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Background: Individuals experiencing socioeconomic inequity have worse health outcomes and face barriers to palliative and end-of-life care. There is a need to develop palliative care programs tailored to this underserved population. Objectives: To understand the characteristics and symptom profiles of a group of urban patients experiencing socioeconomic inequity and receiving palliative care. Design: Descriptive exploratory analysis of a patient dataset. The patient dataset was generated through a pilot research study with patients experiencing socioeconomic inequity and life-limiting illness who received a community-based palliative care intervention. Methods: The intervention took place over 1 year in the Palliative Care Outreach and Advocacy Team, a community-based urban palliative care clinic in Edmonton, Alberta, Canada, serving persons experiencing socioeconomic inequity. Participants had to be at least 18 years of age, be able to communicate in English, require palliative care for a life-limiting illness, and be able to consent to inclusion in the study. Results: Twenty-five participants were enrolled. Participants predominantly identified as male and Indigenous, experienced poverty and housing instability, and had metastatic cancer. Our participants rated their pain, shortness of breath, and anxiety as more severe than the broader community-based palliative care population in the same city. Most patients died in inpatient hospices (73%). Conclusion: Our analysis provides an in-depth picture of an understudied, underserved population requiring palliative care. Given the higher symptom severity experienced by participants, our analysis highlights the importance of person-centered palliative care. We suggest that socioeconomic inequity should be considered in patients with life-limiting illnesses. Further research is needed to explore palliative care delivery to those facing socioeconomic inequity.
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Objective: In Canada, populations experiencing socioeconomic inequality have lower rates of access to screening and diagnosis and higher mortality rates than people from higher-income areas. Limited evidence exists concerning their experiences when living with advanced cancer. We explored how socioeconomic inequality shapes the experiences of patients with advanced cancer. Methods: We utilized a qualitative study design that combined tenets of hermeneutic phenomenological inquiry and critical theory. Four individuals with advanced cancer from low-income neighborhoods, three family members, and six cancer care providers were accrued through a tertiary cancer center in a western Canadian city. One-on-one interviews and brief notes were used for data collection. Data were analyzed through thematic analysis. Results: Three interrelated themes were identified: 'Lack of access to socioeconomic supports,' 'Gaps in access to health care resources and services,' and 'Limited access to symptom relief.' Patients experienced inadequate finances, housing, and transportation. Most patients lived alone and had limited family and social support. Patients reported lack of knowledge of available resources and health system navigation issues, including communication problems with providers and among levels of care. Cancer care providers and patients described issues achieving symptom relief as well as challenges associated with extensive disease. Conclusions: Study findings suggest that socioeconomic inequality interferes with the ability of persons with advanced cancer to access health care and contributes to less optimal cancer outcomes. Socioeconomic inequality may increase symptom severity. Findings call for the development of tailored interventions for populations with advanced cancer and socioeconomic inequality.
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(1) Background: This observational cohort study describes the frequency, content, and satisfaction with advance care planning (ACP) conversations with healthcare providers (HCPs), as reported by patients with advanced colorectal cancer. (2) Methods: The patients were recruited from two tertiary cancer centers in Alberta, Canada. Using the My Conversations survey with previously validated questions, the patients were asked about specific ACP elements discussed, with which HCPs these elements were discussed, their satisfaction with these conversations, and whether they had a goals of care designation (GCD) order. We surveyed and analyzed data from the following four time points: enrollment, months 1, 2, and 3. (3) Results: In total, 131 patients were recruited. At enrollment, 24% of patients reported discussing at least one ACP topic. From enrollment to month 3, patients reported a high frequency of discussions (80.2% discussed fears, 71.0% discussed prognosis, 54.2% discussed treatment preferences at least once); however, only 44.3% of patients reported discussing what is important to them in considering health care preferences. Patients reported having ACP conversations most often with their oncologists (84.7%) and cancer clinic nurses (61.8%). Patients reported a high level of satisfaction with their ACP conversations, with over 80% of patients reported feeling heard and understood. From enrollment to month 3, there was an increase in the number of patients with a GCD order from 53% to 74%. (4) Conclusions: Patients reported more frequent conversations compared to the literature and clinical documentation. While the satisfaction with these conversations is high, there is room for quality improvement, particularly in eliciting patients' personal goals for their treatment.
