Should Subanesthetic Ketamine be Considered When Managing Opioid Refractory Cancer Pain?

In the cancer pain setting, ketamine has been typically employed as a co-analgesic for opioid refractory and neuropathic pain. One controversial topic is whether subanesthetic ketamine be considered when managing opioid refractory cancer pain. In this "Controversies in Palliative Care" article, three clinicians independently answer this question. Specifically, each clinician provides a synopsis of the key studies that inform their thought processes, share practical advice on their clinical approach, and highlight the opportunities for future research. Three independent clinicians reported a divergence of opinion regarding the usefulness of subanesthetic ketamine for managing opioid refractory cancer pain. All investigators acknowledged the lack of high-quality trials. All agreed on the need for adequately powered trials, the development of standardized methodology, and the exploration of any patient sub-populations that may benefit from ketamine for cancer related pain.

A review of the New Zealand National Joint Registry to evaluate the survivorship and revision rates of Nexel and Coonrad-Morrey total elbow arthroplasty.

BACKGROUND: Total elbow arthroplasty (TEA) is an appropriate surgical treatment option for a variety of conditions ranging from inflammatory arthritis to trauma. Due to a high complication profile, implant companies have attempted to improve patient outcomes with evolving design mechanics and philosophy. However, the Nexel TEA prosthesis has been criticized for its unacceptably high revision rate by other research groups in the literature. The purpose of this study was to evaluate the survivorship and revision rates of the Nexel and Coonrad-Morrey total elbow arthroplasty implant systems in New Zealand. METHODS: Prospectively collected national joint registry data was used to compare the survival rates of these prostheses. Underlying diagnoses, reasons for revision, and patient demographics were all recorded. Statistical analysis included survival analysis using Kaplan-Meier curves and comparison between groups using independent t-tests. RESULTS: Over the 23-year study interval, the Nexel and Coonrad-Morrey prostheses showed similar survivorship and revision rates. The revision rates at 5 years were 7.3% for ZN and 4.5% for the Coonrad-Morrey cohorts. The average time to revision for those who are revised was 3.13 ± 1.74 years in the Nexel group and 4.93 ± 4.13 years in the Coonrad-Morrey population. CONCLUSION: Our study confirms a lower revision rate of the Nexel TEA compared to other studies in the literature. Additionally, the Nexel TEA implant performs comparably to its predecessor, the Coonrad-Morrey prosthesis in New Zealand. While it is difficult to explain the discrepancy in results with the study by Morrey et. al, future studies should focus on investigating postoperative radiographs and a deep analysis of the specific surgical technique used for this implant.

Gut permeability, circulating bacterial fragments and measures of congestion in peritoneal dialysis.

Background: Limited data exist on the association between gut permeability, circulating bacterial fragment and volume overload in peritoneal dialysis (PD) patients. We measured circulating bacterial fragments, N-terminal pro B-type natriuretic peptide (NT-proBNP), calprotectin and zonulin levels, and evaluate their association with the clinical outcomes in PD patients. Methods: This was a single-center prospective study on 108 consecutive incident PD patients. Plasma endotoxin and bacterial DNA, and serum NT-proBNP, calprotectin and zonulin levels were measured. Primary outcomes were technique and patient survival, secondary outcomes were hospitalization data. Results: There was no significant correlation between plasma endotoxin and bacterial DNA, and serum NT-proBNP, calprotectin and zonulin levels. The Homeostatic Model Assessment for Insulin Resistance (HOMA)-2ß index, which represents insulin resistance, positively correlated with plasma bacterial DNA (r = 0.421, P < .001) and calprotectin levels (r = 0.362, P = .003), while serum NT-proBNP level correlated with the severity of volume overload and residual renal function. Serum NT-proBNP level was associated with technique survival even after adjusting for confounding factors [adjusted hazard ratio (aHR) 1.030, 95% confidence interval 1.009-1.051]. NT-proBNP level was also associated with patient survival by univariate analysis, but the association became insignificant after adjusting for confounding factors (aHR 1.010, P = .073). Similarly, NT-proBNP correlated with the number of hospitalizations and duration of hospitalization by univariate analysis, but the association became insignificant after adjusting for confounding factors. Conclusion: There was no correlation between markers of gut permeability, circulating bacterial fragments and measures of congestion in PD patients. Bacterial fragments levels and gut permeability are both associated with insulin resistance. Serum NT-proBNP level is associated with the severity of volume overload and technique survival. Further studies are required to delineate the mechanism of high circulating bacterial fragment levels in PD patients.

