Specialist palliative medicine physicians and nurses accuracy at predicting imminent death (within 72 hours): a short report.

OBJECTIVES: Research suggests that clinicians are not very accurate at prognosticating in palliative care. The 'horizon effect' suggests that accuracy ought to be better when the survival of patients is shorter. The aim of this study was to determine the accuracy of specialist palliative care clinicians at identifying which patients are likely to die within 72 hours. DESIGN: In a secondary data analysis of a prospective observational study, specialist palliative care doctors and nurses (in a hospice and a hospital palliative care team) provided survival predictions (yes/no/uncertain) about which patients would die within 72 hours. RESULTS: Survival predictions were obtained for 49 patients. A prediction from a nurse was obtained for 37/49 patients. A prediction from a doctor was obtained for 46/49 patients. In total, 23 (47%)/49 patients actually died within 72 hours of assessment. Nurses accurately predicted the outcome in 27 (73%)/37 cases. Doctors accurately predicted the outcome in 30 (65%)/46 cases. When comparing predictions given on the same patients (27 [55%]/49), nurses were slightly better at recognising imminent death than doctors (positive predictive value (the proportion of patients who died when the clinician predicted death)=79% vs 60%, respectively). The difference in c-statistics (nurses 0.82 vs doctors 0.63) was not significant (p=0.13). CONCLUSION: Even when patients are in the terminal phase and close to death, clinicians are not very good at predicting how much longer they will survive. Further research is warranted to improve prognostication in this population.

How timely is access to palliative care medicines in the community? A mixed methods study in a UK city.

OBJECTIVE: To investigate timely access to palliative medicines/drugs (PMs) from community pharmacies to inform palliative care service delivery. DESIGN: Mixed methods in two sequential phases: (1) prospective audit of prescriptions and concurrent survey of patients/representatives collecting PMs from pharmacy and (2) interviews with community pharmacists (CPs) and other healthcare professionals (HCPs). SETTING: Five community pharmacies in Sheffield, UK and HCPs that deliver palliative care in that community. PARTICIPANTS: Phase 1: five CPs: two providing access to PMs within a locally commissioned service (LCS) and three not in the LCS; 55 patients/representatives who completed the survey when accessing PMs and phase 2: 16 HCPs, including five phase 1 CPs, were interviewed. RESULTS: The prescription audit collected information on 75 prescriptions (75 patients) with 271 individual PMs; 55 patients/representatives (73%) completed the survey. Patients/representatives reported 73% of PMs were needed urgently. In 80% of cases, patients/representatives received all PMs on the first pharmacy visit. One in five had to travel to more than one pharmacy to access PMs. The range of PMs stocked by pharmacies was the key facilitating factor. CPs reported practical issues causing difficulty keeping PMs in stock and playing a reactive role with palliative prescriptions. Confidentiality concerns were cited by other HCPs who were reluctant to share key patient information proactively with pharmacy teams. Inadequate information transfer, lack of CP integration into the care of palliative patients and poor HCP knowledge of which pharmacies stock PMs meant patients and their families were not always able to access PMs promptly. CONCLUSIONS: Consistent routine information transfer and integration of pharmacy teams in the care of palliative patients are needed to achieve timely access to PMs. Commissioners of PM access schemes should review and monitor access. HCPs need to be routinely made aware and reminded about the service and its locations.

[The use of cannabis-based drugs in pain and palliative medicine : Joint online questionnaire conducted by the Professional Association of Physicians and Psychotherapists in Pain and Palliative Medicine in Germany (BVSD), the German Pain Society, and the German Society for Pain Medicine (DGS)]. / Einsatz von Cannabisarzneimitteln in der Schmerz- und Palliativmedizin : Gemeinsame Online-Umfrage des Berufsverbands der Ärzte und Psychotherapeuten in der Schmerz- und Palliativmedizin in Deutschland e. V. (BVSD), der Deutschen Schmerzgesellschaft e. V. und der Deutschen Gesellschaft für Schmerzmedizin e. V. (DGS).

