Examining the Characteristics of Patients With Non-Malignant Lung Disease at the Time of Referral to An Inter-Professional Supportive Care Clinic.

CONTEXT: Patients with non-malignant, advanced lung diseases (NMALD), such as chronic obstructive pulmonary disease (COPD) and interstitial lung disease (ILD), experience a high symptom burden over a prolonged period. Involvement of palliative care has been shown to improve symptom management, reduce hospital visits and enhance psychosocial support; however, optimal timing of referral is unknown. OBJECTIVE: The aim of this study was to identify the stage in the illness trajectory that patients with NMALD are referred to an ambulatory palliative care clinic. METHODS: A retrospective chart review was conducted on all patients with NMALD who attended a Supportive Care Clinic (SCC) between March 1, 2017 and March 31, 2019. RESULTS: Thirty patients attended the SCC during the study period. The most common diagnoses included COPD (36.7%), ILD (36.7%), and bronchiectasis (3.3%). At the time of initial consultation, the majority (89.4%) had Medical Research Council (MRC) class 4-5 dyspnea, however, only 1 patient had been prescribed opioids for management of breathlessness. Twenty-six patients had advance care planning discussions in the SCC. Phone appointments were a highly utilized feature of the program as patients had difficulty attending in-person appointments due to frailty and dyspnea. One-half of patients had at least 1 disease-related hospital admission in the previous year. Six patients were referred directly to home palliative care at their initial consultation. CONCLUSIONS: Referral to palliative care often occurs at late stages in non-malignant lung disease. Further, opioids for the management of dyspnea are significantly underutilized by non-palliative providers.

Pain in patients with newly diagnosed or relapsed acute leukemia.

PURPOSE: Acute leukemia (AL) is associated with substantial morbidity and mortality. We assessed the prevalence and correlates of pain in patients with newly diagnosed or relapsed AL. METHODS: Patients with newly diagnosed or relapsed AL admitted to a comprehensive cancer center completed the Memorial Symptom Assessment Scale (MSAS), which assesses prevalence, severity, and distress associated with pain and other symptoms. Factors associated with severe pain were assessed using logistic regression. Two raters completed chart reviews in duplicate for patients with severe pain (MSAS severity ≥ 3/4) to determine the site of pain. RESULTS: Three hundred eighteen patients were recruited from January 2008 to October 2013: 245 (77.0%) had acute myeloid or acute promyelocytic leukemia (AML/APL) and 73 (23.0%) had acute lymphoblastic leukemia (ALL); 289 (90.9%) were newly diagnosed and 29 (9.1%) had relapsed disease. Pain was reported in 156/318 (49.2%), of whom 55/156 (35.3%) reported severe pain (≥ 3/4). Pain was associated with all psychological symptoms (all p < 0.005) and some physical symptoms. Severe pain was associated with younger age (p = 0.02), worse performance status (p = 0.04), ALL diagnosis (p = 0.04), and time from onset of chemotherapy (p = 0.03), with pain peaking at 4 weeks after chemotherapy initiation. The most common sites of severe pain were oropharynx (22; 40%), head (12; 21.8%), and abdomen (11; 20%). Only 3 patients (0.9%) were referred to the symptom control/palliative care team during the month prior to or following assessment. CONCLUSIONS: Pain is frequent, distressing, and predictable in patients undergoing induction chemotherapy for AL. Further research is needed to assess the efficacy of early supportive care in this population.

Use of Standardized Assessment Tools to Improve the Effectiveness of Palliative Care Rounds: A Quality Improvement Initiative.