Patient and caregiver satisfaction of a palliative care chronic diseases clinic during COVID lockdowns.

OBJECTIVES: To assess the quality assurance of a specialist palliative care clinic focused on chronic diseases and explore the satisfaction and acceptability of the telemedicine model amongst patients and caregivers. METHODS: A cross-sectional 23-item survey was developed by the clinical team, approved by ethics and distributed to patients and caregivers. Data collection ran between September 2021 and February 2022, and SPSS was used for data analysis. Demographics were collected from hospital records. RESULTS: Thirty-five surveys were returned. The cohort had a median age of 82 years, and the most common primary diagnosis was renal failure. Participants rated telemedicine as easier to access than face-to-face appointments due to convenience. Telemedicine was rated highly for future utility, with video consultations being perceived as more useful than telephone consultations. Participants responded overwhelmingly well towards the clinic. DISCUSSION: Findings demonstrated high levels of satisfaction with the Supportive Care Clinic model and for telemedicine. However, logistical challenges and the desire for face-to-face appointments were also identified. The study highlights the importance of offering a range of modalities for patient engagement in healthcare services and suggests that telemedicine should complement, rather than replace, face-to-face consultations. Future investigations should explore patient and caregiver sentiment towards telemedicine platforms alongside patient deterioration.

Does the stemless reverse arthroplasty compare to a conventional stemmed implant? Clinical and radiographic evaluation at 2 years' minimum follow-up.

BACKGROUND: Reverse shoulder arthroplasty (RSA) is a well-recognized treatment for many shoulder conditions, including rotator cuff arthropathy, primary glenohumeral joint arthritis, and rheumatoid arthritis, and can be used in both trauma and revision settings. Over the past 10 years, its popularity in New Zealand has been increasing, with a 6%-7% annual growth rate during this period. Stemless RSA designs have the following proposed advantages: They can preserve humeral bone stock, they can limit periprosthetic fractures, and they can be indicated in patients with abnormal diaphyseal humeral anatomy. To date, only 1 study has evaluated the outcomes of the Lima SMR Stemless implant. We present our data with an aim to report how the stemless reverse arthroplasty compares to a conventional stemmed implant. METHODS: We performed a retrospective review of a consecutive series of patients treated at a single institution between 2015 and 2020. The endpoint was defined as final follow-up at a minimum of 2 years. Patients were excluded from the final analysis if they underwent revision. Thirty-three patients were identified as having undergone stemless RSA. Thirty patients had patient-reported outcome measures and radiographs at a minimum of 2 years' follow-up. Three patients had undergone revision within 2 years. The same sample size of stemmed RSAs (n = 33) was selected for comparison. RESULTS: A total of 60 patients were included in the final analysis, of whom 30 underwent stemless RSA and 30 underwent stemmed RSA. The demographic characteristics of the 2 groups were comparable except age at operation, which showed a statistically significant difference (P = .001): 77 years (stemmed) vs. 65 years (stemless). The mean Oxford Shoulder Score was 40.1 in the stemless group vs. 40 in the stemmed group. The mean American Shoulder and Elbow Surgeons score was 72.9 in the stemless group vs. 79 in the stemmed group. Patient-reported outcome measures, pain scores, and satisfaction ratings were not statistically significantly different between the 2 groups. In terms of radiographic data, subsidence was observed in 2 patients in the stemless RSA group but the patients had no clinical symptoms. Also in the stemless RSA group, 1 patient had an acromial stress fracture and 1 patient had a superficial wound infection successfully treated with oral antibiotics. In terms of revisions in the stemless RSA group, 1 patient underwent revision owing to chronic infection, 1 underwent revision as a result of a periprosthetic fracture after a fall, and 1 underwent revision for gross instability. CONCLUSIONS: The early results of sRSA are promising, and the stemless implant shows similar outcomes to a conventional stemmed implant.

