Evaluation of the effectiveness of the physician education program on primary palliative care in heart failure.

Major cardiology societies' guidelines support integrating palliative care into heart failure (HF) care. This study aimed to identify the effectiveness of the HEart failure Palliative care Training program for comprehensive care providers (HEPT), a physician education program on primary palliative care in HF. We performed a pre- and post-test survey to evaluate HEPT outcomes. Physician-reported practices, difficulties and knowledge were evaluated using the Palliative Care Self-Reported Practices Scale in HF (PCPS-HF), Palliative Care Difficulties Scale in HF (PCDS-HF), and Palliative care knowledge Test in HF (PT-HF), respectively. Structural equation models (SEM) were used to estimate path coefficients for PCPS-HF, PCDS-HF, and PT-HF. A total of 207 physicians participated in the HEPT between February 2018 and July 2019, and 148 questionnaires were ultimately analyzed. The total PCPS-HF, PCDS-HF, and PT-HF scores were significantly improved 6 months after HEPT completion (61.1 vs 67.7, p<0.001, 54.9 vs 45.1, p<0.001, and 20.8 vs 25.7, p<0.001, respectively). SEM analysis showed that for pre-post difference (Dif) PCPS-HF, "clinical experience of more than 14 years" and pre-test score had significant negative effects (-2.31, p = 0.048, 0.52, p<0.001, respectively). For Dif PCDS-HF, ≥ "28 years old or older" had a significant positive direct effect (13.63, p<0.001), although the pre-test score had a negative direct effect (-0.56, p<0.001). For PT-HF, "involvement in more than 50 HF patients' treatment in the past year" showed a positive direct effect (0.72, p = 0.046), although the pre-test score showed a negative effect (-0.78, p<0.001). Physicians who completed the HEPT showed significant improvements in practice, difficulty, and knowledge scales in HF palliative care.

Delivering Community Emergency Medicine during the COVID-19 pandemic: the Physician Response Unit.

The COVID-19 pandemic has presented significant challenges to services providing emergency care, in both the community and hospital setting. The Physician Response Unit (PRU) is a Community Emergency Medicine model, working closely with community, hospital and pre-hospital services. In response to the pandemic, the PRU has been able to rapidly introduce novel pathways designed to support local emergency departments (EDs) and local emergency patients. The pathways are (1) supporting discharge from acute medical and older people's services wards into the community; (2) supporting acute oncology services; (3) supporting EDs; (4) supporting palliative care services. Establishing these pathways have facilitated a number of vulnerable patients to access patient-focussed and holistic definitive emergency care. The pathways have also allowed EDs to safely discharge patients to the community, and also mitigate some of the problems associated with trying to maintain isolation for vulnerable patients within the ED. Community Emergency Medicine models are able to reduce ED attendances and hospital admissions, and hence risk of crowding, as well as reducing nosocomial risks for patients who can have high-quality emergency care brought to them. This model may also provide various alternative solutions in the delivery of safe emergency care in the postpandemic healthcare landscape.

Organizational Strategies for Providing Cancer Palliative Care to Many.

PURPOSE: Hospitals and healthcare organizations are today operating in an extremely competitive environment, with increasing pressure to improve quality while reducing costs. In responding to this dynamic situation, transformation of any organization requires the will to organize delivery around the needs of patients. RECENT FINDINGS: Providing palliative care to the many who require it needs the value agenda to be formulated based on mutually reinforcing components. Here we present an overview of the framework for a palliative care department in a comprehensive cancer center, which includes different levels that are embedded within a comprehensive system. Detailed information on each level is presented, followed by a discussion of quality of care, as an integrating theme for the framework. The chapter concludes by detailing the benefits that a comprehensive cancer palliative care center provides to a country's healthcare efforts through service, education, research, and advocacy.

Global Perspectives on Palliative Care for Cancer Patients: Not All Countries Are the Same.

