Factors influencing place of death and disenrollment among patients receiving specialist palliative care.

BACKGROUND AND AIM OF THE WORK: Place of death and disenrollment from specialized palliative care services (SPCSs) are two aspects that determine service utilization. These aspects should be determined by patient needs and preferences, but they are often associated to patient sociodemographic or contextual characteristics. The aim of this study was to describe which factors are associated with utilizing SPCSs in terms of place of death and disenrollment. METHODS: Retrospective cohort study. Patients (>18 years) who died or were disenrolled during SPCSs utilization. Two hierarchical regression models were performed, and variables were categorized in predisposing, enabling, and need factors according to the Andersen behavioral model of health services use. RESULTS: We included 35,869 patients (52,5% male, mean age 74,6 ± 12,3 SD), where 17,225 patients died in hospice and 16,953 at home, while 1,691 patients were disenrolled. Dying at home was associated with older age, oncological diagnosis, painful symptoms and longer survival time. Instead, service disenrollment was associated with less education, longer wait time and longer length of stay. CONCLUSIONS: SPCS utilization was not influenced only by patient need, but also by other factors, such as social and contextual factors. These factors need to be considered by health care providers and efforts are needed for 1) identifying barriers and implementing effective interventions to support patients and caregivers in their preferred place of care and death and 2) for avoiding SPCS disenrollment with an increased probability of aggressive treatments and worse quality of life for patients.

Oncology and Palliative Care Nurses' Knowledge and Attitudes Toward Artificial Nutrition and Hydration for Patients at End of Life in Italy: A Cross-sectional Survey.

BACKGROUND: Nutrition is a basic patients' need and an important component of nursing. End-of-life cancer patients can experience difficulties in eating and drinking, sometimes requiring artificial nutrition and hydration (ANH). Nurses' knowledge and attitudes greatly influence nursing care. Nurses may lack knowledge of ANH. To date, no study has explored the knowledge and attitudes of oncology and palliative care nurses toward end-of-life ANH. OBJECTIVE: To describe oncology and palliative care nurses' knowledge of and attitudes toward ANH. METHODS: A multicenter cross-sectional study was conducted in 7 regions of Italy using the Italian version of the Questionnaire on Knowledge and Attitudes in Providing ANH for Terminal Cancer Patients. Attitudes were divided into benefits and burdens of providing ANH. Data were analyzed by descriptive statistics. RESULTS: High percentages of oncology and palliative care nurses showed reasonable knowledge about ANH. More disagreement was evidenced about benefits and burdens of ANH, and lower importance was given to them. CONCLUSIONS: Some misconceptions and a low level of awareness exist among some nurses about ANH. More nursing studies should be conducted and extended to different care settings. Moreover, guidelines should be reinforced with a nursing perspective to better define nurses' role in the decision-making process on ANH. IMPLICATIONS FOR PRACTICE: This exploration of nurses' knowledge of and attitudes toward ANH in end-of-life cancer patients can contribute to an understanding of how nurses can be involved in better meeting cancer patients' nutritional needs at the end of life.

Supportive and palliative care indicators tool (SPICT™): content validity, feasibility and pre-test of the Italian version.

BACKGROUND: Difficulties in identifying patients at risk of clinical deterioration or death represent one of the main barriers to Palliative Care (PC) development in the community. Currently, no specific Italian tools aimed at identifying patients with PC needs are available. Of the different European tools available, the SPICT™ can be used easily in any kind of setting and does not include the Surprise Question. The purpose of the study was to translate, cross-culturally adapt and pre-test the Italian version of the SPICT™. METHODS: The Beaton recommendations for the cross-cultural adaptation of instruments were followed. Content validity was assessed using the Lynn method. A sample of Italian General Practitioners (GPs) assessed the SPICT-IT™ for feasibility and tested it. RESULTS: During the cross-cultural adaptation, some issues regarding semantic, experiential, idiomatic and conceptual equivalences were raised and resolved. The Scale-Content Validity Index/Ave was 0.86. Of the 907 GPs included in the sample, 71 (7.8%) agreed to test the SPICT-IT™ and to assess its feasibility. The participants provided care for 73,526 people in the community. Of these people, 1.7% (N = 1303) were identified as being in need of PC according to the SPICT-IT™. Sixty-six (93.0%) GPs stated they would use the SPICT-IT™ in their daily clinical practice. CONCLUSIONS: The SPICT-IT™ demonstrated acceptable content validity. The percentage of patients identified through the SPICT-IT™ was comparable to findings from literature. The next phase of this project will investigate the impact of a proactive training programme aimed at supporting GPs in identifying patients with PC needs and delivering appropriate Primary Palliative Care (PPC).