Hematologic Malignancy: Who Cares in the End? A Retrospective Cohort Study of Markers of Quality End-of-Life Care.

BACKGROUND: Early palliative care is increasingly used in solid organ malignancy but is less established in patients with hematologic malignancy. Disease-related factors increase the demand for hospitalization, treatment, and supportive care in patients with hematologic malignancy. The terminal phase of illness in patients with hematologic malignancy can be difficult to predict, resulting in complexities in establishing a standard for quality end-of-life care. METHODS: This is a retrospective single-center cohort study of adult patients with hematologic malignancy who died between October 2019 and July 2022. Patients were identified, and disease characteristics, therapy, and outcomes were extracted from medical records. Descriptive statistics are reported and univariate analyses were performed across a range of factors to assess for associations. RESULTS: A total of 229 patients were identified, with a median age of 77 years and 35% female. In the final 30 days of life, 65% presented to the emergency department, 22% had an ICU admission, 22% had an invasive procedure, 48% received cytotoxic therapy, 61% received a RBC transfusion, and 46% received a platelet transfusion. Use of intensive chemotherapy was particularly associated with hospitalization and ICU admission. A total of 74% referred to palliative care, with a median time from referral to death of 13 days. Of these patients, one-third were referred within the last 5 days of life. In terms of place of death, 54% died in the acute hospital setting and 30% in hospice, with a median hospice length of stay of 4 days. CONCLUSIONS: These findings highlight the need for further research into quality indicators for end of life in hematologic malignancy and earlier integration of specialist supportive and palliative care in both inpatient and outpatient settings.

Urinary Long Non-Coding RNA Levels as Biomarkers of Lupus Nephritis.

BACKGROUND: Emerging evidence suggests that long non-coding RNA (lncRNA) plays important roles in the regulation of gene expression. We determine the role of using urinary lncRNA as a non-invasive biomarker for lupus nephritis. METHOD: We studied three cohorts of lupus nephritis patients (31, 78, and 12 patients, respectively) and controls (6, 7, and 24 subjects, respectively). The urinary sediment levels of specific lncRNA targets were studied using real-time quantitative polymerase chain reactions. RESULTS: The severity of proteinuria inversely correlated with urinary maternally expressed gene 3 (MEG3) (r = -0.423, p = 0.018) and ANRIL levels (r = -0.483, p = 0.008). Urinary MEG3 level also inversely correlated with the SLEDAI score (r = -0.383, p = 0.034). Urinary cancer susceptibility candidate 2 (CASC2) levels were significantly different between histological classes of nephritis (p = 0.026) and patients with pure class V nephritis probably had the highest levels, while urinary metastasis-associated lung carcinoma transcript 1 (MALAT1) level significantly correlated with the histological activity index (r = -0.321, p = 0.004). Urinary taurine-upregulated gene 1 (TUG1) level was significantly lower in pure class V lupus nephritis than primary membranous nephropathy (p = 0.003) and minimal change nephropathy (p = 0.04), and urinary TUG1 level correlated with eGFR in class V lupus nephritis (r = 0.706, p = 0.01). CONCLUSIONS: We identified certain urinary lncRNA targets that may help the identification of lupus nephritis and predict the histological class of nephritis. Our findings indicate that urinary lncRNA levels may be developed as biomarkers for lupus nephritis.

A rapid umbrella review of the literature surrounding the provision of patient-centred end-of-life care.

BACKGROUND: Patients have reported a broad range of unmet needs in their receipt of clinical care at the end of life. Therefore, enhancing the quality of end-of-life care through patient-centred healthcare interactions is warranted. AIM: The aim of this rapid umbrella review was to synthesise previous literature reviews that have examined: (1) patient preferences for patient-centred end-of-life care; (2) barriers and enablers to patient-centred end-of-life care; (3) interventions designed to enhance patient-centred end-of-life care; and (4) patient-centred models of end-of-life care. DESIGN: A rapid umbrella review was conducted and informed by the Joanna Briggs Institute's methodological guidance for conducting umbrella reviews. DATA SOURCES: Three academic databases were searched for relevant literature in May 2022: MEDLINE, PsycINFO and CINAHL Plus. Inclusion criteria encompassed literature reviews that examined the topic of patient-centred care for any adult patients in end-of-life care. RESULTS: A total of 92 literature reviews were identified. Findings suggest that there is often a discrepancy between patient preferences and the provision of care. These discrepancies have been associated with a range of barriers at the patient, staff and system levels. Common interventions included education and training for staff which were often met with improved patient outcomes. Patient-centred models of care were underrepresented across the literature. CONCLUSIONS: This review highlighted a need for healthcare systems to support staff in providing a patient-centred end of life experience through the development of a co-designed patient-centred model of care, supplemented by professional development and a systematic approach to identifying and documenting patient preferences.

