Continuous Ambulatory Delivery Device Use for Patients Managed by an Inpatient Palliative Care Team.

BACKGROUND: The use of Patient Controlled Analgesia (PCA) via a Continuous Ambulatory Delivery Device (CADD) is a common and effective means of pain and symptom management for hospitalized patients with a malignancy. Studies exploring the indications for starting such a device for hospitalized inpatients referred to inpatient palliative care teams are limited. AIM: This retrospective chart review aims to explore indications, timing of initiation, and barriers to the use of a CADD. METHODS: Over a six month period, during daily inpatient palliative care consult team rounds, patients who required a CADD were enrolled in this study. Sixty-one adult patients were identified who required a pump for symptom control. The team's database sheets were used to capture patient demographics. RESULTS: The main reasons for initiating a Continuous Ambulatory Delivery Device in the above setting included: lack of efficacy of oral opioids and to increase patient autonomy of their pain management. Approximately 20% of patients required transfer to another unit that could accommodate the CADD. The median length of stay for these patients was 13 days, with a median length of half a day for a pump to be started. CONCLUSIONS: This initial study provides the Palliative Care Consult Team with information on the indications for the use of a CADD. The lack of universal access to a CADD in various areas of our hospital due to differences in departmental protocols may compromise good symptom management and patient safety. These results strengthen the argument that the existing hospital policy requires revamping to improve CADD access. A CADD has been shown to provide hospitalized patients, with a malignancy, with timely access to effective symptom management, and in turn, reducing their length of stay in hospital. These findings will help inform this organization's CADD policy and support the need to broaden access to this device.

Promoting Self-Care in Palliative Care: Through the Wisdom of My Grandmother.

In the post COVID-19 pandemic period, targeted efforts are needed more than ever to improve frontline nurses' well-being. In the field of palliative care, there is recognition of the importance of self-care, but the concept itself remains nebulous, and proactive implementation of self-care is lacking. Reflective writing has been noted to have positive impacts on health care providers' well-being. This piece brings to light the author's interest and work in reflective writing, sharing a personal account that provides a source of happiness and an opportunity to better understand her palliative care practice. Beyond the individual level, organizations are also encouraged to invest in their nurses' overall well-being.

Improving timely transfers from acute care to the local palliative care unit for patients at the end of life.

BACKGROUND: Despite evidence showing that nearly two thirds of the Canadian population prefer to die at home, the majority die in hospital. Honoring a patient's wish for their preferred location of death is an essential component in end-of-life care. Therefore, for those patients admitted to acute care whose choice is to transfer to a palliative care unit for end-of-life care, it is imperative that this occurs in a safe and timely manner. The General Internal Medicine ward at this local tertiary care academic center, did not have a standardized process for transferring patients at the end-of-life to the local palliative care unit. With bed calls made between Monday to Saturday at 8 am, weekday and weekend transfer times ranged between 1 to 6 hours. The aim of this project was to establish a standardized, safe and efficient patient transfer from acute care to the palliative care unit for a daily standard arrival time. METHODS: A multidisciplinary quality improvement team was formed to analyze the transfer process. Several Plan Do Study Act cycles were tested, targeting all steps of the transfer process and turnaround time. An outcome measure aiming for a turnaround time of two hours was set as the target. RESULTS: A total of fourteen patient transfers were included. Average transfer time during the weekday was reduced from a baseline average of 180.2 to 128.3 min. This change was found to be statistically significant and sustained (P<0.003). The average transfer time on weekends remained stable at 234 min. The outcome target of a 10:00 am arrival time to the palliative care unit was achieved 42% of the time. CONCLUSIONS: This project remains on-going and early data is encouraging as it met the targeted transfer time 42% of the time. Fidelity in the process measures helped to meet the targeted turnaround time of two hours for a safe and efficient transfer to the palliative care unit and ensured patients got to their preferred location for end of life care. The goal is to expand this project to other general internal medicine wards across the organization.

The specialist palliative care team as a local resource.

Background: Specialist-level palliative care support is intended for patients with complex physical and psychosocial needs. In addition to direct clinical care, specialist teams can be utilized to support the delivery of community-based palliative care by providing 24/7 access to advice and support for primary care providers, patients, and their families. Aim: This paper describes how a specialist palliative care team, based in a tertiary level hospital, can provide timely access to palliative care for patients in a surrounding sub-region that has historically lacked a robust network of community-based palliative care supports. Design: A retrospective database analysis was conducted from January 1 - December 31, 2019, to describe the demographic and clinical characteristics of patients referred to the Palliative Care Consult Team who reside in the sub-region of Scarborough, Ontario. Data were reviewed to highlight the role the team plays in supporting end-of-life care for this community of patients, families, and providers. Patients referred to the Palliative Care Consult Team with a residential address within the sub-region of interest were the focus. Results: In total, 343 patients living in the selected sub-region were seen by the Palliative Care Consult Team during a 12-month period, representing 18% of the team's annual clinical volume. The majority of these patients (94%) had a cancer diagnosis. Median Palliative Performance Scale score at time of initial consult was 40 for inpatients and 60 for ambulatory patients. More than half the patients (56%) were "full code" at the time of initial palliative care consultation. Median survival from initial consult to death was 18 days for inpatients and 68 days for ambulatory patients. More than half of the patients (54%) died in a palliative care unit, with a smaller percentage dying in the home setting (7%). Conclusions: Our report highlights the utilization of a database as a quality improvement tool to illustrate our institution's palliative care mission and vision of engaging in the provision of palliative care expertise to community-based patients and healthcare colleagues.