Inequity in palliative care service full utilisation among patients with advanced cancer: a retrospective Cohort study.

Background: Advanced cancer patients often die in hospital after receiving needless, aggressive treatment. Although palliative care improves symptom management, barriers to accessing palliative care services affect its utilisation, and such disparities challenge the equitable provision of palliative care. This study aimed to identify which factors are associated with inequitable palliative care service utilisation among advanced cancer patients by applying the Andersen Behavioural Model of Health Services Use.Material and methods: This was a retrospective cohort study using administrative healthcare data. A total of 13,656 patients residing in the Lazio region of Italy, who died of an advanced cancer-related cause-either in hospital or in a specialised palliative care facility-during the period of 2012-2016 were included in the study. Potential predictors of specialised palliative service utilisation were explored by grouping the following factors: predisposing factors (i.e., individuals' characteristics), enabling factors (i.e., systemic/structural factors) and need factors (i.e., type/severity of illness).Results: The logistic hierarchical regression showed that older patients (odds ratio [OR] = 1.45; <0.0001) of Caucasian ethnicity (OR = 4.17; 0.02), with a solid tumour (OR = 1.87; <0.0001) and with a longer survival time (OR = 2.09; <0.0001) were more likely to be enrolled in a palliative care service. Patients who lived farther from a specialised palliative care facility (OR = 0.13; <0.0001) and in an urban area (OR = 0.58; <0.0001) were less likely to be enrolled.Conclusion: This study found that socio-demographic (age, ethnicity), clinical (type of tumour, survival time) and organisational (area of residence, distance from service) factors affect the utilisation of specialised palliative care services. The fact that service utilisation is not only a function of patients' needs but also of other aspects demonstrates the presence of inequity in access to palliative care among advanced cancer patients.

Oral Hygiene Care in Patients With Advanced Disease: An Essential Measure to Improve Oral Cavity Conditions and Symptom Management.

BACKGROUND: Oral problems are frequent in palliative care and can cause disabling symptoms such as orofacial pain, dysgeusia, and xerostomia. Even if oral care is an essential aspect of nursing, it is often not considered as a priority, especially when various complex patients' needs have to be managed. OBJECTIVE: The aim of this study was to describe oral conditions and evaluate the impact of standard oral care on symptom control and patient's perceived comfort in a sample of terminally ill patients. METHOD: A prospective cohort study was carried out among 415 patients who were admitted to hospice. Patients were recruited before undergoing standard assisted procedure for oral hygiene care. Oral cavity condition, symptoms, and comfort were assessed at the recruitment (T0) and after 3 days (T2). RESULTS: Seventy-five eligible patients were recruited. The Oral Assessment Guide score was significantly decreased after oral standard care (P value <.0001). The average time spent by nursing staff for oral hygiene care was 5.3 minutes. Dysgeusia and xerostomia were significantly decreased after oral standard care (P = .02 and P = .03). Patients reported a high level of comfort (86.6%) after the procedures for oral hygiene care. CONCLUSION: Patients admitted to hospice had frequent alterations in oral cavity with partial loss of its functions that can compromise their quality of life. Standard procedures for oral hygiene care are simple and fast to perform, and they may improve oral cavity conditions, symptoms control, and patients' comfort.

The effectiveness of progressive muscle relaxation and interactive guided imagery as a pain-reducing intervention in advanced cancer patients: A multicentre randomised controlled non-pharmacological trial.

BACKGROUND AND PURPOSE: Interactive guided imagery (IGI) and progressive muscle relaxation (PMR) are complementary therapies with a recognised positive effect on cancer pain relief. This multicentre randomised controlled trial was designed to assess the adjuvant effect of PMR-IGI in alleviating pain in a sample of hospice patients with terminal cancer. MATERIALS AND METHODS: A total of 104 patients were randomised to two groups. Group A patients (n = 53) were administered the Revised Edmonton Symptom Assessment Scale (ESAS-r) and the numerical rating scale (NRS) for pain immediately prior to (T1) and 2 h following an individual PMR-IGI session (T3). Group B patients (n = 51) received usual care and were assessed using the same tools. Acute pain episodes and rescue analgesics over the following 24 h were recorded. RESULTS: The Pain Intensity Difference (NRS at T3-NRS at T1) was 1.83 in group A and 0.55 in group B and was significant in both groups (p < 0.0001). The mean Total Symptom Distress Score declined by 8.83 in group A and by 1.84 in group B.The average difference in the emotional symptoms ESAS-r subscore (anxiety and depression) was 2.93 in group A (p < 0.0001) and 0.07 in group B (p > 0.05). CONCLUSION: The results of this trial suggest that PMR-IGI may be considered as an effective adjuvant in alleviating pain-related distress in terminal cancer patients. Further studies should be performed to assess the effectiveness of repeated interventions.