Triceps Split and Snip Approach for Distal Humerus Fractures.

Background: The senior author adopted a Triceps Split and Snip approach in 2011. This paper details the results of patients for whom this approach was utilised for open reduction and internal fixation of complex AO type C distal humerus fractures. Methods: A retrospective analysis of a single surgeon's cases was conducted. Range of movement, as well as Mayo Elbow Performance Score (MEPS), and QuickDASH scores were evaluated. Two independent consultants with upper extremity practises evaluated pre- and post-operative radiographs. Results: Seven patients were available for clinical review. The mean age at the time of surgery was 47.7 years (range, 20.3-83.2) and the mean follow-up time was 3.6 years (range, 0.58-8). The average QuickDASH score was 15.85 (range, 0-52.3), average MEPS was 86.88 (range, 60-100) and average total arc of movement (TAM) was 103° (range, 70°-145°). All patients demonstrated 5/5 MRC triceps strength compared to the contralateral side. Conclusions: The Triceps Split and Snip approach for complex distal humerus fractures provided comparable mid-term clinical outcomes when compared to other published data regarding distal humerus fractures. It is versatile and does not compromise the intra-operative option of conversion to a total elbow arthroplasty. Level of Evidence: Level IV (Therapeutic).

Short-term outcomes following 159 stemmed pyrolytic carbon shoulder hemiarthroplasties and how they compare with conventional hemiarthroplasties and total shoulder arthroplasties in patients younger than 60 years with osteoarthritis: results from the New Zealand National Joint Registry.

BACKGROUND: Despite the increasing use of pyrolytic carbon (pyrocarbon) hemiarthroplasty (PyCHA), clinical data reporting on its outcomes remain scarce. To date, no studies have compared the outcomes of stemmed PyCHA vs. conventional hemiarthroplasty (HA) and anatomic total shoulder arthroplasty (aTSA) in young patients. The primary aim of this study was to report on the outcomes of the first 159 stemmed PyCHAs performed in New Zealand. The secondary aim was to compare the outcomes of stemmed PyCHA vs. HA and aTSA in patients aged <60 years with osteoarthritis. We hypothesized that stemmed PyCHA would be associated with a low revision rate. We further hypothesized that in young patients, PyCHA would be associated with a lower revision rate and superior functional outcomes compared with HA and aTSA. METHODS: Data from the New Zealand National Joint Registry were used to identify patients who underwent PyCHA, HA, and aTSA between January 2000 and July 2022. The total number of revisions in the PyCHA group was determined, and the indications for surgery, reasons for revision, and types of revision were recorded. In patients aged <60 years, a matched-cohort analysis was performed comparing functional outcomes using the Oxford Shoulder Score (OSS). The revision rate of PyCHA was compared with that of HA and aTSA, calculated as revisions per 100 component-years. RESULTS: In total, 159 cases of stemmed PyCHA were performed and 5 cases underwent revision, resulting in an implant retention rate of 97%. Among patients aged <60 years with shoulder osteoarthritis, 48 underwent PyCHA compared with 150 who underwent HA and 550 who underwent aTSA. Patients treated with aTSA had a superior OSS compared with PyCHA and HA patients. The difference in the OSS between the aTSA and PyCHA groups exceeded the minimal clinically important difference of 4.3. There was no difference in revision rates between the groups. CONCLUSIONS: This study represents the largest cohort of patients treated with PyCHA and is the first to compare stemmed PyCHA with HA and aTSA in young patients. In the short term, PyCHA appear to be a promising implant with an excellent implant retention rate. In patients aged <60 years, the revision rate is comparable between PyCHA and aTSA. However, aTSA remains the implant of choice to optimize early postoperative function. Further studies are required to elucidate the long-term outcomes of PyCHA, particularly how they compare with those of HA and aTSA in young patients.

