients in the RAH acute care group, intravenous (IV) hydration was ordered; and for approximately one third of the hydrated RAH palliative care consult group HDC was ordered, and for the remainder IV hydration was ordered. The RAH acute care group represented the largest percentage of hydrated patients receiving diuretics while the Norwood hospice site represented the lowest. The data raise the possibility that more patients in the RAH acute care group were overhydrated and may have developed symptoms such as edema, ascites, and respiratory distress. This study suggests that hydration at the end of life is managed differently in different settings of care and highlights areas for education to improve management.

The cultural differences in perceived value of disclosure and cognition: Spain and Canada.

A previous multicentre international study on sedation at the end of life has detected major differences between Canadian and Spanish patients. This was particularly evident in the need to sedate Spanish patients for psychological/existential distress. This study was designed to explore the hypothesis that marked differences in the value patients and families attach to disclosure and cognition were a factor. The study population included patients referred to two palliative care consulting services based in acute care hospitals in Madrid, Spain (M), and in Edmonton, Canada (E). Questions addressed the issue of clear thinking, pain/nausea-medication-induced somnolence/confusion, anxiety/antidepressant-medication-induced somnolence/confusion, details of diagnosis. One hundred patients were evaluated on each site. Patients and families in E placed a higher value on clear thinking, change in medication causing somnolence/confusion, and wanting full disclosure. Patients and families in E agreed almost 100% of the time, while agreement in M varied from 42% to 67%. These results suggest major differences in the perceived value of clear cognition and disclosure of information between patients and families in E and M. The lack of agreement between patients and families in M is a further significant factor that may complicate communication with patients and families, as well as medical management.

Antibiotic use in the last week of life in three different palliative care settings.

The purpose of this study was to examine the frequency and types of antibiotics prescribed in the last week of life in three different palliative care settings, including an acute care hospital, tertiary palliative care unit, and three hospice units. A total of 150 consecutive patients were evaluated, 50 in each of the three settings. Twenty-nine patients (58%) in the acute hospital setting, 26 (52%) in the tertiary palliative care unit, and 11(22%) in the hospice settings were prescribed antibiotics. In the acute care and tertiary palliative care settings, the most frequent route of antibiotic administration was intravenous and, in the hospice setting, oral. We conclude that there is marked variability in the numbers and types of antibiotics prescribed in these different palliative care settings in the last week of life. The high use of intravenous antibiotics and the large number of patients who were still receiving antibiotics at the time of death indicate the need for further prospective studies.