A Targeted Discharge Pathway to Reduce Hospital Readmission and Dying in Hospital in Cancer Patients at the End of Life.

OBJECTIVES: There is a need for better information exchange between primary and secondary care healthcare professionals in cancer patients with limited life expectancy, most of whom prefer to be at home but are admitted frequently at the end of life (EoL). We conducted a file search to assess this among our patients and developed a discharge pathway to decrease readmission rate and dying in hospital. DATA SOURCES: We performed an in-depth file search among 150 patients who died within 1 month after hospital admission (July 2013 to January 2014); 60 were admitted once, and 90 were admitted twice or more. Mean time spent in hospital at EoL was 12 days; 37% died in hospital, and 49% died at home. We included 31 admitted cancer patients at the EoL in whom home-discharge was planned for the intervention (February 2017 to December 2018). Median survival was 24 days, time spent in hospital decreased from 15.5 to 2.5 days, and number of readmissions fell from 2.8 to 0.57. One patient (3.1%) died in hospital, and 77% died at home. And 78% of general practitioners found the provided information useful. CONCLUSION: A proactive discharge pathway may reduce hospital readmission rates, time spent in hospital, and in-hospital death. IMPLICATIONS FOR NURSING PRACTICE: Ever more patients with complex care needs at the EoL are being discharged early. Being informed about patients' wishes, preferences, and treatment options for symptom management at home is essential for doctors and nurses in primary care. A systematic discharge pathway can be useful for information transfer when admitted patients are discharged home.

Teaching Oncology Nurses a Psychosocial Intervention for Advanced Cancer: A Mixed-Methods Feasibility Study.

OBJECTIVES: Psychological interventions for advanced cancer patients are effective in decreasing distress but are not well integrated into cancer care. Oncology nurses are well positioned to deliver such interventions, and their participation may enhance professional satisfaction and wellbeing. Managing Cancer and Living Meaningfully (CALM) is an evidence-based psychotherapy supporting advanced cancer patients. A CALM-Nurses (CALM-N) training program was developed to teach oncology nurses the basics of CALM for use in daily practice. Feasibility and acceptability of CALM-N and its impact on professional wellbeing were assessed in this pilot study. DATA SOURCES: Fifty-five nurses attended CALM-N in three groups. Thirty-five nurses completed the first e-learning, 29 nurses (83%) attended the first group session, and 22 (63%) attended all sessions. At baseline, 35 questionnaires were collected. Response rate at follow-up was 63% for Jefferson Scale of Empathy (n=22), 66% for self-efficacy scale (n=23), and for subscales of Professional Quality of Life Scale burnout; 51% (n=18), secondary traumatic stress; 49% (n=17), compassion satisfaction; 57% (n=20). A statistically significant increase in self-efficacy was found, but there were no significant changes in PROQOL and empathy. Focus groups suggested CALM-N helped nurses' understanding of patients and nurse-patient communication and increased reflection and perspective taking. CONCLUSION: CALM-N is a feasible and acceptable intervention for oncology nurses, with the potential to improve nurse-patient communication and the nurses' reflective capacities. IMPLICATIONS FOR NURSING PRACTICE: CALM-N has the potential to improve the capacity of oncology nurses to provide psychosocial care for advanced cancer patients and its application to nursing practice merits further investigation.

Palliative and End-of-Life Care for LGBT+ Cancer Patients: Scoping the Problems and Identifying the Solutions.

OBJECTIVES: People who identify as lesbian, gay, bisexual, and transgender (LGBT+) face inequalities in healthcare and are receiving less palliative and end-of-life care than others with a comparable need. Since the global resolution to improve palliative care made by the World Health Assembly, the World Health Organization, and member states, some progress has been made. However, LGBT+ people are discriminated and marginalized, which leads to suboptimal palliative care. Research on the needs of LGBT+ people and their access to palliative care is limited. Therefore, the aim of this discussion article is to scope unique problems around palliative and end-of-life care for LGBT+ people and identify possible solutions to address these problems with direct links to nursing practice. DATA SOURCES: Journal articles and author experience were used for this discussion article. CONCLUSION: Oncology nurses need to be educated in communication skills, specific assessment tools, and awareness of the history of LGBT+ people. Increasing knowledge for cancer nurses is pivotal because this affects their views, needs, and perceptions in providing palliative and end-of-life care. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses have a pivotal role in caring for all cancer patients at the end of their life. LGBT+ patients and their caregivers need competent nurses to support them, especially during transitions. Implementing LGBT+-inclusive education, training, and practice will improve outcomes for LGBT cancer patients and their caregivers, and potentially all patients. More research is needed to implement such training in nursing education. ("LGBT+" has been used throughout the article. There are many arguments in favor of using different variations of the acronym, but for purposes of understanding and ease, LGBT+ is the acronym of choice here.).

Hospice Care Access: a national cohort study.