Perspectives of family-centred care at the end of life during the COVID-19 pandemic: A qualitative descriptive study.

AIM: To explore nurses' and family members' perspectives of family care at the end of life, during restricted visitation associated with the COVID-19 pandemic. BACKGROUND: To minimise the transmission of COVID-19, stringent infection prevention and control measures resulted in restricted hospital access for non-essential workers and visitors, creating challenges for the provision of family-centred care at the end of life. DESIGN: Qualitative descriptive approach based on naturalistic inquiry. METHODS: At a large public hospital in Melbourne, Australia, individual semi-structured interviews were undertaken with 15 registered nurses who cared for patients who died during restricted visitation associated with the COVID-19 pandemic, and 21 bereaved family members. COREQ guidelines informed analysis and reporting. RESULTS: Five themes developed from the data: (i) impact of visitor restrictions, which describes uncertain, ambiguous and arbitrary rules, onerous and inconsistent requirements; (ii) nurse-family communication; (iii) family-centred care and interrupted connections; (iv) well-being and negative emotions; and (v) suggestions for a better way, such as moving away from the black and whiteness of the rules, prioritising communication, compassion and advocacy. CONCLUSIONS: Negative consequences for communication and the patient-family connection at the end of life were felt deeply. The evolving COVID-19 rules that were frequently revised and applied at short notice, and the subsequent consequences for clinical practices and care were felt deeply. RELEVANCE TO CLINICAL PRACTICE: Technology-facilitated communication, innovation and increased resources must be prioritised to overcome the challenges described in this study. A family-centred approach to care and emphasising the patient-family connection at the end of life is fundamental to minimising trauma and distress associated with future public health emergencies. PATIENT OR PUBLIC CONTRIBUTION: Bereaved family members contributed their first-hand experience. Members of the health service's patient experience team ensured the research was conducted in accordance with health service guidelines for patient and public contribution.

Integrated telehealth-assisted home-based specialist palliative care in rural Australia: A feasibility study.

INTRODUCTION: This study assessed the feasibility of integrating telehealth-assisted home-based specialist palliative care (TH-SPC) into a rural community setting. METHODS: This was a prospective mixed-methods pilot study conducted in rural Victoria, Australia. Newly engaged adult patients and their caregivers of a community palliative-care service received video consultations with metropolitan-located specialist palliative-care physicians, alongside standard care. Those eligible patients who failed to receive TH-SPC were treated as a control group upon analysis. Data were collected over three months and at 30 days prior to death. Feasibility outcomes included efficiency of process, user satisfaction, clinical outcome and health-care metrics. RESULTS: A total of 21 patients completed the study, with an average age of 70.4 years and an average survival of 5.8 months. Fourteen patients received TH-SPC, and seven received standard care alone. Patient-caregiver feedback for TH-SPC showed a high level of overall satisfaction. Compared to standard care, the TH-SPC group demonstrated less functional decline from baseline at two weeks (Australia-modified Karnofsky Performance Status: -1.35 vs. -12.30, p = 0.067) and three months (8.48 vs. -10.79, p = 0.04) after the intervention. At 30 days prior to death, functional status remained better in the TH-SPC group, with fewer per capita community palliative-care nursing visits (5.46 vs. 9.32, effect size = 0.7), general practitioner visits (0.13 vs. 3.88, effect size = 1.34) and hospital admissions (0.02 vs. 0.2, effect size = 0.65). DISCUSSION: TH-SPC was successfully integrated into rural community-based palliative care, with potential benefits in performance status preservation and health-care resource utilisation.

Psycho-Existential Symptom Assessment Scale (PeSAS) Screening in Palliative Care.