BACKGROUND AND METHODS: An online questionnaire about cannabis medication (CAM) was sent to German pain therapists 1 year after the introduction of the new act "Amendment to drug and other regulations" of 06.03.2017. RESULTS: A total of 120 pain therapists participated. Information on 1560 treated patients was analyzed. Only in the case of Dronabinol and Sativex® did at least 50% of physicians feel well informed. Requests for the coverage of costs were sent to the statuary health insurance companies for 1521 patients. These requests had already been decided for 1265 patients (83%) at the time of the questionnaire. A total of 457 requests (36.1%) were denied, including 28 requests from palliative care patients. Most of the pain therapists (67.5%) were well informed about Dronabinol, but less so about the other CAM. CONCLUSION: The study shows an information deficit in knowledge and handling of selected CAM among physicians. Given the high rejection rate, there may also be a knowledge gap on the side of the health insurances. From a certain number of patients upwards, the non-interventional accompanying survey required by law was deemed to be barely practicable from both a time and an economical point of view.

Aportes para la validez y fiabilidad de cuestionarios utilizados en medicina paliativa / Contributions for the validity and reliability of questionnaires used in palliative medicine

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Revistas de acceso abierto y voracidad editorial en cuidados paliativos / Open access journals and predatory publishing in palliative care

OBJETIVO: Las revistas de acceso abierto han aumentado en los últimos años en todos los ámbitos de la medicina. Una corrupción de este acceso abierto es lo que se ha llamado voracidad editorial (predatory publishing). Pretendemos conocer qué revistas del ámbito de cuidados paliativos están disponibles en acceso abierto y saber si pueden tener perfil de voracidad editorial. MÉTODO: Búsqueda de revistas sobre cuidados paliativos en acceso abierto en buscadores online, registros de revistas y correos electrónicos recibidos de estas publicaciones. Variables registradas: nombre, editorial y página web de la revista, perfil del pago, inclusión en lista de Beall, registro e indexación, correos electrónicos solicitando trabajos, posibilidad de optar a revisor o comité editorial. RESULTADOS: Se encontraron 32 revistas del ámbito de cuidados paliativos con opción total o parcial de acceso abierto; tres de ellas no se encontraban activas. La mediana de coste por publicación de un trabajo original fue de 1.389€. Se encontraron tres perfiles de publicación: nueve revistas de editoriales reconocidas, indexadas e incluso con factor de impacto que admiten la posibilidad de publicar con acceso abierto; siete revistas de editoriales de perfil académico (open access scholarly), algunas indexadas y con factor de impacto, que solo publican con acceso abierto, y 16 revistas sospechosas de voracidad editorial. Encontramos asociación entre la presencia en la lista de Beall y algunos criterios de sospecha de voracidad editorial: ausencia de factor de impacto (p = 0,004) o de indexación en PubMed (p = 0,001); ausencia de registro en OASPA (p = 0,001); envío de correos electrónicos solicitando trabajos (p = 0,05); opción de pago único por periodo de tiempo (p = 0,02), y flexibilidad en el pago según tipo de artículo (p = 0,02). CONCLUSIONES: En el ámbito de los cuidados paliativos hay publicaciones de acceso abierto, algunas de ellas sospechosas de ser voracidad editorial

OBJECTIVE: Open access journals have increased in recent years in all areas of medicine. Predatory publishing is corrupting this open access. The objective of this study is to find out the medical journals that are available in open access in the field of Palliative Care and establish whether they could have a predatory publishing profile. Method: Online search with Google and Bing, and a search in open access journal registries, and e-mails from open access Palliative Care journals. Registered variables: name, editorial and website of the journal, payment profile, inclusion in Beall's list register and indexation, e-mails requesting articles, and possibility to become reviewer or editorial committee. RESULTS: We found 32 journals in the field of Palliative Care with full or partial open access option; three of them were not active. The median original publication fee was 1389€. Globally, three types of journal could be distinguished: 9 journals of recognized publishers, indexed and even with impact factor, that allow the possibility of publishing with open access; 7 open access scholarly journals, some indexed and with impact factor, that only publish open access, and 16 suspected predatory journals. We found an association between the presence of the journal on Beall's list and some suspicion criteria for predatory publishing such as: absence of impact factor (P=.004) or PubMed indexation (P=.001); no OASPA registration (P=.001); e-mails requesting works (P=.05); option of payment per time period (P=.02); and flexibility in payment according to type of article (P=.02). CONCLUSIONS: In the field of Palliative Care there open access publications, however some of them are suspected predatory publishing