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Planejamento Antecipado de Cuidados , Neoplasias Colorretais , Humanos , Alberta , Satisfação do PacienteRESUMO
BACKGROUND: Cancer disparities are a major public health concern in Canada, affecting racialized communities of Latin American and African descent, among others. This is evident in lower screening rates, lower access to curative, and palliative-intent treatments, higher rates of late cancer diagnoses and lower survival rates than the general Canadian population. We will develop an Access to Palliative Care Strategy informed by health equity and patient-oriented research principles to accelerate care improvements for patients with advanced cancer of African and Latin American descent. METHODS: This is a community-based participatory research study that will take place in two Canadian provinces. Patients and community members representatives have been engaged as partners in the planning and design of the study. We have formed a patient advisory council (PAC) with patient partners to guide the development of the Access to Palliative Care Strategy for people of African and Latin American descent. We will engage100 participants consisting of advanced cancer patients, families, and community members of African and Latin American descent, and health care providers. We will conduct in-depth interviews to delineate participants' experiences of access to palliative care. We will explore the intersections of race, gender, socioeconomic status, language barriers, and other social categorizations to elucidate their role in diverse access experiences. These findings will inform the development of an action plan to increase access to palliative care that is tailored to our study population. We will then organize conversation series to examine together with community partners and healthcare providers the appropriateness, effectiveness, risks, requirements, and convenience of the strategy. At the end of the study, we will hold knowledge exchange gatherings to share findings with the community. DISCUSSION: This study will improve our understanding of how patients with advanced cancer from racialized communities in Canada access palliative care. Elements to address gaps in access to palliative care and reduce inequities in these communities will be identified. Based on the study findings a strategy to increase access to palliative care for this population will be developed. This study will inform ways to improve access to palliative care for racialized communities in other parts of Canada and globally.
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Neoplasias , Cuidados Paliativos , Humanos , América Latina , Canadá , Saúde Pública , Neoplasias/terapiaRESUMO
INTRODUCTION: In Canada, people experiencing socioeconomic inequities have higher rates of late diagnosis and lower survival rates than the general population. Palliative care services focussed on this population are scarce. We developed a community-based nursing intervention to improve access to palliative care for people experiencing socioeconomic inequities and living with life-limiting illnesses in an urban Canadian setting. METHODS: This community-based, qualitative research study combined critical and participatory research methodologies. The study was conducted in partnership with the Palliative Care Outreach Advocacy Team (PCOAT) based in Edmonton, Alberta, a team dedicated to serving populations experiencing socioeconomic inequities who require palliative care. Following an exploratory phase that served to delineate the intervention, we undertook a one-year pilot implementation during which a part-time registered nurse (RN) joined PCOAT. The RN engaged in trust building, resolution of health and practical needs and complex care coordination. Twenty-five patients participated in the intervention. Participants were interviewed at least once to explore their experiences with the intervention. Data were analyzed through thematic analysis. RESULTS: Most participants were men, were Indigenous and had advanced cancer. Participants had significant financial concerns, lived or had lived in precarious housing situations and had previously faced serious challenges accessing health care. Participants reported social and health needs including housing, finances, transportation, symptom control, harm reduction and end-of-life care. Participants reported improved access to health and social services and expressed satisfaction with the study intervention. CONCLUSION: Study findings suggest the study intervention may have contributed to improved access to palliative care, improved experiences for participants and increased equity in the delivery of care.
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Cuidados Paliativos , Assistência Terminal , Masculino , Humanos , Feminino , Atenção à Saúde , Pesquisa Qualitativa , Fatores Socioeconômicos , AlbertaRESUMO
Literature assessing the impact of palliative care (PC) consultation on aggressive care at the end of life (EOL) within a comprehensive integrated PC program is limited. We retrospectively reviewed patients with advanced cancer who received oncological care at a Canadian tertiary center, died between April 2013 and March 2014, and had access to PC consultation in all healthcare settings. Administrative databases were linked, and medical records reviewed. Composite score for aggressive EOL care was calculated, assigning a point for each of the following: ≥2 emergency room visits, ≥2 hospitalizations, hospitalization >14 days, ICU admission, and chemotherapy administration in the last 30 days of life, and hospital death. Multivariable logistic regression was adjusted for age, sex, income, cancer type and PC consultation for ≥1 aggressive EOL care indicator. Of 1414 eligible patients, 1111 (78.6%) received PC consultation. In multivariable analysis, PC consultation was independently associated with lower odds of ≥1 aggressive EOL care indicator (OR 0.49, 95% CI 0.38−0.65, p < 0.001). PC consultation >3 versus ≤3 months before death had a greater effect on lower aggressive EOL care (mean composite score 0.59 versus 0.88, p < 0.001). We add evidence that PC consultation is associated with less aggressive care at the EOL for patients with advanced cancer.