BACKGROUND: Optimal care for patients in the palliative care setting requires effective clinical teamwork. Communication may be challenging for health-care workers from different disciplines. Daily rounds are one way for clinical teams to share information and develop care plans for patients. OBJECTIVE: The objective of this initiative was to improve the structure and process of daily palliative care rounds by incorporating the use of standardized tools and improved documentation into the meeting. We chose a quality improvement (QI) approach to address this initiative. Our aims were to increase the use of assessment tools when discussing patient care in rounds and to improve the documentation and accessibility of important information in the health record, including goals of care. METHODS: This QI initiative used a preintervention and postintervention comparison of the outcome measures of interest. The initiative was tested in a palliative care unit (PCU) over a 22-month period from April 2014 to January 2016. Participants were clinical staff in the PCU. RESULTS: Data collected after the completion of several plan-do-study-act cycles showed increased use and incorporation of the Edmonton Symptom Assessment System and Palliative Performance Scale into patient care discussions as well as improvement in inclusion of goals of care into the patient plan of care. CONCLUSION: Our findings demonstrate that the effectiveness of daily palliative care rounds can be improved by incorporating the use of standard assessment tools and changes into the meeting structure to better focus and direct patient care discussions.

Simple prognostic model for patients with advanced cancer based on performance status.

PURPOSE: Providing survival estimates is important for decision making in oncology care. The purpose of this study was to provide survival estimates for outpatients with advanced cancer, using the Eastern Cooperative Oncology Group (ECOG), Palliative Performance Scale (PPS), and Karnofsky Performance Status (KPS) scales, and to compare their ability to predict survival. METHODS: ECOG, PPS, and KPS were completed by physicians for each new patient attending the Princess Margaret Cancer Centre outpatient Oncology Palliative Care Clinic (OPCC) from April 2007 to February 2010. Survival analysis was performed using the Kaplan-Meier method. The log-rank test for trend was employed to test for differences in survival curves for each level of performance status (PS), and the concordance index (C-statistic) was used to test the predictive discriminatory ability of each PS measure. RESULTS: Measures were completed for 1,655 patients. PS delineated survival well for all three scales according to the log-rank test for trend (P < .001). Survival was approximately halved for each worsening performance level. Median survival times, in days, for each ECOG level were: EGOG 0, 293; ECOG 1, 197; ECOG 2, 104; ECOG 3, 55; and ECOG 4, 25.5. Median survival times, in days, for PPS (and KPS) were: PPS/KPS 80-100, 221 (215); PPS/KPS 60 to 70, 115 (119); PPS/KPS 40 to 50, 51 (49); PPS/KPS 10 to 30, 22 (29). The C-statistic was similar for all three scales and ranged from 0.63 to 0.64. CONCLUSION: We present a simple tool that uses PS alone to prognosticate in advanced cancer, and has similar discriminatory ability to more complex models.

Efficacy of Routine Notification and Request on reducing corneal transplantation wait times in Canada.

OBJECTIVE: To determine whether the implementation of Routine Notification and Request (RNR) has been effective in increasing the amount of donor corneal tissue available and reducing wait times for corneal transplant (CT) surgeries. DESIGN: Survey of the CT surgeons and eye banks in Canada. PARTICIPANTS: CT surgeons and representatives of the 10 eye banks in Canada. METHODS: Voluntary, anonymous questionnaires were distributed between May 1 and September 30, 2006. RESULTS: Following the implementation of RNR, 3 eye banks had an increase in the amount of corneal tissue available: Manitoba, 81% (from 42 tissues in 2004 to 76 tissues in 2006); Ontario, 25% (from 1304 tissues in 2005 to 1626 tissues in 2006); New Brunswick, 129% (from 86 tissues in 2005 to 197 tissues in 2006). British Columbia, where RNR was implemented in 1999, had a 6% increase (from 766 in 2005 to 812 in 2006). There has been a significant decrease in wait times from the time of diagnosis by CT surgeons to the time of surgery in British Columbia (from 48+/-18 weeks in 2004 to 39+/-20 weeks in 2006), Manitoba (from 82+/-56 weeks in 2004 to 32+/-23 weeks in 2006), Ontario (from 82+/-56 weeks in 2004 to 31+/-34 weeks in 2006), and Nova Scotia (from 44+/-12 weeks in 2004 to 32+/-28 weeks in 2006). CONCLUSIONS: RNR has been effective in increasing corneal tissue availability and decreasing wait times in provinces where it has been implemented. We recommend similar legislative changes to be considered in those provinces where corneal tissue shortage is delaying the availability of CT surgery.