Use of Artificial Hydration at the End of Life: A Survey of Australian and New Zealand Palliative Medicine Doctors.

BACKGROUND: Dying is ubiquitous, yet the optimal management of hydration in the terminal phase is undetermined. Palliative care (PC) doctors' practices may act as a de facto measure of the benefits and burdens of artificial hydration (AH) use. OBJECTIVE: To identify PC doctors' AH prescribing practices for imminently dying patients and possible influencing factors. METHODS: An online survey of doctors belonging to the Australian and New Zealand Society of Palliative Medicine. RESULTS: One hundred and thirty-six surveys were completed (30% response rate). AH use for patients in the prognosticated last week of life was low: 77% of respondents prescribed AH to 0-10% of patients and 3% of respondents prescribed to more than 20%. The most common reason for prescribing AH was palliation of family/patient concern rather than a physical symptom. The majority thought there was no effect of AH on survival, or on symptoms of fatigue (90%), reduced level of consciousness (88%), agitation (75%), nausea (69%), vomiting (68%), myoclonus (66%), thirst (65%), delirium (62%), cough (57%), or bowel obstruction (50%). AH was thought to worsen subcutaneous edema (94%), upper respiratory tract secretions (85%), ascites (73%), physical discomfort (72%), dyspnea (62%), and urinary symptoms (57%). CONCLUSION: PC doctors from Australia and New Zealand reported lower use of AH for dying patients compared to international counterparts. The study showed high concordance in respondents' opinions: most thought AH was unlikely to provide clinical benefit and might cause harm. Further studies are needed to determine best practice of AH use at the end of life.

Doctor-Related Medication Safety Incidents on a Specialist Palliative Medicine Inpatient Unit: A Retrospective Analysis of Three Years of Voluntary Reporting.

Patients receiving palliative care and those at the end of life are known to be susceptible to medical errors. Errors related to medications are the most avoidable cause of patient harm. This retrospective study examined reported anonymized medication safety incidents, related to physician errors, assessed by the risk committee in a specialist palliative care unit over a 3-year time period. The aim of the study was to describe medication errors, with specific attention paid to what type of errors occurred and when these errors happened. Of the 218 reported medication safety incidents 28% (n = 62) were related to doctor prescribing. The data showed that there was a wide variation per year in the numbers of reported medication safety incidents. Medication prescribing errors were the most common error, followed by medication omissions. Medication safety incidents are at least in part dependent on staff reporting. Fostering a culture of openness that is blame free is crucial to medication error reporting. Formal reporting may help to increase patient safety and forms an essential element in the clinical governance and risk management of an institution.

[Attitudes and experiences regarding physician assisted suicide : A survey among members of the German Association for Palliative Medicine]. / Einstellungen zu und Erfahrungen mit ärztlich assistiertem Suizid : Eine Umfrage unter Mitgliedern der Deutschen Gesellschaft für Palliativmedizin.