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Neoplasias , Assistência Terminal , Humanos , Cuidados Paliativos , Estudos Retrospectivos , Canadá , Neoplasias/terapia , Encaminhamento e ConsultaRESUMO
PURPOSE: Palliative radiotherapy (PRT) in advanced cancer improves symptom control and quality of life. PRT consultations take place in various clinical settings, including through dedicated rapid access clinics. We examined holistic assessment and PRT delivery by consultation setting. METHODS: We analyzed patients with breast cancer who died (01/04/2013-31/03/2014), after at least one lifetime PRT consultation. Data abstracted included Karnofsky Performance Status (KPS), Edmonton Symptom Assessment System Revised (ESAS-r) ratings, and PRT timelines. Descriptive statistics, t tests of proportions, independent t tests, and chi-square tests were calculated. RESULTS: One hundred thirty patients were assessed for PRT over 224 consults, 28/224 (12.5%) in the rapid access clinic. In non-rapid access versus rapid access visits, KPS was documented in 30.1% versus 89.3%, and medication history in 53.6% versus 96.4%, respectively (both p < 0.0001). Baseline ESAS-r scores were available for 67.9% of rapid access visits, versus no non-rapid access visit. Rapid access consults had a higher proportion of subsequent supportive care referrals (46.4% versus 8.2%; p < 0.0001). Same day PRT start occurred in 37% of rapid access versus 23.4% of non-rapid access visits (p = 0.13). CONCLUSIONS: Assessment for PRT by a dedicated multidisciplinary team provides a comprehensive picture of patient needs and streamlines PRT delivery, essential to personalizing supportive care.
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Neoplasias da Mama , Neoplasias , Neoplasias da Mama/radioterapia , Feminino , Humanos , Avaliação de Estado de Karnofsky , Neoplasias/radioterapia , Cuidados Paliativos , Qualidade de Vida , Encaminhamento e ConsultaRESUMO
BACKGROUND: Early integration of Specialist Palliative Care (SPC) with oncological care improves quality of life (QOL) of patients with advanced cancer; however, patients tend to access SPC late in their disease trajectory, if at all. Routine referral of all patients to SPC would quickly overwhelm available resources, suggesting a need for widespread accessibility of generalist PC competencies. This has been increasingly facilitated by dedicated palliative radiotherapy (PRT) clinics, such as the multidisciplinary Palliative Radiation Oncology (PRO) program at the Cross Cancer Institute (CCI). Our objectives were to estimate the proportion of patients dying with breast cancer seen in consultation for PRT, and the interaction between PRT delivery and SPC referral. METHODS: This secondary analysis of routinely collected health data examined female adults with breast cancer who died between 04/01/2013 and 03/31/2014, and had advanced disease while under the care of a CCI oncologist. Alberta Cancer Registry, electronic medical records, and Edmonton Zone Palliative Care Program data were linked. During the study period, referrals for SPC, and setting of assessment for PRT, were at the attending physicians' discretion. Clinical data were abstracted including summaries of intervals between PRT and SPC consultations, as well as from consults to death. Kaplan-Meier survival estimates, independent samples median tests, t tests of proportions, independent t tests and Chi-square tests compared groups. RESULTS: Of 194 patients, median age at cancer diagnosis was 59 years (range 24-95yrs), median one-way distance from the CCI was 18.8km, and overall median survival (MS) was 4.4 years. 130/194 (67.0%) and 110/194 (56.7%) were assessed for PRT and by SPC respectively; 22/194 (11.3%) saw neither prior to death. Median time between first PRT consultation and death was 11.7 months (interquartile range 3.7-22.2 mos). Median time between first SPC consult and death was 2.9 mos (IQR 1-6.2 mos). 65.6% of those who never had PRT ultimately required SPC involvement, versus 52.3% of those receiving PRT. Of the 68/130 who had both, 91.2% were seen for PRT first, a median of 7.9 mos prior to seeing SPC. Patients who had SPC consultation without previous PRT were seen by PC a median 1.5 mos prior to death (IQR 0.6-4.9 mos). Patients seen for PRT outside of the PRO clinic had SPC consultation a median of 3.3 mos before death (IQR 1.2-6.2 mos), versus those seen by the PRO clinic team, who were referred a median of 6.2 mos prior (IQR 2.4-8.1 mos). CONCLUSIONS: Fewer advanced breast cancer patients who received PRT ultimately required SPC consultation, but those who did were referred earlier in their disease course, especially if PRT assessment and delivery had taken place in the setting of a dedicated multidisciplinary team.