CONTEXT: Psycho-existential symptoms are common yet often missed or neglected in palliative care. Screening can be an effective way to recognize and respond to this need. OBJECTIVES: We aimed to implement routine use of the Psycho-existential Symptom Assessment Scale (PeSAS) as a screening tool in Australian palliative care services and discern the symptom prevalence identified. METHODS: In a multi-site rolling design, we established implementation site committees and embarked on experiential workshops to train clinicians in the tool's efficient use. Patient symptom prevalence data were collected to compare uptake across sites. Descriptive statistics were applied. RESULTS: Over one year, we trained 216 clinicians across six palliative care services in the use of the PeSAS as a screening tool and collected data from 1405 patients. Clinicians reported significant growth in their sense of efficacy in assessing psycho-existential wellness. Services using electronic records implemented most easily. Psycho-existential symptoms with clinically significant prevalence (scores ≥ 4/10) included anxiety 41.1%, discouragement 37.6%, hopelessness 35.8%, pointlessness 26.9%, depression 30.3%, and the wish to die 17%. The precision of measurement within 3% was found for severe ratings (score ≥ 8/10) including anxiety 10.6%, depression 10.2%, the wish to die 7.6%, and confusion 3.6%. CONCLUSION: Clinicians can be trained to screen with the Psycho-existential Symptom Assessment Scale, which serves as a valuable measure to better recognize symptoms of psycho-existential distress among palliative care patients. Implementation barriers included the prior ethos of the service, confidence in talking about these themes, electronic data entry, and perceived time pressures.

Facilitating family needs and support at the end of life in hospital: A descriptive study.

BACKGROUND: Caring for family members of dying patients is a vital component of end-of-life care, yet family members' needs at the end of life may be unmet. AIM: To explore hospital clinician assessment and facilitation of family needs and practices to support families at the end of life. DESIGN: Descriptive study utilising a retrospective medical record audit. SETTING AND SAMPLE: Undertaken in a large public hospital, the sample included 200 deceased patients from four specialities; general medicine (n = 50), intensive care (n = 50), inpatient palliative care (n = 50) and aged rehabilitation (n = 50). Data were analysed according to age; under 65-years and 65-years or over. RESULTS: Deceased patients' mean age was 75-years, 60% were Christian and Next-of-Kin were documented in 96% of cases. 79% spoke English, yet interpreters were used in only 6% of cases. Formal family meetings were held in 64% of cases. An assessment of family needs was undertaken in 52% of cases, and more likely for those under 65-years (p = 0.027). Cultural/religious practices were supported/facilitated in only 6% of all cases. Specialist palliative care involvement was more likely for those aged 65-years or over (p = 0.040) and social work involvement more likely for those under 65-years (p = 0.002). Pastoral care and bereavement support was low across the whole sample. CONCLUSIONS: Prioritising family needs should be core to end-of-life care. Anticipation of death should trigger routine referral to support personnel/services to ensure practice is guided by family needs. More research is needed to evaluate how family needs assessment can inform end-of-life care, supported by policy.

Is Nice knot suture comparable to wire for cerclage fixation? A biomechanical performance study.

Background: Cerclage fixation is a known orthopedic technique shown to be beneficial for circumferential augmentation when screw fixation cannot be used or is undesirable. However, ongoing advances in suture materials and knot techniques exist, and there is a paucity of evidence existing which evaluates comparisons between the two. The objective of this study was to investigate the strength and durability of cerclage fixation between the Nice knot suture technique and monofilament wire. Methods: Static displacement over time and compression load testing were analyzed. Compression testing was conducted with the Jamar Hydraulic Hand Dynamometer. Distraction testing was conducted using the Instron test system with its associated program. The Nice knot was tied using number 2 and number 5 FiberWire (Arthrex) and compared to monofilament wire. Clinical failure (displacement of 10 mm), absolute failure (opening of the knot or material failure), maximum compression achieved, and steady state compression maintained were the outcomes of interest. Results: Double-stranded monofilament wire produces maximum consistent compression of 90 kg, followed by single-stranded monofilament wire (60 kg). Number 5 FiberWire has a higher maximum compression load than number 2 FiberWire (50 kg vs. 22 kg), but it is lower than that of the double-stranded monofilament wire constructs. When compared to the single-stranded monofilament construct, the number 5 FiberWire Nice knot is comparable (P < .05). Average steady state compression achieved after 10 minutes of resting showed double-stranded monofilament wire to be 65 kg compared to single- stranded monofilament wire at 42 kg, which when, compared to suture, number 5 FiberWire measured at 15 kg and number 2 FiberWire at 8 kg. Average tension results from Instron distraction testing showed the double-stranded monofilament wire construct was able to withstand greater forces up to a displacement of 6 mm, after which the number 5 FiberWire Nice knot was stiffer. Number 5 FiberWire shows the most linear tension relationship, revealing it more efficiently withstands elastic forces. Load to failure was higher in the number 5 FiberWire Nice knot construct than that in both the monofilament wire constructs. The modes of failure for the Nice knot were always at the knot suture interface rather than at the knot. Conclusion: We propose this suture technique to be a viable alternative method for cerclaging to fix upper limb long-bone fractures.