BACKGROUND: The need to regulate physician-assisted suicide (PAS) and organizations offering assisted suicide has been controversially debated in Germany. Before the German parliament voted on various drafts in November 2015, the German Association for Palliative Medicine surveyed its members on their attitudes and experiences regarding PAS. METHOD: Items for the survey were derived from the literature and consented in a focus group. LITERATURE SEARCH: 2005-2015 - PubMed: PAS [Title/Abstract] UND survey (all countries), grey literature. We invited 5152 members of the DGP to participate in the online/paper survey. Descriptive quantitative and content analytic qualitative analysis of data using SPSS and MaxQDA. RESULTS: We obtained 1811 valid data sets (response rate 36.9%). 33.7% of the participants were male, 43.6% were female, and 0.4% identifed as other. Physicians accounted for 48.5% of the respondents, 17.8% nurses, other professions 14.3%, and about 20% of the data was missing socio-demographic information. More than 90% agreed that "wishes for PAS may be ambivalent" and "are rather a wish to end an unbearable situation". Of the 833 participating physicians, 56% refused participating in PAS and 74.2% had been asked to perform PAS. PAS was actually performed by 3%. Of all participating members, 56% approved of a legal ban of organizations offering assisted suicide. More than 60% of all professions agreed that PAS is not a part of palliative care. CONCLUSION: The respondents show a broad spectrum of attitudes, only partly supporting statements of relevant bodies, such as DGP. Because many are confronted with the issue, PAS is relevant to professionals in palliative care.

Undergraduate education in palliative medicine in Germany: a longitudinal perspective on curricular and infrastructural development.

BACKGROUND: In 2009, palliative medicine became an integrated and compulsory part of undergraduate training in Germany by legislation. After a transitional period, all medical faculties were required to provide adequate teaching with an according examination and certification procedure. In parallel, we conducted bi-annual surveys on all medical faculties in Germany to examine for potential discrepancies between the implementation process and their intended consequences on teaching time and content. METHODS: Four consecutive bi-annual surveys (2006, 2008, 2010, 2012) of all 36 medical faculties in Germany were performed, using purposively for this study developed questionnaires. Likert scales and closed questions were analyzed descriptively. RESULTS: Medical Faculty response rate increased from 50 % in 2006 to 88.9 % in 2012. Teaching coordinators in palliative medicine primarily had an anesthesiology or internal medicine background. There was a noted increase over time of the involvement of specialized palliative care units (PCUs) as providing the setting for education. The number of faculties that were able to offer a complete 16 weeks of training in palliative medicine during the "final year" rose steadily. In addition, increased patient-centered teaching formats have been implemented over time. The faculties which offered innovative teaching formats with actors as patients (standardized patient interaction) increased, as did the total number of mandatory examinations. The number of faculties that provided compulsory teaching in a condensed manner within a single academic year increased sharply from 3 of 31 responding faculties in 2010 to 19 of 32 responding faculties in 2012. CONCLUSIONS: Until now, teaching conditions and structures in palliative medicine in Germany have proven to be extraordinarily heterogeneous. Although professorships ("Chairs") in palliative medicine proved to be particularly beneficial and supportive in curricular and structural development, only a minority of faculties provide leading academic positions in palliative medicine.

Palliative Care Medical Education in European Universities: A Descriptive Study and Numerical Scoring System Proposal for Assessing Educational Development.

CONTEXT: The lack of palliative medicine (PM) education has been identified as a barrier to the development of the discipline. A number of international institutions have called for its implementation within undergraduate medical curricula. OBJECTIVES: The objectives are to describe the situation of undergraduate PM education in Europe and to propose a scoring system to evaluate its status. METHODS: This descriptive study was conducted with data provided by key experts from countries of the World Health Organization European Region (n = 53). A numerical scoring system was developed through consensus techniques. RESULTS: Forty-three countries (81%) provided the requested information. In 13 countries (30%), a PM course is taught in all medical schools, being compulsory in six of them (14%). In 15 countries (35%), PM is taught in at least one university. In 14 countries (33%), PM is not taught within medical curricula. A full professor of PM was identified in 40% of countries. Three indicators were developed to construct a scale (rank 0-100) of educational development: 1) proportion of medical schools that teach PM (weight = 32%); 2) proportion of medical schools that offer PM as a compulsory subject (weight = 40%); 3) total number of PM professors (weight = 28%). The highest level of PM educational development was found in Israel, Norway, the U.K., Belgium, France, Austria, Germany, and Ireland. CONCLUSION: PM is taught in a substantial number of undergraduate medical programs at European universities, and a qualified teaching structure is emerging; however, there is a wide variation in the level of PM educational development between individual countries.