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Neoplasias da Mama , Radioterapia (Especialidade) , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/radioterapia , Feminino , Humanos , Pessoa de Meia-Idade , Cuidados Paliativos , Equipe de Assistência ao Paciente , Qualidade de Vida , Dados de Saúde Coletados Rotineiramente , Adulto JovemRESUMO
Despite the known benefits, healthcare systems struggle to provide early, integrated palliative care (PC) for advanced cancer patients. Understanding the barriers to providing PC from the perspective of oncology clinicians is an important first step in improving care. A 33-item online survey was emailed to all oncology clinicians working with all cancer types in Alberta, Canada, from November 2017 to January 2018. Questions were informed by Michie's Theoretical Domains Framework and Behaviour Change Wheel (BCW) and queried (a) PC provision in oncology clinics, (b) specialist PC consultation referrals, and (c) working with PC consultants and home care. Respondents (n = 263) were nurses (41%), physicians (25%), and allied healthcare professionals (18%). Barriers most frequently identified were "clinicians' limited time/competing priorities" (64%), "patients' negative perceptions of PC" (63%), and clinicians' capability to manage patients' social issues (63%). These factors mapped to all three BCW domains: motivation, opportunity, and capability. In contrast, the least frequently identified barriers were clinician motivation and perceived PC benefits. Oncology clinicians' perceptions of barriers to early PC were comparable across tumour types and specialties but varied by professional role. The main challenges to early integrated PC include all three BCW domains. Notably, motivation is not a barrier for oncology clinicians; however, opportunity and capability barriers were identified. Multifaceted interventions using these findings have been developed, such as tip sheets to enhance capability, reframing PC with patients, and earlier specialist PC nursing access, to enhance clinicians' use of and patients' benefits from an early PC approach.
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Oncologia , Neoplasias , Alberta , Humanos , Neoplasias/terapia , Cuidados Paliativos , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To assess the prevalence and association of depression among Canadian adults with cancer in a population-based context. METHODS: The Canadian Community Health Survey (CCHS) (2015-2016) was accessed and adult participants with cancer who completed the Personal Health Questionnaire (PHQ9) were included in the current analysis. Multivariable logistic regression was conducted to elucidate the factors associated with the development of depression. An additional multivariable logistic regression analysis was conducted to evaluate the association of depression with ever contemplating suicide (suicidal ideation). RESULTS: A total of 867 participants with cancer have completed PHQ9 were included in the current analysis (including 603 participants (69.6%) without depression (PHQ9 ≤ 4) and 264 participants (30.4%) with depression (PHQ9 > 4)). Moreover, 92 participants (10.6%) fulfill the criteria for moderate/severe depression (PHQ9 > 9). The following factors were associated with the presence of depression (PHQ9 > 4), female sex (OR for males versus females: 0.56; 95% CI: 0.34-0.93; P = 0.02); poor self-perceived health (OR for excellent health versus poor health: 0.12; 95% CI: 0.02-0.62; P = 0.01) and poor self-perceived mental health (OR for excellent mental health versus poor mental health: 0.02; 95% CI: <0.01-0.24; P < 0.01). Additional multivariable logistic regression analysis showed that depression (PHQ9 > 4) was associated with a higher probability of suicidal ideation (OR for no depression versus depression: 0.43; 95% CI: 0.21-0.91; P = 0.02). CONCLUSIONS: Depression seems to be an underdiagnosed and possibly undertreated comorbid condition among Canadian adults with cancer.