Peripherally inserted central catheter, midline, and "short" midline in palliative care: Patient-reported outcome measures to assess impact on quality of care.

OBJECTIVES: A prospective, observational study was conducted in our palliative care unit to assess the impact of peripherally inserted central catheters (PICCs), midline, and "short" midline catheters on the quality of care in cancer and non-cancer patients. The secondary objective was to assess pain and distress during vascular access device insertion. METHODS: Patients were recruited if they underwent insertion of a PICC, midline, or "short" midline catheter as part of their standard care. The Palliative care Outcome Scale was used to assess changes in quality of care after vascular access device positioning. A numerical rating scale was used to measure pain intensity during catheter insertion. RESULTS: Of the 90 patients enrolled, 52.2% were male with a mean age of 73.0 ± 13 years. Among these patients, 64.4% patients underwent "short" midline insertion, 26.7% PICC, and 8.9% midline catheter. The patients' mean baseline Palliative care Outcome Scale score was 15.7 ± 5.6. Three days after vascular access device positioning, the patients' mean Palliative care Outcome Scale score was 11.5 ± 5.5 (p < 0.0001). Mean pain score during vascular access device insertion was 1.26 ± 1.63, and mean procedural distress score was 1.78 ± 1.93. CONCLUSION: These findings suggest that medium-term intravenous catheters can have a favorable impact on quality of care and the procedures for these vascular access device insertions are well tolerated. Further research on the performance of different vascular access devices and their appropriateness in palliative care should be encouraged.

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.

Procedural Pain in Palliative Care: Is It Breakthrough Pain? A Multicenter National Prospective Study to Assess Prevalence, Intensity, and Treatment of Procedure-related Pain in Patients With Advanced Disease.

OBJECTIVE: To assess the prevalence of breakthrough pain (BTP) provoked by 6 common procedures in patients with advanced disease. METHODS: A prospective, cross-sectional, multicenter, national study was performed in 23 palliative care units in Italy. Patients were recruited if they were undergoing one of the following procedures as part of normal care: turning, personal hygiene care, transfer from bed to chair, bladder catheterization, pressure ulcer care, and subcutaneous drug administration. The Numerical Rating Scale was used to measure pain intensity before, during, and after the procedure. RESULTS: One thousand seventy-nine eligible patients were enrolled: 49.7% were male and their mean age was 78.0±11.2 years. Of all patients, 20.9% had experienced a BTP episode within the 24 hours before recruitment. The overall prevalence of procedure-induced BTP was 11.8%, and the mean intensity score (Numeric Rating Scale) was 4.72±1.81. Notably, patients experienced a significant increase in pain intensity during all procedures (P<0.0001). A small proportion of patients (12.7%) received analgesics before undergoing any of the procedures, and almost none (1.7%) received analgesics during the procedures to alleviate acute pain. DISCUSSION: Our findings highlight that simple daily care procedures can lead to BTP among patients with advanced disease. Because such procedures are performed very often during palliative care, more individualized attention to procedural pain control is necessary. Additional research on procedural pain in patients with advanced disease should be encouraged to provide further evidence-based guidance on the use of the available medication for predictable pain flares.

The positive role of caregivers in terminal cancer patients' abilities: usefulness of the ICF framework.