'We couldn't have managed without your team': A collaborative palliative care response to the COVID-19 pandemic in residential aged care.

The global COVID-19 pandemic has challenged healthcare, aged care and palliative care provision in ways previously unimaginable. In Australia, this has been felt particularly amongst our most vulnerable members of society, those residing in residential aged care. Currently representing the majority (75%) of COVID-19 deaths and health-care worker infections, this vulnerable sector has borne the greatest impact. A collaborative response comprising a tertiary hospital palliative care outreach service, residential InReach geriatric service and a community palliative care service effectively delivered comprehensive and timely specialist care to residents infected with COVID-19. Daily videoconferencing rounds were efficient, minimised infection risk and facilitated family members attending virtually during patient assessments and care planning discussions. This model was both reactive and proactive and importantly scalable should further infective outbreaks occur in Australasian residential aged care facilities.

Journey mapping as a novel approach to healthcare: a qualitative mixed methods study in palliative care.

BACKGROUND: Journey mapping involves the creation of visual narrative timelines depicting the multidimensional relationship between a consumer and a service. The use of journey maps in medical research is a novel and innovative approach to understanding patient healthcare encounters. OBJECTIVES: To determine possible applications of journey mapping in medical research and the clinical setting. Specialist palliative care services were selected as the model to evaluate this paradigm, as there are numerous evidence gaps and inconsistencies in the delivery of care that may be addressed using this tool. METHODS: A purposive convenience sample of specialist palliative care providers from the Supportive and Palliative Care unit of a major Australian tertiary health service were invited to evaluate journey maps illustrating the final year of life of inpatient palliative care patients. Sixteen maps were purposively selected from a sample of 104 consecutive patients. This study utilised a qualitative mixed-methods approach, incorporating a modified Delphi technique and thematic analysis in an online questionnaire. RESULTS: Our thematic and Delphi analyses were congruent, with consensus findings consistent with emerging themes. Journey maps provided a holistic patient-centred perspective of care that characterised healthcare interactions within a longitudinal trajectory. Through these journey maps, participants were able to identify barriers to effective palliative care and opportunities to improve care delivery by observing patterns of patient function and healthcare encounters over multiple settings. CONCLUSIONS: This unique qualitative study noted many promising applications of the journey mapping suitable for extrapolation outside of the palliative care setting as a review and audit tool, or a mechanism for providing proactive patient-centred care. This is particularly significant as machine learning and big data is increasingly applied to healthcare.

Examining the role of specialist palliative care in geriatric care to inform collaborations: a survey on the knowledge, practice and attitudes of geriatricians in providing palliative care.

BACKGROUND: The global population is ageing, and rates of multimorbidity and chronic illness are rapidly rising. Given specialist palliative care has been shown to improve overall care and reduce health care costs, how best to provide this care to older people is internationally significant. AIM: To examine the knowledge, attitudes and practices of geriatricians in providing palliative care and working with specialist palliative care services. We also aimed to capture self-reported barriers, confidence and satisfaction in providing palliative care. DESIGN: A prospective cross-sectional study surveying Australasian geriatricians was conducted. SETTING/PARTICIPANTS: This was a voluntary anonymous online survey, distributed to all full members of the Australian and New Zealand Society of Geriatric Medicine. RESULTS: A total of 168 completed responses were received; 58.3% were female and 36.6% had over 20 years of clinical experience. Most geriatricians (85%) reported caring for patients in their last 12 months of life represented a substantial aspect or most of their practice. Geriatricians overwhelmingly believed they should coordinate care (84%) and derived satisfaction from providing palliative care (95%). The majority (69%) believed all patients with advanced illness should receive concurrent specialist palliative care. Regarding knowledge, participants scored an average of 13.5 correct answers out of 18 in a Modified Palliative Care Knowledge Test. CONCLUSIONS: Geriatricians find reward in providing generalist palliative care to their patients; however, potential exists for improved collaborations with specialist palliative care services. An evidence base for geriatric patients who benefit most from specialist palliative care services is needed to improve resourcing, collaborative practice and ultimately palliative care delivery.