OBJECTIVES: Hospice care in the Netherlands is provided in three different types of hospice facilities: volunteer-driven hospices (VDH), stand-alone hospices (SAHs) and hospice unit nursing homes (HU). The organisational structures range from care directed by trained volunteers in VDH to care provided by multiprofessional teams in SAH and HU units.This study aims to characterise the patient populations who access Dutch hospices and describe the patient profiles in different hospice types. METHODS: A retrospective cohort study using clinical records of adult hospice inpatients in 2017-2018 from a random national sample of hospices. RESULTS: In total 803 patients were included from 51 hospices, mean age 76.1 (SD 12.4). 78% of patients had a primary diagnosis of cancer, 3% identified as non-Dutch cultural background and 17% were disorientated on admission. At admission, all patients were perceived to have physical needs. Psychological needs were reported in 37%, 36% and 34%, social needs by 53%, 52% and 62%, and existential needs by 23%, 30% and 18% of patients in VDH, SAH, HU units, respectively. 24%, 29% and 27% of patients from VDHs, SAHs and HUs had care needs in three dimensions, and 4%, 6% and 3% in all four dimensions. CONCLUSIONS: People who access Dutch hospices predominantly have cancer, and have a range of physical, psychological, social and existential needs, without substantial differences between hospice types. Patients with non-malignant disease and non-Dutch cultural backgrounds are less likely to access hospice care, and future policy would ideally focus on facilitating their involvement.

Who Are Hospice Patients and What Care Is Provided in Hospices? A Pilot Study.

BACKGROUND: Hospices provide multidimensional care. In the Netherlands, patients with <3 months estimated life expectancy have access to hospice care. Insight into patients admitted to hospices and the care provided is lacking. In preparation for a national multicenter study, a pilot study was performed. OBJECTIVE: The primary objective was to test the appropriateness of the study procedures and the availability of hospice patient records (HPRs), and patient and care characteristics. METHOD: A cross-sectional pilot study was performed using a descriptive exploratory design. Sixteen hospices were invited to participate, and HPRs from 8 deceased patients per hospice were selected. Data were collected using self-developed electronic case report forms. OUTCOMES: (1). Appropriateness of procedures: availability of HPRs and identified barriers and strategies. (2) Availability of patient and care characteristics in HPRs. RESULTS: In total, 104 HPRs of patients from 13 hospices were enrolled. Various types of HPRs were found with different availabilities: nurses' records were most available (98%) compared to volunteers' records (62%). Overarching barriers were as follows: ethical issues, lack of knowledge, and lack of communication. Information about the illness was most available (97%), whereas descriptions of experienced symptoms were least available (10%). CONCLUSION: Collecting HPRs is difficult and time-consuming. Specifically, data from separate records of home care nurses and general practitioners were difficult to come by. Patient and care characteristics were alternately present, which led to an extension of data collection in HPRs to 3 time periods. Piloting is essential to adjust study procedures and outcome measures to ensure a feasible national multicenter hospice study.

What do Future Hospice Patients Expect of Hospice Care: Expectations of Patients in the Palliative Phase Who Might be in Need of Hospice Care in the Future: A Qualitative Exploration.

INTRODUCTION: Hospice care (HC) in the Netherlands is available for patients with life expectancies <3 months. Little is known about expectations of patients who might be in need of HC. This study aims to gain insight into expectations of patients regarding HC in order to ameliorate HC to become driven by patient needs. DESIGN: A generic qualitative study, using semistructured interviews and thematic analysis, is performed in the Netherlands from January to June 2018. A purposeful sample of 13 participants was drawn. RESULTS: Participants expected hospice admission only when the burden became unbearable and a home death cannot be reached. Participants expected a homely atmosphere, where one can continue the life lived at home as much as possible. Participants supposed empathic professional caregivers, capable of providing appropriate care. The general practitioner is expected to stay involved in the care process due to the mutual trust. Medical and daily care are required to be provided by competent professionals, where volunteers are expected to provide supportive care. All caregivers are supposed to provide a listening ear and "being there" for participants. Social care and spiritual care are generally projected to be private matters, unless it is requested. CONCLUSIONS: Patients in the palliative phase who might be in need of HC have specific expectations. Perceptions of HC in the public domain should be nuanced in response to these expectations, and information provision on HC should be improved. Then, expectations could be met to make HC more driven by patient needs and future oriented.

From concept to practice, is multidimensional care the leading principle in hospice care? An exploratory mixed method study.

BACKGROUND: Hospice care (HC) aims to optimise the quality of life of patients and their families by relief and prevention of multidimensional suffering. The aim of this study is to gain insight into multidimensional care (MC) provided to hospice inpatients by a multiprofessional team (MT) and identify facilitators, to ameliorate multidimensional HC. METHODS: This exploratory mixed-method study with a sequential quantitative-qualitative design was conducted from January to December 2015. First a quantitative study of 36 patient records (12 hospices, 3 patient records/hospice) was performed. The outcomes were MC, clinical reasoning and assessment tools. Second, MC was qualitatively explored using semistructured focus group interviews with multiprofessional hospice teams. Both methods had equal priority and were integrated during analysis. RESULTS: The physical dimension was most prevalent in daily care, reflecting the patients' primary expressed priority at admission and the nurses' and physicians' primary focus. The psychological, social and spiritual dimensions were less frequently described. Assessment tools were used systematically by 4/12 hospices. Facilitators identified were interdisciplinary collaboration, implemented methods of clinical reasoning and structures. CONCLUSIONS: MC is not always verifiable in patient records; however, it is experienced by hospice professionals. The level of MC varied between hospices. The use of assessment tools and a stepped skills approach for spiritual care are recommended and multidimensional assessment tools should be developed. Leadership and commitment of all members of the MT is needed to establish the integration of multidimensional symptom management and interdisciplinary collaboration as preconditions for integrated multidimensional HC.