Comparative analysis of specialization in palliative medicine processes within the World Health Organization European region.

CONTEXT: Palliative medicine (PM), still in the development phase, is a new, growing specialty aimed at caring for both oncology and non-oncology patients. There is still confusion about the training offered in the various European PM certification programs. OBJECTIVES: To provide a detailed, comparative update and analysis of the PM certification process in Europe, including the different training approaches and their main features. METHODS: Experts from each country completed an online survey addressing historical background, program name, training requirements, length of time in training, characteristic and content, official certifying institution, effectiveness of accreditation, and 2013 workforce capacity. We prepared a comparative analysis of the data provided. RESULTS: In 2014, 18 of 53 European countries had official programs on specialization in PM (POSPM): Czech Republic, Denmark, Finland, France, Georgia, Germany, Hungary, Ireland, Israel, Italy, Latvia, Malta, Norway, Poland, Portugal, Romania, Slovakia, and the U.K. Ten of these programs were begun in the last five years. The PM is recognized as a "specialty," "subspecialty," or "special area of competence," with no substantial differences between the last two designations. The certification contains the term "palliative medicine" in most countries. Clinical training varies, with one to two years being the most frequent duration. There is a clear trend toward establishing the POSPM as a mandatory condition for obtaining a clinical PM position in countries' respective health systems. CONCLUSION: PM is growing as a specialization field in Europe. Processes leading to certification are generally long and require substantial clinical training. The POSPM education plans are heterogeneous. The European Association for Palliative Care should commit to establishing common learning standards, leading to additional European-based recognition of expertise in PM.

Assessing prognostic documentation and accuracy among palliative care clinicians.

BACKGROUND: Prognostication is an important element of palliative care consultations. Research has shown that estimated survivals offered by clinicians are often inaccurate; however, few of these studies have focused on the documentation and prognostic accuracy of palliative care providers. OBJECTIVE: Our aim was to determine whether palliative care clinicians document specific estimates of survival in the electronic medical record and whether these survival estimates are accurate. METHODS: We retrospectively analyzed 400 consecutive, new palliative care consults at an urban, academic medical center from October 1, 2009 to December 31, 2010. Descriptive statistics were used to summarize patient demographics, median patient survival, documented estimated survival, agreement between estimated and actual survival, and agreement differences among disease groups. RESULTS: The inpatient consult note template was utilized by the clinicians in 94.2% of the patients analyzed, and 69.4% of the patients analyzed had a specific survival estimate documented. Of the patients with specific survival estimates documented, 42.6% died in the time frame estimated. Weighted kappa coefficients and Kaplan survival estimators showed fair to moderate agreement between actual survival and estimated survival offered by palliative care clinicians. Survival groups with the shortest prognosis had the most accurate estimates of prognosis. Cancer had the least agreement between estimated and actual survival among disease types. Overestimation of survival was the most common prognostic error. Use of a template resulted in significantly greater documentation of a specific estimated survival. CONCLUSIONS: The prognostic accuracy of palliative care physicians in this study was similar to physician accuracy in other studies. Trends toward overestimation were also similar to those seen in previous research. Use of a template in the electronic medical record (EMR) increases documentation of estimated prognosis.

Nurse practitioners and the growth of palliative medicine.

As Americans live longer they are likely to suffer from chronic, life-limiting illness. Because there are not enough hospice and palliative medicine (HPM) trained physicians to care for these people, there have been recent calls to increase the number of HPM trained physicians. We, however, believe that greater involvement of nurse practitioners (NPs) is a step in remedying this deficit. The philosophy and culture in which nurse practitioners are trained make them ideal clinicians to provide excellent palliative care. In addition, NPs are not only numerous, they can provide care that is on par with that provided by physicians. Removal of barriers to NP practice and increasing the quality of their palliative care education/training needs to occur in order to make this suggestion a reality.

Exploring education and training needs among the palliative care workforce.