PURPOSE OF THE REVIEW: The integration of cancer-related palliative care is essential to holistic, quality cancer care. While some similarities exist between countries, this manuscript will focus on five differences that impact palliative care for cancer patients including the epidemiology of cancer and related symptoms, cancer-specific integration into care, palliative care education, economic development of the country, and cultural and religious differences. RECENT FINDINGS: The epidemiology of cancer varies around the world resulting in variable symptoms and the need for individualized approaches to palliative care. While palliative care is integrated in some countries, it is lacking in over half of the world, and specific integration into cancer care is virtually absent. Education and training are the key to expansion, and yet oncology-focused palliative care education is lacking or is not well-reported in the literature. To complicate this global lens even further are the economic disparities that exist. Low-to-middle-income countries (LMICs) are resource poor and have the fewest resources and least amount of integration, and yet patients with advanced cancer are over-represented in these countries. Essential to cancer-related palliative care is a tailored approach that addresses cultural and religious differences around the globe. Palliative care is developing around the globe and yet palliative care specific for cancer patients is in its infancy. Cancer care professionals should (1) understand the epidemiologic differences that exist globally and the impact this has on palliative care, (2) integrate palliative care into the cancer care arena, (3) provide cancer-specific palliative education focused on the cancer trajectory from diagnosis through survivorship and end of life, (4) advocate for LMICs, which suffer from a lack of resources and services, and (5) understand cultural and religious differences that exist to provide holistic and sensitive cancer-related palliative care.

Primary Palliative Care Clinical Implications: Oncology Nursing During the COVID-19 Pandemic.

The COVID-19 pandemic continues to affect the health and well-being of individuals and communities worldwide. Patients with cancer are particularly vulnerable to experiencing serious health-related suffering from COVID-19. This requires oncology nurses in inpatient and clinic settings to ensure the delivery of primary palliative care while considering the far-reaching implications of this public health crisis. With palliative care skills fully integrated into oncology nursing practice, health organizations and cancer centers will be better equipped to meet the holistic needs of patients with cancer and their families receiving care for serious illness, including improved attention to physical, psychosocial, cultural, spiritual, and ethical considerations.

Supportive and palliative care in hemato-oncology: how best to achieve seamless integration and subspecialty development?

While recent medical advances have led to cure, remission, or long-term disease control for patients with hematologic malignancy, many still portend poor prognoses, and frequently are associated with significant symptom and quality of life burden for patients and families. Patients with hematological cancer are referred to palliative care (PC) services less often than those with solid tumors, despite higher inpatient mortality and shorter interval between first consultation and death. The complexity of individual prognostication, ongoing therapeutic goals of cure, the technical nature and complications of treatment, the intensity of medical care even when approaching end of life, and the speed of change to a terminal event all pose difficulties and hinder referral. A modified palliative care model is an unmet need in hemato-oncology, where PC is introduced early from the diagnosis of hematological malignancy, provided alongside care of curative or life-prolonging intent, and subsequently leads to death and bereavement care or cure and survivorship care depending on disease course. From current evidence, the historical prioritization of cancer care at the center of palliative medicine did not guarantee that those diagnosed with a hematological malignancy were assured of referral, timely or otherwise. Hopefully, this article can be a catalyst for debate that will foster a new direction in integration of clinical service and research, and subspecialty development at the interface of hemato-oncology and palliative care.

[Oncologic supportive care for a personalized support of all patients]. / Les soins de support pour améliorer l'accompagnement personnalisé des patients.

Ever since the officialization of oncologic supportive care by the DHOS circular in February 22nd, 2005 and measure 42 of the 2003-2007 Cancer Plan, their content has been enriched for inpatients and outpatients. A guaranteed care package was determined in February 2017 following a study lead by AFSOS and INCa. It adds adapted physical activity and sexual health support to basic supportive care such as pain relief, nutrition, psychology, social support. Supportive cares in pediatric oncology were defined in March 2004. They always were part of holistic pediatric care. The offer in supportive care for children and AYA and the offer in adult supportive care can complete, inspire or improve each other.

Integration of palliative care in services for children with life-limiting neurodevelopmental disabilities and their families: a Delphi study.

BACKGROUND: The aim of this study was to explore expert professionals' opinions on service provision to children under six with life-limiting neurodevelopmental disabilities (LLNDD), including the goals of care and the integration and coordination of palliative care in general and specialist services. METHODS: A Delphi design was used with three questionnaire rounds, one open-ended and two closed response rounds. Primary data collected over a six-month period from expert professionals with five years' (or more) experience in pediatric, intellectual disability and/or palliative care settings. Ratings of agreement and prioritization were provided with agreement expressed as a median (threshold = 80%) and consensus reported as interquartile ranges. Stability was measured using non-parametric tests. RESULTS: Primary goals of care were achievement of best possible quality of life, effective communication and symptom management. Service integration and coordination were considered inadequate, and respondents agreed that areas of deficiency included palliative care. Improvement strategies included a single care plan, improved communication and key worker appointments. CONCLUSIONS: The findings suggest that services do not serve this group well with deficiencies in care compounded by a lack of information on available services and sub-optimal communication between settings. Further research is needed to develop an expert-based consensus regarding the care of children with LLNDD.

