Current definitions of advanced multimorbidity: a protocol for a scoping review.

INTRODUCTION: People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice. METHODS AND ANALYSIS: Scoping review methodology, based on Arksey and O'Malley's framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of 'multimorbidity', 'end of life' and 'palliative care'. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions. ETHICS AND DISSEMINATION: Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB's PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination.

Community prescribing trends and prevalence in the last year of life, for people who die from cancer.

BACKGROUND: People who die from cancer ('cancer decedents') may latterly experience unpleasant and distressing symptoms. Prescribing medication for pain and symptom control is essential for good-quality palliative care; however, such provision is variable, difficult to quantify and poorly characterised in current literature. This study aims to characterise trends in prescribing analgesia, non-analgesic palliative care medication and non-palliative medications, to cancer decedents, in their last year of life, and to assess any associations with demographic or clinical factors. METHODS: This descriptive study, analysed all 181,247 prescriptions issued to a study population of 2443 cancer decedents in Tayside, Scotland (2013-2015), in the last year of life, linking prescribing data to demographic, and cancer registry datasets using the unique patient-identifying Community Health Index (CHI) number. Anonymised linked data were analysed in Safe Haven using chi-squared test for trend, binary logistic regression and Poisson regression in SPSSv25. RESULTS: In their last year of life, three in four cancer decedents were prescribed strong opioids. Two-thirds of those prescribed opioids were also prescribed laxatives and/or anti-emetics. Only four in ten cancer decedents were prescribed all medications in the 'Just in Case' medication categories and only one in ten was prescribed breakthrough analgesia in the last year of life. The number of prescriptions for analgesia and palliative care drugs increased in the last 12 weeks of life. The number of prescriptions for non-palliative care medications, including anti-hypertensives, statins and bone protection, decreased over the last year, but was still substantial. Cancer decedents who were female, younger, or had lung cancer were more likely to be prescribed strong opioids; however, male cancer decedents had higher odds of being prescribed breakthrough analgesia. Cancer decedents who had late diagnoses had lower odds of being prescribed strong opioids. CONCLUSIONS: A substantial proportion of cancer decedents were not prescribed strong opioids, breakthrough medication, or medication to alleviate common palliative care symptoms (including 'Just in Case' medication). Many patients continued to be prescribed non-palliative care medications in their last days and weeks of life. Age, gender, cancer type and timing of diagnosis affected patients' odds of being prescribed analgesic and non-analgesic palliative care medication.

Death from cancer: frequent unscheduled care.

OBJECTIVE: To examine the demographic, clinical, and temporal factors associated with cancer decedents being a frequent or very frequent unscheduled care (GP-general practice Out-Of-Hours (GPOOH) and Accident & Emergency (A&E)) attender, in their last year of life. METHODS: Retrospective cohort study, of all 2443 cancer decedents in Tayside, Scotland, over 30- months period up to 06/2015, comparing frequent attenders (5-9 attendances/year) and very frequent attenders (≥10 attendances/year) to infrequent attenders (1-4 attendances/year) and non-attenders. Clinical and demographic datasets were linked to routinely-collected clinical data using the Community Health Index number. Anonymised linked data were analysed in SafeHaven, using binary/multinomial logistic regression, and Generalised Estimating Equations analysis. RESULTS: Frequent attenders were more likely to be older, and have upper gastrointestinal (GI), haematological, breast and ovarian malignancies, and less likely to live in accessible areas or have a late cancer diagnosis. They were more likely to use GPOOH than A&E, less likely to have face-to-face unscheduled care attendances, and less likely to be admitted to hospital following unscheduled care attendance. CONCLUSIONS: Age, cancer type, accessibility and timing of diagnosis relative to death were associated with increased likelihood of being a frequent or very frequent attender at unscheduled care.

Factors associated with unscheduled care use by cancer decedents: a systematic review with narrative synthesis.

BACKGROUND: People who die from cancer (cancer decedents) may experience unpleasant and distressing symptoms which cause them to present to unscheduled care. Unscheduled care is unplanned care delivered by general practitioner out-of-hours and emergency departments. Use of unscheduled care can disrupt treatment plans, leading to a disjointed patient care and suboptimal outcomes. OBJECTIVES: This systematic review aimed to identify factors associated with unscheduled care use by cancer decedents. METHOD: Systematic review with narrative synthesis of seven electronic databases (PubMed; Medline; Embase; Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; Web of Science; Cumulative Index to Nursing and Allied Health Literature) from inception until 01 January 2020. All observational and experimental studies were included, irrespective of their research design. RESULTS: The search yielded 238 publications included at full-text, of which 47 were included in the final review and synthesis. Unscheduled care use by cancer decedents was influenced by multiple factors, synthesised into themes: demography, clinical and patient, temporal, prescribing and systems. Cancer decedents who were older, men, had comorbidities, or lung cancer, were most likely to use unscheduled care. Unscheduled care presentations were commonly due to pain, breathlessness and gastrointestinal symptoms. Low continuity of care, and oncology-led care were associated with greater unscheduled care use. Access to palliative care, having an up-to-date palliative care plan, and carer education were associated with less unscheduled care use. CONCLUSION: The review identifies multiple factors associated with unscheduled care use by cancer decedents. Understanding these factors can inform future practice and policy developments, in order to appropriately target future interventions, optimise service delivery and improve the patient journey. PROSPERO REGISTRATION NUMBER: CRD42016047231.