OBJECTIVES: Education and training are seen as 'absolutely essential parts of providing palliative care'. As part of a larger study to explore the extent of palliative care need in two acute hospital settings, we report the perceptions of healthcare professionals regarding their training and educational needs. METHODS: In Phase 1, we undertook eight focus groups and four individual interviews with 58 health professionals from general practice, specialist palliative care and acute hospitals, exploring perceived education and training priorities. Phase 2 of the study involved a survey of palliative care need at two hospitals in England. Hospital based doctors and nurses completed questionnaires to identify patients with palliative care needs and to respond to questions about their training and education needs. RESULTS: Various barriers exist to the provision and management of palliative care, not least a need for more education and training. Focus group participants felt they were not adequately trained to address prognosis and goals of care with patients and their families. In Phase 2 of the study, 171 nursing staff and 81 medical staff completed the questionnaire and two-thirds of our sample felt they required additional training in palliative care. CONCLUSIONS: Although important, the use of standardised care pathways alongside the provision of education and training for healthcare professionals alone will not improve quality of care. More work is needed to examine and clarify the interplay of: behaviour change, setting, the 'cure' orientation approach, type of health professional and nature of any educational intervention in order to effect sustained behavioural change.

Palliative care education in neonatal units: impact on knowledge and attitudes.

OBJECTIVE: To facilitate improved and earlier access to palliative care for babies, a 4-h workshop on the principles, practice and resources in palliative care was delivered in 21 neonatal units across London. This paper assesses the impact of these workshops. DESIGN: As part of mixed methods, processual evaluation of a series of education workshops, a pre and post survey instrument was developed, consisting of open and closed questions assessing knowledge of services and attitudes towards palliative care. Before and after each workshop attendees were invited to complete the survey. SETTING: Neonatal units in hospitals across London, including examples of intensive care, high dependency and special care units. RESULTS: 331 healthcare professionals attended the sessions, and 264 (80%) completed questionnaires. The majority of attendees were experienced neonatal nurses working in neonatal intensive care  (61% more than 7 years) but with limited experience of palliative care services. Over 79% of respondents reported that the workshop completely met their learning needs. Post-session 80% of respondents felt confident referring to palliative care services, compared with 46% before (p<0.001). Analysis of open and closed text responses revealed a shift in attitude after the sessions from a focus on dying/end-of-life, towards integrating palliative care as part of a holistic treatment plan. CONCLUSIONS: A short (half day), locally delivered workshop can change attitudes and increase knowledge in neonatal staff. Such a workshop can serve as a first step in facilitating access to and utilisation of a variety of palliative care services.

Depression assessment by oncologists and palliative care physicians.

OBJECTIVE: Depression is a frequent problem in cancer patients, which is known to reduce quality of life; however, many cancer patients with depression are not treated because of the difficulties in assessing depression in this population. Our aim was to evaluate and improve the depression assessment strategies of palliative care (PC) physicians and oncologists. METHOD: We invited all medical oncologists and PC physicians from three cancer centers to participate in this multicenter prospective study. They were asked to classify 22 symptoms (related and specific to depression in cancer patients, related but not specific, and unrelated) as "very important," "important," "less important," or "not important" for the diagnosis of depression in cancer patients, at three different time points (at baseline, after a video education program, and after 4 weeks). They were also asked to complete a questionnaire exploring physicians' perceptions of depression and of their role in its systematic screening. RESULTS: All 34 eligible physicians participated. Baseline performance was good, with >70% of participants correctly classifying at least seven of nine related and specific symptoms. We found no significant improvement in scores in the immediate and 4-week follow-up tests. Additionally, 24 (83%) and 23 (79%) participants expressed support for systematic depression screening and a role for oncologists in screening, respectively. SIGNIFICANCE OF RESULTS: Oncologists had good baseline knowledge about depression's main symptoms in cancer patients and a positive attitude toward being involved in screening. Underdiagnosis of depression is probably related to problems associated with the oncology working environment rather than the physicians' knowledge.