BACKGROUND: Among the purposes of palliative care, reducing perceived disability during the terminal stages of illness is of paramount importance. AIM: The aim of this study was to shed light on the possible role of the caregiver as a modulator of disability in patients with advanced cancer receiving end-of-life palliative care by means of the WHO International Classification of Functioning, Disability and Health (ICF). DESIGN: Observational prospective cross-sectional study. SETTING: Inpatients of a Palliative Care Unit. POPULATION: Fifty consecutively-enrolled inpatients (aged 69.9±10.6), in bed on average for more than 50% of daily hours (Karnofsky Performance Status Scale: 31.2±10.0) and functionally severely compromised (Barthel Index: 45.3±19.7); the average estimated survival was 6 weeks or more (Palliative Prognostic Index: 5.5±2.4). METHODS: Inpatients compiled a self-report questionnaire on quality of life (SF-12) and were interviewed on the ICF checklist. RESULTS: Patients reported significantly lower quality of life scores (SF-12) than the normative sample for both the Physical Component Summary Score (29.2±8.1 vs. 50.0±9.4; Student's t-test P=0.00001) and the Mental Component Summary Score (39.7±11.8 vs. 50.0±9.9; P=0.01). As to ICF Activity and Participation delta (Δ) values, describing caregiver's impact on patient's life: 26 domains had a median Δ=0 (neutral caregiver's role), 10 domains had a median Δ>0 (caregiver as a positive modulator of the patient's disability); no negative Δ values were reported (caregiver never considered as a barrier). Environmental Factors were mainly facilitators. CONCLUSIONS: Even if patients were mostly confined to bed, with reduced functional autonomy and marked dependency on others, their disability was reduced thanks to the caregiver's modulator role. CLINICAL REHABILITATION IMPACT: The ICF framework could also be extended to palliative care, because by integrating the standard functional assessment, it allows to identify two levels of intervention: one directly affecting patients' activity and participation, and one related to barriers and facilitators (i.e., caregivers, environmental factors).

[International Classification of Functioning, Disability and Health (ICF) and quality of life in cancer patients in a terminal condition]. / International Classification of Functioning, Disability and Health (ICF) e qualità della vita nel paziente oncologico in fase avanzata di malattia.

INTRODUCTION: Quality of life (QoL) preservation for the patient with cancer in a terminal condition is a central goal in palliative care. Aim of the present study is to assess QoL and to verify the additive value of the ICF in a sample of cancer inpatients of a palliative care unit. Method. 32 terminal palliative care inpatients were evaluated by means of traditional assessment tools: Karnofsky Performance Status (KPS), Palliative Prognostic Index (PPI), Barthel Index (BI), SF-12, EuroQol VAS (today and last 30 days) and ICF checklist. Results. Among the 32 patients (age 70.4 +/- 10.2), 17 male (53.1%) and 15 female (49.6%), 8 were alive at the end of the study (24 deceased: survival days 41.0 +/- 46.4). As to the traditional assessment instruments, patients resulted severely impaired: KPS 30.0 +/- 10.4; PPI 5.7 +/- 2.7; BI 35.6 +/- 22.2; EuroQol-VAS today 46.5 +/- 19.7; EuroQol-VAS last 30 days 29.0 +/- 22.5; SF-12: PCS 29.2 +/- 8.1 e MCS 39.7 +/- 11.8. As to the ICF Activity and Participation categories 21 out of 42 (with equipment aids only) and 12 out of 42 (with equipment aids and with a person's help) resulted at least mildly impaired in > or =50% of patients. Delta values of the former scores (caregiver's impact) were calculated: in 10 categories the median value was > or =1 (caregiver as a positive disability modulator) and in 32 the median value was 0 (neutral role of the caregiver). Environmental Factors were mainly facilitators. Conclusions. Traditional QoL assessment highlights the severity of this condition. Whereas the ICF Checklist shows a more diversified situation, where some aspects of daily life are maintained, safeguarding personal dignity and family role. An integrated use of these instruments may grant an overall assessment, showing both difficulties and resources, confirming the importance of a unique interdisciplinary approach with patients at end of life.

Airway control via the CobraPLA during percutaneous dilatational tracheotomy in five patients.

PURPOSE: To evaluate the use of the new supraglottic airway device CobraPLA (CPLA) for performing percutaneous dilatational tracheotomy (PDT) utilizing continuous fibreoptic visualization of the larynx and trachea and uninterrupted airway control. CLINICAL FEATURES: The percutaneous tracheotomies were carried out in five patients (four males and one female; mean age 72 yr, mean height 164.6 cm, mean weight 74 kg) following the Griggs technique under continuous fibreoptic vision and airway control provided by the CPLA. The mean time required for removal of the ETT, positioning of the CPLA, and confirmation of adequate ventilation and cuff seal was 78 sec. The mean time for the entire PDT procedure was six minutes and 57 sec. In one patient a 7-mm tracheostomy cannula was used, and in the other four patients an 8-mm cannula was used. The hemodynamic and respiratory variables remained stable during the entire procedure; there were no adverse events. At no point was there any significant difficulty in placing the CPLA or in providing ventilation or oxygenation. Each procedure could be observed easily in its entirety through the FOB. CONCLUSIONS: This technique can be considered simple and safe because it is video-assisted and ensures a continuous airway control. The CPLA offers several advantages over some other supraglottic devices when performing this surgical procedure.