Bereaved families' experiences of end-of-life decision making for general medicine patients.

BACKGROUND: Family involvement in decision making for hospitalised patients is associated with improved end-of-life care. Yet, these discussions can be challenging for physicians and families and associated with distress, confusion and conflict. There is a need to understand how best to support families involved in decisions regarding the transition from active to palliative treatment in hospital settings. AIM: To explore bereaved families' experiences of end-of-life decision making for general medicine patients. DESIGN: A qualitative exploratory study framed by social constructionism using semistructured interviews and thematic analysis. SETTING AND PARTICIPANTS: The general medicine units of one large public hospital in Melbourne, Australia. We recruited 28 bereaved family members of patients who had received end-of-life care. FINDINGS: Patients and families depended on physicians to explain clinical complexity and treatment beneficence; however, trust in medical judgement was mediated by participant's own interpretations of clinical progress. Families sought to be respected as advocates and experienced distress if physicians disregarded their perspectives and insight concerning patient preferences. Ideally, families supported patients to express their preferences to physicians. Otherwise, families contextualised treatment decisions through their knowledge of patient's values and quality of life. Families often felt burdened by or excluded from medical decision making and experienced distress and confusion regarding their rights to request or refuse treatment. CONCLUSION: Our study highlights how families contribute to decision making to ensure end-of-life care treatments reflect patient preferences. Physicians can ease families' distress around treatment withdrawal by providing a meaningful explanation of complex clinical issues, clarifying decision-making roles and acknowledge families' desire to protect and advocate for their loved one.

The Manchester Respiratory Activities of Daily Living Questionnaire: Reliability and Validity of the Chinese Version with Pictorial Enhancement.

BACKGROUND: The Manchester Respiratory Activities of Daily Living Questionnaire (MRADLQ) is a valid and reliable tool measuring the functional level of patients with COPD in multidimensional aspects. However, a local validation of the questionnaire is lacking in Hong Kong. OBJECTIVE: To develop a Chinese version of MRADLQ with pictorial enhancement (C-MRADLQ) and study its reliability and validity. PATIENTS AND METHODS: A total of 238 patients suffering from COPD were recruited from nine public hospitals and five Nurse and Allied Health Respiratory Clinics by convenient sampling. A total of 64 patients with normal spirometry results and no previous clinical diagnosis of COPD were invited to complete the C-MRADLQ for comparison and examination of its validity. Ten out of 302 patients were re-assessed with the C-MRADLQ after one week by the same rater for test-retest reliability. The C-MRADLQ was correlated with spirometry result, COPD classifications and groups by Global Initiative for Chronic Obstructive Lung Disease (GOLD), the modified Medical Research Council Dyspnea Scale (mMRC Dyspnea Scale), COPD Assessment Test (CAT), Chinese Version of the Shortness of Breath Questionnaire (C-SOBQ), number of admission and the ADO index. RESULTS: The C-MRADLQ shows good test-retest reliability as indicated by an intra-class correlation coefficient value of 0.975. It is significantly correlated with COPD stage, COPD group, SOBQ score, CAT score, mMRC, ADO index, spirometry results, and number of admissions. The SOBQ score, number of admissions, FEV1/FVC, and COPD group could significantly predict the total C-MRADLQ score. A total of 67.9% of participants' mMRC levels were correctly classified by using the C-MRADLQ total score. The agreement of the original and new versions of questions 20 and 21 of C-MRADLQ was 97.3% and 90.1%, respectively. CONCLUSION: The pictorial version of the C-MRADLQ is a validated and reliable functional assessment tool to measure functional status among patients with COPD in the Chinese population.