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Depressão/epidemiologia , Saúde Mental , Neoplasias/psicologia , Ideação Suicida , Adulto , Idoso , Canadá/epidemiologia , Estudos Transversais , Depressão/psicologia , Feminino , Inquéritos Epidemiológicos , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Índice de Gravidade de Doença , Fatores SexuaisRESUMO
INTRODUCTION: Early integration of palliative care (PC) with oncological care is associated with improved outcomes in patients with advanced cancer. Limited information exists on the frequency, timing, and predictors of PC consultation in patients receiving oncological care. The Cross Cancer Institute (CCI) is the sole tertiary cancer center serving the northern half of the Canadian province of Alberta, located in the city of Edmonton. The objectives of this study were to estimate the proportion of patients with advanced cancer at the CCI who received consultation by the CCI PC program and the comprehensive integrated PC program in Edmonton, and to determine the timing and predictors of consultation. MATERIALS AND METHODS: In this secondary analysis of routinely collected health data, adult patients who died between April 2013 and March 2014, and had advanced disease while under the care of a CCI oncologist, were eligible. Data from the Alberta Cancer Registry, electronic medical records, and Edmonton PC program database were linked. RESULTS: Of 2,253 eligible patients, 810 (36%) received CCI PC consultation. Median time between consultation and death was 2 months (range, 1.1-5.4). In multivariable logistic regression analysis, age, residence, income, cancer type, and interval from advanced cancer diagnosis to death influenced odds of receiving consultation. Among 1,439 patients residing in Edmonton, 1,121 (78%) were referred to the Edmonton PC program. CONCLUSION: A minority of patients with advanced cancer received PC consultation at the tertiary cancer center, occurring late in the disease trajectory. Frequency and timing of PC consultation varied significantly, according to multiple factors. IMPLICATIONS FOR PRACTICE: Clinical and demographic factors are associated with variations in frequency and timing of palliative care consultation at a cancer center and may, in some cases, reflect barriers to access that warrant attention.
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Neoplasias , Cuidados Paliativos , Adulto , Canadá , Humanos , Neoplasias/epidemiologia , Neoplasias/terapia , Encaminhamento e Consulta , Estudos Retrospectivos , Dados de Saúde Coletados RotineiramenteRESUMO
Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations. PURPOSE: To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer. METHODS: Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists. RESULTS: Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues. CONCLUSION: Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.
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Acessibilidade aos Serviços de Saúde , Disparidades em Assistência à Saúde , Neoplasias/economia , Neoplasias/terapia , Cuidados Paliativos/economia , Canadá , Feminino , Pessoal de Saúde , Humanos , Masculino , Neoplasias/patologia , Cuidados Paliativos/métodos , Pesquisa Qualitativa , Classe Social , Apoio SocialAssuntos
Neoplasias do Colo/terapia , Drenagem , Edema/terapia , Doenças dos Genitais Masculinos/terapia , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Neoplasias do Colo/patologia , Fluoruracila/uso terapêutico , Humanos , Leucovorina/uso terapêutico , Extremidade Inferior , Metástase Linfática , Masculino , Limitação da Mobilidade , Compostos Organoplatínicos/uso terapêutico , EscrotoRESUMO
PURPOSE: Palliative care referral is primarily based on clinician judgment, contributing to highly variable access. Standardized criteria to trigger automatic referral have been proposed, but it remains unclear how best to apply them in practice. We conducted a Delphi study of international experts to identify a consensus for the use of standardized criteria to trigger automatic referral. METHODS: Sixty international experts stated their level of agreement for 14 statements regarding the use of clinician-based referral and automatic referral over two Delphi rounds. A consensus was defined as an agreement of ≥70% a priori. RESULTS: The response rate was 59/60 (98%) for the first round and 56/60 (93%) for the second round. Twenty-six (43%), 19 (32%), and 11 (18%) respondents were from North America, Asia/Australia, and Europe, respectively. The panel reached consensus that outpatient palliative care referral should be based on both automatic referral and clinician-based referral (agreement = 86%). Only 18% felt that referral should be clinician-based alone, and only 7% agreed that referral should be based on automatic referral only. There was consensus that automatic referral criteria may increase the number of referrals (agreement = 98%), facilitate earlier palliative care access, and help administrators to set benchmarks for quality improvement (agreement = 86%). CONCLUSIONS: Our panelists favored the combination of automatic referral to augment clinician-based referral. This integrated referral framework may inform policy and program development.