Bringing Palliative Care Downstairs: A Case-Based Approach to Applying Palliative Care Principles to Emergency Department Practice.

Although the emergency department (ED) may not be traditionally thought of as the ideal setting for the initiation of palliative care, it is the place where patients most frequently seek urgent care for recurrent issues such as pain crisis. Even if the patients' goals of care are nonaggressive, their caregivers may bring them to the ED because of their own distress at witnessing the patients' suffering. Emergency department providers, who are trained to focus on the stabilization of acute medical crises, may find themselves frustrated with repeat visits by patients with chronic problems. Therefore, it is important for ED providers to be comfortable discussing goals of care, to be adept at symptom management for chronic conditions, and to involve palliative care consultants in the ED course when appropriate. Nurse practitioners, with training rooted in the holistic tradition of nursing, may be uniquely suited to lead this shift in the practice paradigm. This article presents case vignettes of 4 commonly encountered ED patient types to examine how palliative care principles might be applied in the ED.

Increasing Critical Care Nurse Engagement of Palliative Care During the COVID-19 Pandemic.

BACKGROUND: The coronavirus disease 2019 pandemic has led to escalating infection rates and associated deaths worldwide. Amid this public health emergency, the urgent need for palliative care integration throughout critical care settings has never been more crucial. OBJECTIVE: To promote palliative care engagement in critical care; share palliative care resources to support critical care nurses in alleviating suffering during the coronavirus disease 2019 pandemic; and make recommendations to strengthen nursing capacity to deliver high-quality, person-centered critical care. METHODS: Palliative and critical care literature and practice guidelines were reviewed, synthesized, and translated into recommendations for critical care nursing practice. RESULTS: Nurses are ideally positioned to drive full integration of palliative care into the critical care delivery for all patients, including those with coronavirus disease 2019, given their relationship-based approach to care, as well as their leadership and advocacy roles. Recommendations include the promotion of healthy work environments and prioritizing nurse self-care in alignment with critical care nursing standards. CONCLUSIONS: Nurses should focus on a strategic integration of palliative care, critical care, and ethically based care during times of normalcy and of crisis. Primary palliative care should be provided for each patient and family, and specialist services sought, as appropriate. Nurse educators are encouraged to use these recommendations and resources in their curricula and training. Palliative care is critical care. Critical care nurses are the frontline responders capable of translating this holistic, person-centered approach into pragmatic services and relationships throughout the critical care continuum.

The Urgency of Spiritual Care: COVID-19 and the Critical Need for Whole-Person Palliation.

The coronavirus disease 2019 (COVID-19) crisis has amplified the importance of palliative care to countless patients suffering with and dying from this disease, as well as to their families, communities, and the worldwide cadre of overburdened health care workers. Particularly urgent is the need for spiritual care specialists and generalists to address spiritual suffering given the degree of isolation, loneliness, and vulnerability caused by this pandemic. Although spiritual care has long been recognized as one of the domains of quality palliative care, it is often not fully integrated into practice. All disciplines are ultimately responsible for ensuring that spiritual care is prioritized to improve quality of life and the experience of patients and families facing spiritual emergencies amid the complex life-and-death scenarios inherent to coronavirus disease 2019. Although the pandemic has revealed serious fault lines in many health care domains, it has also underscored the need to recommit to spiritual care as an essential component of whole-person palliative care.

Live discharge from hospice care: psychosocial challenges and opportunities.

Hospice social workers face many challenges in attempts to replicate or supplement the holistic support and unique services hospice provides for individuals discharged alive. This discontinuity in care can impact the types of supports needed by individuals and caregivers, which may or may not be accessible within their community. Patients and families who have access to community-based palliative care programs following a discharge generally tend to navigate the process with fewer challenges. This qualitative study (N = 24) explored both the challenges of the live discharge process and the opportunities within social work practice in the US. Results from this study emphasize the need for a framework to better approach a live discharge to ensure appropriate supports are accessible for all patients and caregivers. Specifically, results highlight both the concrete and psychosocial challenges in live discharges as a result of tension between current eligibility requirements and individual feelings and needs. Social workers also provided suggestions to improve the live discharge process, including attention to communication and preparation. This paper outlines specific challenges of live discharge from hospice, a framework for understanding presented challenges, and implications for policy and practice.

