Implementation of a Multi-Disciplinary Team and Quality of Goals of Care Discussions in Palliative Surgical Oncology Patients.

BACKGROUND: Palliative surgical oncology patients represent a unique group with complex needs who often require multidisciplinary input for the provision of timely and holistic care. The authors assembled a multi-disciplinary palliative intervention team and evaluated its association with the quality of discussions on goals of care (GOC) among advanced cancer patients undergoing palliative interventions. METHODS: This prospective cohort study analyzed advanced cancer patients undergoing palliative interventions at a single urban academic center from October 2019 to March 2022. In January 2021, a multi-disciplinary palliative surgical intervention (MD-PALS) team was assembled. All palliative surgical oncology patients were discussed at multi-disciplinary meetings and managed by members of the MD-PALS team. An interrupted time series (ITS) model was built to evaluate the association of MD-PALS implementation and the quality of GOC discussions as measured by a consensus-derived four-point GOC discussion quality score. RESULTS: The study recruited 126 palliative surgical oncology patients: 44 in the pre-MD-PALS group and 82 in the post-MD-PALS group. The two groups did not differ significantly in baseline demographics, treatment, or postoperative and survival outcomes. Compared with the pre-MD-PALS group, the post-MD-PALS group had a significantly higher mean GOC discussion quality score (1.34 vs 2.61; p < 0.001). Based on the ITS model, the average quarterly GOC discussion quality score increased significantly among patients after implementation of the MD-PALS team (change = 1.93; 95 % confidence interval, 0.96-2.90; P = 0.003). CONCLUSION: The implementation of an MD-PALS team was associated with improvements in the quality of GOC discussions among palliative surgical oncology patients.

Early Outcomes of a National Cancer Center's Strategy Against COVID-19 Executed Through a Disease Outbreak Response Taskforce.

PURPOSE: We present the strategy of a comprehensive cancer center organized to make operations pandemic proof and achieve continuity of cancer care during the COVID-19 pandemic. METHODS: Disease Outbreak Response (DORS) measures implemented at our center and its satellite clinics included strict infection prevention, manpower preservation, prudent resource allocation, and adaptation of standard-of-care treatments. Critical day-to-day clinical operations, number of persons screened before entry, staff temperature monitoring, and personal protection equipment stockpile were reviewed as a dashboard at daily DORS taskforce huddles. Polymerase chain reaction swab tests performed for patients and staff who met defined criteria for testing of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were tracked. Descriptive statistics of outpatient attendances and treatment caseloads from February 3 to May 23, 2020, were compared with the corresponding period in 2019. RESULTS: We performed COVID-19 swabs for 80 patients and 93 staff, detecting three cancer patients with community-acquired COVID-19 infections with no nosocomial transmission. Patients who required chemotherapy, radiotherapy, or surgery and patients who are on maintenance treatment continued to receive timely treatment without disruption. The number of intravenous chemotherapy treatments was maintained at 97.8% compared with 2019, whereas that of weekly radiotherapy treatments remained stable since December 2019. All cancer-related surgeries proceeded without delay, with a 0.3% increase in workload. Surveillance follow-ups were conducted via teleconsultation, accounting for a 30.7% decrease in total face-to-face clinic consultations. CONCLUSION: Through the coordinated efforts of a DORS taskforce, it is possible to avoid nosocomial SARS-CoV-2 transmissions among patients and staff without compromising on care delivery at a national cancer center.

Burnout and Resilience After a Decade in Palliative Care: What Survivors Have to Teach Us. A Qualitative Study of Palliative Care Clinicians With More Than 10 Years of Experience.

CONTEXT: Burnout is common among palliative care clinicians (PCCs). Resilience helps to reduce burnout, compassion fatigue, and is associated with longevity in palliative care. OBJECTIVES: We aimed to study PCCs who have remained in the field for longer than 10 years to deepen our understanding on their views on burnout and resilience. METHODS: We conducted a qualitative study using semistructured interviews and purposive sampling on 18 PCCs - five doctors, 10 nurses, and three social workers who worked in various palliative care settings (hospital palliative care team, home hospice, and inpatient hospice). The mean age of the interviewees was 52 years, and the mean number of years practicing palliative care was 15.7 years (range 10-25). The interviews were recorded verbatim, transcribed, and analyzed using a grounded theory approach. RESULTS: Four major themes emerged from our analysis - struggling, changing mindset, adapting, and resilience. Intervening conditions, such as self-awareness, reflection, and evolution, were also important factors. The core phenomenon of our study was that of transformational growth - a process that PCCs have to go through before they achieve resilience. We also further classified resilience into both personal and collective resilience. CONCLUSION: Our findings highlight the evolving process of transformational growth that PCCs must repeatedly undergo as they strive toward sustained resilience and longevity. It also stresses the importance of taking individual and collective responsibility toward building a culture of personal and team resilience.

Improving Quality of Palliative Care Through Implementation of National Guidelines for Palliative Care.

Background: Palliative care guidelines and quality measures have been developed in many countries to improve the quality of care. The challenge is to implement quality measures nationally to improve quality of care across all settings. Objective: This article describes the development and implementation of National Guidelines for Palliative Care (NGPC) in Singapore. Design: The NGPC was developed through literature review, multidisciplinary inputs, and modified RAND Delphi method. Quality measures for the guidelines were developed through literature review and multidisciplinary inputs and implemented with an audit of specialist palliative care providers. Results: The NGPC consisted of 13 guidelines and 64 quality measures. A total of 11 palliative care services (73.3%) participated in the audit from September 2015 to October 2015. National-level and service-level gaps in quality of care were identified and individual providers identified priority areas for improvement. Conclusion: We successfully developed the national palliative care guidelines and quality measures. We implemented voluntary self-assessment among health care institutions in various settings nationally that serve to catalyze quality improvement and cultivate a culture of quality improvement.

Improvements in end-of-life care with a protocol-based pathway for cancer patients dying in a Singapore hospital.

INTRODUCTION: More than half of all deaths in Singapore occur in hospitals. Little is known about the quality of care received by dying patients in hospitals. The Liverpool Care Pathway (LCP) provides a framework of providing good end-of-life care for dying patients and has been used with success in the United Kingdom (UK). In this study, we investigate whether adoption of a modified LCP in a Singapore hospital translated to better end-of-life care for cancer patients. MATERIALS AND METHODS: The LCP was adapted and implemented as a pilot project on an oncology ward in Singapore General Hospital. A baseline review of 30 consecutive death records was performed, followed by a 4-month pilot and post-implementation audit of 30 consecutive patients on the adapted LCP. RESULTS: Five types of end-of-life symptoms were analysed. There was only 1 uncontrolled symptom at death in the post-implementation group compared to 24 uncontrolled symptoms in the retrospective audit group. The prescription of breakthrough medications for symptom control increased from 21% in the retrospective audit group to 79% in the post-implementation group. Inappropriate monitoring was discontinued in 25 patients in the post-implementation group compared to none in the retrospective audit group. The documentation of resuscitation status and religion of the patient was improved, achieving full documentation in the post-implementation group. CONCLUSION: This study shows promising results for improving end-of-life care in cancer patients with a protocol-based pathway in a Singapore hospital. Extension of this care pathway to other settings should be explored to maximise its benefits to patients dying from all causes in hospital.