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Acessibilidade aos Serviços de Saúde , Cuidados Paliativos/métodos , Encaminhamento e Consulta , Consenso , Técnica Delphi , Feminino , Humanos , Masculino , Pacientes Ambulatoriais , Cuidados Paliativos/normas , Melhoria de Qualidade , Inquéritos e QuestionáriosRESUMO
BACKGROUND: The Edmonton Symptom Assessment System-revised (ESAS-r) is a nine-item self-report symptom intensity tool developed for palliative care patients, with the option of adding a 10th patient-specific symptom. Due to growing international uptake, the ESAS-r has been translated into different languages. There has not been agreement, however, regarding a standard process for translation into multiple languages, which also includes patients' perspectives. OBJECTIVE: The purpose of this study was to develop a French version of the ESAS-r, using a standardized translation protocol, and to obtain palliative care patients' perspectives regarding this translated tool. DESIGN: We developed a French version of the ESAS-r, using a standard translation method, involving both professional translators (n = 2) and bilingual palliative care experts (n = 3). Fifteen Francophone participants recruited from palliative care sites in two urban centers in Canada completed the ESAS-r and provided feedback on the translation, in the presence of a trained interviewer. Descriptive statistics and thematic analysis were used to analyze the quantitative and qualitative data, respectively. SETTING/SUBJECTS: Fifteen Francophone participants were recruited from palliative care sites in two urban centers in Canada. MEASUREMENTS: Participants completed the ESAS-r and provided feedback on the translation in the presence of a trained interviewer. Descriptive statistics and thematic analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS: Based on participants' concerns, translations for four of the nine symptoms were revised: drowsiness, nausea, lack of appetite, and shortness of breath. Concerns expressed for three additional symptoms (depression, anxiety, and well-being) were related to overall difficulty rating these symptoms, not specific to the translation. CONCLUSION: The French version of the ESAS-r is a credible tool for symptom assessment in Francophone patients. The study findings provide a vital step in the development of a standardized translation protocol, including patients' perspectives, which can be applied to other languages.
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Cuidados Paliativos , Preferência do Paciente , Inquéritos e Questionários/normas , Avaliação de Sintomas/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Projetos Piloto , AutorrelatoRESUMO
CONTEXT: Current health care delivery models have increased the need for safe and concise patient handover. Handover interventions in the literature have focused on the use of structured tools but have not evaluated their ability to facilitate retention of patient information. OBJECTIVES: In this study, mock pictorial displays were generated in an attempt to create a snapshot of each patient's medical and social circumstances. These pictorial displays contained the patient's photograph and other disease- and treatment-related images. The objective of this randomized trial was to assess the ability of these snapshots to enhance delayed information recall by care providers. METHODS: Participating physicians were given four advanced cancer patient histories to review, two at a time over two weeks. Pictorial image displays, referred to as the Electronic Whiteboard (EWB) were added, in a randomized manner to half of the textual histories. The impact of the EWB on information recall was tested in immediate and delayed time frames. RESULTS: Overall, patient information recall declined significantly over time, with or without the EWB. Still, this trial demonstrates significantly higher test scores after 24 hours with the addition of pictures to textual patient information, compared with textual information alone (P = 0.0002). A more modest improvement was seen with the addition of the EWB for questionnaires administered immediately after history review (P = 0.008). Most participants agreed that the EWB was a useful enhancement and that seeing a patient's photograph improved their ability to retain information. CONCLUSION: Most studies examining the institution of handover protocols in the health care setting have failed to harness the power of pictures and other representative images. This study demonstrates the ability of pictorial displays to improve both immediate and delayed recall of patient histories without increasing review time. These types of displays may be amenable to generation by software programs and have the potential to enhance information transfer in various settings.
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Continuidade da Assistência ao Paciente , Rememoração Mental , Estimulação Luminosa/métodos , Médicos , Humanos , Inquéritos e QuestionáriosRESUMO
Although outpatient specialty palliative-care clinics improve outcomes, there is no consensus on who should be referred or the optimal timing for referral. In response to this issue, we did a Delphi study to develop consensus on a list of criteria for referral of patients with advanced cancer at secondary or tertiary care hospitals to outpatient palliative care. 60 international experts (26 from North America, 19 from Asia and Australia, and 11 from Europe) on palliative cancer care rated 39 needs-based criteria and 22 time-based criteria in three iterative rounds. Nearly all experts responded in each round. Consensus was defined by an a-priori agreement of 70% or more. Panellists reached consensus on 11 major criteria for referral: severe physical symptoms, severe emotional symptoms, request for hastened death, spiritual or existential crisis, assistance with decision making or care planning, patient request for referral, delirium, spinal cord compression, brain or leptomeningeal metastases, within 3 months of advanced cancer diagnosis for patients with median survival of 1 year or less, and progressive disease despite second-line therapy. Consensus was also reached on 36 minor criteria for specialist palliative-care referral. These criteria, if validated, could provide guidance for identification of patients suitable for outpatient specialty palliative care.