Priorities of palliative care: comparison of perspectives of patients and nurses in a haemodialysis ward in Iran.

BACKGROUND: Palliative care is an important branch of nursing care. Patients with end-stage renal disease, owing to the chronic nature of the disease, will require palliative care, with nursing staff being responsible for delivering these services. Understanding the priorities of this type of care from the perspective of patients and nursing staff can be helpful in delivering it effectively and efficiently. This study was conducted to determine and compare palliative care priorities from the perspectives of patients and nursing staff in a haemodialysis ward in Iran. METHOD: This research is a cross-sectional and descriptive-analytic study with a sample size equal to the research population (322 patients and 45 nursing staff) in a haemodialysis ward in Kerman, Iran. Data were collected using two self-administered questionnaires that included demographic information and palliative care priorities. Data were analysed using SPSS19 with central tendency and dispersion indicators (frequency, percentage, mean and standard deviation, Mann-Whitney U-test, Kruskal-Wallis, independent t, ANOVA and one-way ANOVA). The significance level was P<0.05. RESULTS: The mean total score (± standard deviation) of palliative care priorities from the patients' and nurses' perspective was 268.83±3.90 and 271.11±29.76, respectively, which was categorised for both groups as 'high priority'. From the patients' perspective, the highest mean score was obtained from 'supporting patient with insurance concerns', while the lowest mean score was derived from 'managing diarrhoea'. The nurses also believed that 'managing and relief of pain' had the highest priority and 'bloating' had the lowest priority in palliative care. From the perspective of both groups, holistic support and relief of physical disorders had the highest and lowest mean scores, respectively. Further, the mean scores of palliative care priorities did not differ significantly from the perspective of patients and nursing staff in the haemodialysis ward (P=0.68). CONCLUSION: Palliative care is a high priority for both haemodialysis patients and nursing staff and both groups prioritised it similarly. As palliative care has not yet been initiated formally across all treatment centres in Iran, it is necessary to prioritise its inclusion within the renal and haemodialysis wards in Iran and provide further training or education for nurses to ensure they are equipped to deliver effective and informed palliative care.

A pilot study exploring interventions for physician distress in pediatric subspecialists.

BACKGROUND: While institution-sponsored wellness programs may be effective, little is known about their availability and utilization in pediatric subspecialists, and about programs physicians wish were available. METHODS: A survey of perceptions about, and availability and utilization of institutional wellness activities, was distributed electronically to pediatric subspecialists nationally. Bivariate analyses were performed using χ2 tests or independent t tests. Multivariable logistic regression models for categories of institution-sponsored programming as a function of potential predictors of program utilization were performed. Qualitative content analysis was performed for free-text survey answers. RESULTS: Approximately 60% of respondents participated in institution-sponsored wellness opportunities. Debriefs, Schwartz Center Rounds, mental health services, and team building events were the most available institution-sponsored wellness activities, whereas debriefs, team building, Schwartz Center Rounds, and pet therapy were most frequently utilized. Respondents desired greater social/emotional support, improved leadership, enhanced organizational support, and modifications to the physical work environment, with no significant differences across subspecialties for "wish list" items. CONCLUSIONS: Physician wellness requires more than a "one-size-fits-all" initiative. Our data highlight the importance of encouraging and normalizing self-care practices, and of listening to what physicians articulate about their needs. Pre-implementation needs assessment allows a "bottom-up" approach where physician voices can be heard.

Dissemination and Implementation of Palliative Care in Oncology.

Palliative care began in academic centers with specialty consultation services, and its value to patients, families, and health systems has been evident. The demand for palliative care to be integrated throughout the cancer trajectory, combined with a limited palliative care workforce, means that new models of care are needed. This review discusses evidence regarding the need for integration of palliative care into routine oncology care and describes best practices recognized for dissemination of palliative care. The available evidence suggests that palliative care be widely adopted by clinicians in all oncology settings to benefit patients with cancer and their families. Efforts are needed to adapt and integrate palliative care into community practice. Limitations of these models are discussed, as are future directions to continue implementation efforts. The benefits of palliative care can only be realized through effective dissemination of these principles of care, with more primary palliative care delivered by oncology clinicians.

A New Perspective on Spiritual Care: Collaborative Chaplaincy and Nursing Practice.

