Opioid prescribing attitudes of palliative care physicians versus other specialists: a questionnaire-based survey.

PURPOSE OF THE STUDY: While opioid overuse is a public health crisis in the USA, opioid analgesics are used suboptimally in Central and Eastern Europe, causing many pain cases to remain untreated or undertreated. STUDY DESIGN: This questionnaire study aimed to identify the prevalent prescribing patterns and attitudes and the possible internal impediments to optimal opioid use among palliative care physicians and other specialists in Poland. RESULTS: Tramadol was the most commonly preferred opioid. While palliative care physicians (n=81) used various strong opioids, other physicians (n=87) prescribed mostly buprenorphine, accessible with standard prescription forms. Neither internal prejudices and beliefs nor administrative regulations impede prescribing opioids by palliative care physicians, unlike specialists other than palliative medicine. Special prescription forms for psychoactive medications, fear of drug addiction of their patients and penalties for possible errors on prescriptions affect the latter's optimal prescribing. They also revealed significant gaps in the knowledge of prescribing opioids and would take part in additional training. Palliative care physicians appeared optimally prepared for cancer pain management and report fewer internal barriers than other specialists. CONCLUSIONS: Continuous medical education on cancer pain treatment should be provided to all specialists to ensure optimal opioid pharmacotherapy and avoid overprescribing or underprescribing opioids. Administrative restrictions are the main barrier to optimal pain treatment.

Effectiveness and Reach of the Primary Palliative Care for Emergency Medicine (PRIM-ER) Pilot Study: a Qualitative Analysis.

BACKGROUND: Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centered outcomes. OBJECTIVE: To understand the facilitators that contributed to the success of the Primary Palliative Care for Emergency Medicine (PRIM-ER) quality improvement pilot intervention. DESIGN: Effectiveness was evaluated through semi-structured interviews. Reach outcomes were measured by percent of all full-time emergency providers (physicians, physician assistants, nurses) who completed the intervention education components and baseline survey assessing attitudes and knowledge on end-of-life care. PARTICIPANTS: Emergency medicine providers affiliated with two medical centers (N = 197). Interviews conducted with six key informants at both institutions. APPROACH: Interviews were recorded, transcribed, and analyzed using deductive and inductive approaches. Descriptive statistics include reach outcomes and baseline survey results. KEY RESULTS: Both sites successfully implemented all components of the intervention and achieved a high level (> 75%) of intervention reach. Two themes emerged as facilitators to successful effectiveness facilitators of PRIM-ER: (1) institutional leadership support and (2) leveraging established quality improvement (QI) processes. Institutional support included leveraging leadership with authority to (a) mandate trainings; (b) substitute PRIM-ER education for normally scheduled education; and (c) provide protected time to implement intervention components. Effectiveness was also enhanced by capitalizing on existing QI processes which included (a) leveraging interdisciplinary partnerships and communication plans and (b) monitoring performance improvement data. CONCLUSIONS: Capitalizing on strong institutional leadership support and established QI processes enhanced the reach and effectiveness of the PRIM-ER pilot. These findings will guide the PRIM-ER researchers in scaling up the intervention in the remaining 33 sites, as well as enhance the planning of other complex quality improvement interventions in clinical settings. REGISTRATION DETAILS: ClinicalTrials.gov Identifier: NCT03424109; Grant Number: AT009844-01.

Improving the use of treatment escalation plans: a quality-improvement study.

OBJECTIVES: Treatment escalation plans (TEPs) are vital in communicating a ceiling of care. However, many patients still deteriorate and die without a pre-established ceiling of care for attending clinicians to rely on. We aimed to increase the proportion of suitable patients that have TEPs in place in a rural district general hospital. METHODS: We undertook three 'Plan-Do-Study-Act' (PDSA) cycles between 1 December 2016 and 9 June 2017. These cycles aimed to assess the problem, implement a solution and monitor its sustainability. We sampled all acute medical admissions at different time points, focusing on the acute medical unit. We identified patients requiring TEP forms using SupportiveandPalliative Care Indicators Tool. Stakeholders were surveyed during the project, and a process communication map was developed to understand the human interfaces that occur when producing a TEP. RESULTS: We sampled a total of 323 patients (PDSA 1, n=128; PDSA 2, n=95; PDSA 3, n=100). Following implementation of a 'talking to your doctor about treatment' leaflet, the proportion of patients who did not have a TEP but required one fell from 43% (n=38, PDSA 1) to 27% (n=20, PDSA 3) then to 23% (n=77, PDSA 3) (CI 0.6631 to 39.917, p=0.028). CONCLUSIONS: This study highlights the challenges of TEP form completion. The impact of our intervention appeared to raise awareness of advanced care planning. The information contained in our leaflet could be distributed in more innovative ways to ensure patients unable to access textual information are able to receive this message.

Futility and appropriateness: challenging words, important concepts.

The provision of healthcare is being challenged by a 'perfect storm' of forces including an increasing population with multiple comorbidities, high expectations and resource limitations, and in the background, the pre-eminence of the 'curative medical model'. Non-beneficial (futile) treatments are wasteful and costly. They have a negative impact on quality of life especially in the last year of life. Among professionals, frequent encounters with futility cause moral distress and demoralisation. The factors that drive non-beneficial treatments include personal biases, patient-related pressures and institutional imperatives. Breaking loose from the perceived necessity to deliver non-beneficial treatment is a major challenge. Curative intent should give way to appropriateness such that curative and palliative interventions are valued equally. Goals of treatment should be shaped by illness trajectory, the risk of harms as well as potential benefits and patient preferences. This strategy should be reflected in professional training and the design of acute services.

Breakthrough cancer pain tailored treatment: which factors influence the medication choice? An observational, prospective and cross-sectional study in patients with terminal cancer.

BACKGROUND: Various options for the pharmacological treatment of breakthrough cancer pain (BTcP) are available. International guidelines on BTcP treatment are not univocal. A tailored treatment should be based on the assessment of different variables such as BTcP characteristics, oral mucositis, chronic rhinitis and a patient's ability to take medication. OBJECTIVE: The goal of this study is to assess the relationship between these variables and the medication treatment for BTcP in a sample of patients with terminal cancer. METHODS: A prospective, cross-sectional study was carried out among 1180 patients who were receiving palliative care programmes. Patients were recruited if they had a diagnosis of BTcP and had been prescribed rescue opioids. Variables that might influence the BTcP treatment were assessed. RESULTS: One hundred and forty-nine eligible patients were enrolled; 59.1% of patients received short-acting oral morphine (OM), 27.5% transmucosal immediate-release fentanyl (TIRF) and 13.4% parenteral morphine for BTcP treatment. Short-acting OM prescription was related to background pain treatment with OM <60 mg daily (p<0.0001) and to home-care setting of assistance (p=0.004). Continuous intravenous morphine infusion and the presence of a vascular access were the main factors related to intravenous morphine prescription for BTcP. TIRF use was mainly related to background opioid dosage and the patient's self-sufficiency in taking medication. CONCLUSION: In clinical practice, the factors that most influenced the pharmacological treatment for BTcP were baseline opioid dosage, setting of assistance and self-ability to take medication. Further research is needed to improve the knowledge on tailored BTcP treatment.