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Neoplasias/terapia , Cuidados Paliativos , Encaminhamento e Consulta , Consenso , Técnica Delphi , Humanos , Medicina , Pacientes AmbulatoriaisRESUMO
Caring for patients with incurable cancer presents unique challenges. Managing symptoms that evolve with changing clinical status and, at the same time, ensuring alignment with patient goals demands specific attention from clinicians. With care needs that often transcend traditional service provision boundaries, patients who seek palliation commonly interface with a team of providers that represents multiple disciplines across multiple settings. In this case study, we explore some of the dynamics of a cross-disciplinary approach to symptom management in an integrated outpatient radiotherapy service model. Providers who care for patients with incurable cancer must rely on one another to secure delivery of the right services at the right time by the right person. In a model of shared responsibilities, flexibility in who does what and when can enhance overall team performance. Adapting requires within-team and between-team monitoring of task and function execution for any given patient. This can be facilitated by a common understanding of the purpose of the clinical team and an awareness of the particular circumstances surrounding care provision. Backup behavior, in which one team member steps in to help another meet an expectation that would otherwise not be fulfilled, is a supportive team practice that may follow naturally in high-functioning teams. Such team processes as these have a place in the care of patients with incurable cancer and help to ensure that individual provider efforts more effectively translate into improved palliation for patients with unmet needs.
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Neoplasias Ósseas/terapia , Carcinoma de Células Renais/terapia , Neoplasias Renais/terapia , Cuidados Paliativos , Equipe de Assistência ao Paciente/organização & administração , Neoplasias Ósseas/radioterapia , Neoplasias Ósseas/secundário , Carcinoma de Células Renais/patologia , Carcinoma de Células Renais/radioterapia , Feminino , Humanos , Neoplasias Renais/patologia , Neoplasias Renais/radioterapia , Pessoa de Meia-IdadeRESUMO
BACKGROUND: Progressive, incurable cancer is associated with increased fatigue, increased muscle weakness, and reduced physical functioning, all of which negatively impact quality of life. Physical activity has demonstrated benefits on cancer-related fatigue and physical functioning in early-stage cancer patients; however, its impact on these outcomes in end-stage cancer has not been established. The aim of this systematic review is to determine the potential benefits, harms, and effects of physical activity interventions on quality of life outcomes in advanced cancer patients. METHODS/DESIGN: A systematic review of peer-reviewed literature on physical activity in advanced cancer patients will be undertaken. Empirical quantitative studies will be considered for inclusion if they present interventional or observational data on physical activity in advanced cancer patients. Searches will be conducted in the following electronic databases: CINAHL; CIRRIE Database of International Rehabilitation Research; Cochrane Database of Systematic Reviews (CDSR); Database of Abstracts of Reviews of Effects (DARE); Cochrane Central Register of Controlled Trials (CENTRAL); EMBASE; MEDLINE; PEDro: the Physiotherapy Evidence Database; PQDT; PsycInfo; PubMed; REHABDATA; Scopus; SPORTDiscus; and Web of Science, to identify relevant studies of interest. Additional strategies to identify relevant studies will include citation searches and evaluation of reference lists of included articles. Titles, abstracts, and keywords of identified studies from the search strategies will be screened for inclusion criteria. Two independent reviewers will conduct quality appraisal using the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies (EPHPP) and the Cochrane risk of bias tool. A descriptive summary of included studies will describe the study designs, participant and activity characteristics, and objective and patient-reported outcomes. DISCUSSION: This systematic review will summarize the current evidence base on physical activity interventions in advanced cancer patients. The findings from this systematic review will identify gaps to be explored by future research studies and inform future practice guideline development of physical activity interventions in advanced cancer patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015026281.