Spirituality is a key focus and ethical obligation of nursing practice, but many nurses express uncertainty or discomfort with this aspect of their role. The purpose of this article is to explore the domains of religion, spirituality, and culture as commonly conceptualized by chaplains, as a framework for nurses to provide spiritual care interventions to patients in acute care hospitals. Using anecdotes and illustrations from palliative care practice, this article discusses the enhanced benefits to patients and families when spiritual needs are addressed, with specialty-level chaplain interventions, primary spiritual interventions provided uniquely by nurses, or interventions that require the cooperation of both professions. Lessons learned from the inpatient palliative care team experience can also apply to chaplaincy and nursing care for patients in settings beyond the acute care hospital and in disciplines beyond palliative care.

A gap between the philosophy and the practice of palliative healthcare: sociological perspectives on the practice of nurses in specialised palliative homecare.

Palliative care philosophy is based on a holistic approach to patients, but research shows that possibilities for living up to this philosophy seem limited by historical and administrative structures. From the nurse perspective, this article aims to explore nursing practice in specialised palliative homecare, and how it is influenced by organisational and cultural structures. Qualitative, semi-structured interviews with nine nurses were conducted, inspired by Bourdieu. The findings showed that nurses consolidate the doxa of medicine, including medical-professional values that configure a control-oriented, positivistic approach, supported by the organising policy for clinical practice. Hierarchically, nurses were positioned under doctors: medical rounds functioned as a structuring structure for their working day. They acted as medical assistants, and the prevailing medical logic seemed to make it difficult for nurses to meet their own humanistic ideals. Only short time slots allowed nurses to prioritise psychosocial needs of patients and relatives. Point-of-actions had high priority, added financial resources and ensured that budgets were allocated. Weekly visits made it possible for nurses to measure, control and govern patients' drugs and symptoms which was a necessity for their function as medical assistants. The findings challenge nurses to take on an ethical point of view, partly to ensure that patients and their families receive good palliative care focusing on more than medical issues and logic, and partly to strengthen the nurses' profession in the palliative field and help them implement palliative care philosophy in practice.

Spirituality in heart failure: a review of the literature from 2014 to 2019 to identify spiritual care needs and spiritual interventions.

PURPOSE OF REVIEW: The burden of heart failure is significant and its management is complex. Current evidence confirms a high level of spiritual distress and a strong desire for spiritual support, which is endorsed by healthcare policy, yet spiritual support is rarely provided for this patient group. There is a need to identify how spiritual support might be meaningfully included within holistic heart failure multidisciplinary care and how its effectiveness might be demonstrated. RECENT FINDINGS: A literature review was undertaken to identify recent evidence (2014-2019) of the spiritual care needs of heart failure patients/carers and the nature and effectiveness of spiritual interventions in heart failure care. SUMMARY: Taken as a whole, studies exploring heart failure patients'/carers' needs reflected the broad spectrum of spirituality as defined by international consensus, however, some studies focused on only some aspects of spirituality and on advanced disease. All studies were limited. No single spiritual intervention was identified as effective in enhancing quality of life in patients with heart failure. Life review and relaxation/meditation appeared ineffective. Interventions, which included elements of 'talking' about spiritual matters, 'spiritual coping' and those involving a holistic person-centred team approach to care of which spiritual care was an aspect, are worth investigating further in well designed randomized controlled trials.

Unpacking 'the cloud': a framework for implementing public health approaches to palliative care.

Designing and implementing population-based systems of care that address the social determinants of health, take action on multiple levels, and are guided by evidence-based principles is a pressing priority, and an international challenge. Aging persons are a priority demographic whose health needs span physical, psychosocial and existential care domains, increase in the last year of life, are often poorly coordinated and therefore remain unmet. Compassionate communities (CCs) are an example of a public health approach that fully addresses the holistic healthcare needs of those who are aging and nearing end of life. The sharing of resources, tools, and innovations among implementers of CCs is occurring globally. Although this can increase impact, it also generates complexity that can complicate robust evaluation. When initiating population health level projects, it is important to clearly define and organize concepts and processes that are proposed to influence the health outcomes. The Health Impact Change Model (HICM) was developed to unpack the complexities associated with the implementation and evaluation of a Canadian CC intervention. The HICM offers utility for citizens, leaders and decision-makers who are engaged in the implementation of population health level strategies or other social approaches to care, such as compassionate cities and age or dementia-friendly communities. The HICM's concepts can be adapted to address a community's healthcare context, needs, and goals for change. We share examples of how the model's major concepts have been applied in the development, evaluation and spread of a complex CC approach.