Palliative care Advanced Practice Nurse role in engaging in serious illness conversations.

Having advanced care planning conversations with patients and/or their substitute decision maker has been shown to lead to many benefits, including aligning a patient's priorities and health expectations with his or her wishes. Typically, these conversations have been held with physicians, but have evolved over time to also be incorporated into the roles of other healthcare professionals. Advanced practice nurses who are trained to use a framework or an approach when having such conversations has been shown to have merit. As a result, advanced practice nurses are well positioned to be leaders in facilitating such conversations. In this project, the documentation notes of one advanced practice nurse on an in-patient palliative care team were examined, using the Serious Illness Conversation Guide, to evaluate the Advanced Practice Nurse's contribution to the process of holding advanced planning conversations with patients.

Challenges in nursing care for patients with cancer and severe mental illness: A case report.

Patients with severe mental illness often present with more advanced cancer at diagnosis, experience poorer quality of care, receive fewer medical treatments, have higher overall disease mortality, and are less likely to access timely palliative care when compared to patients without severe mental illness. Research findings have shown that early involvement of specialized palliative care services for patients with advanced cancer improves quality of life, increases satisfaction with care, and mitigates depression. This case study will highlight the spectrum of challenges in caring for patients with a severe mental illness and advanced cancer from the perspective of an inpatient palliative care consult team.

Factors that Delay Transfers from Acute Care to a Local Palliative Care Unit.

For patients desiring end-of-life care in a palliative care unit, ensuring a safe and timely transfer while reducing length of stay in acute care is optimal. A chart review of 130 patients was completed on those who either died in acute care or were transferred to a palliative care unit. In all, 31% of patients died in acute care and 69% were transferred to a palliative care unit. Barriers impacting a timely transfer included disposition planning, behavioural changes requiring monitoring, imminently dying patients and those awaiting medical assistance in dying. This article makes clinical recommendations to address these barriers.

Quality improvement of the end of life care experience through bereavement calls made by spiritual care.

Improving the end of life care experience of people dying in acute care has become a priority for our organization since 2016 with the launch of the "Quality Living and Dying Initiative." This initiative has three distinct foci. The first two areas of focus, advance care planning and standardized comfort measures, are well established while the third focus bereavement program remains in its early stages. Bereavement is recognized as an essential component along the continuum of palliative care. Despite this recognition, bereavement care is often lacking in hospital settings. This paper will describe a telephone bereavement initiative spearheaded by the Spiritual Care Team at our organization.

Spiritual Care as Part of an Interprofessional Model for Debriefing on an Oncology Unit.

Health care clinicians who care for seriously ill and dying patients have been known to be at higher risk for burnout and moral distress. When not well supported in their workplace, clinicians may suffer additional adverse outcomes to their overall wellbeing. Self-care is one way to help mitigate these adverse outcomes. The literature has described formalized debriefing not only as a self-care strategy but an intervention to promote healthy team development. The focus of this paper will showcase how social work and spiritual care practitioners in our institution worked collaboratively to support an inpatient oncology unit to address issues related to burnout by providing staff with monthly debriefing sessions intended to enhance self-care and wellness in the workplace.

Call to action: The need to expand spiritual care supports during the COVID-19 pandemic.

Providing a 'good death' for patients dying in acute care is more challenging than ever with the COVID-19 pandemic. Spiritual care teams and palliative care providers strive to address the physical, psychosocial, and spiritual care needs at end of life-for both patients and their families, and often in concert with patients' own faith groups. During the strict lockdown policy imposed in Ontario, Canada during the pandemic, external faith groups, and religious rituals requiring direct contact were restricted. Delivering spiritual care in our "new normal" environment challenged us to think more broadly, beyond the walls of our own institutions, particularly when external resources exist outside of acute care centres, and are often of paramount importance to dying patients and their families in acute care.

Quality dying: An approach to ICD deactivation in the hospital setting.

BACKGROUND: In Canada, cardiovascular disease is the second most common cause of death. A subset of these patients will require a cardiovascular implantable electronic device (CIED). An estimated 200 000 Canadians are living with a CIED. CIEDs can improve life and prevent premature death. However, when patients reach the end of their lives, they can pose a challenge. An example of which is a painful shock delivered from an implantable cardioverter defibrillator (ICD) for an arrhythmia in a dying patient. Receiving a shock at the end of life (EOL) is unacceptable in an age when we aim to ease the suffering of the dying and allow for a comfortable death. METHODS: As a quality standard of practice, all clinicians are expected to engage in EOL conversations in patients requiring CIED deactivation. Due to the potential discomfort of an ICD shock, specific conversations about deactivation of an ICD are encouraged. A process improvement approach was developed by our hospital that included an advance care planning simulation lab, electronic documentation and a standardized comfort measures order set that includes addressing the need for ICD deactivation at EOL. RESULTS: EOL conversations are complex. Health care providers have been equally challenged to have conversations about ICD deactivation. Standardization of the process of ICD deactivation ensures an approach to EOL which respects the individuality of patients and promotes quality dying. CONCLUSION: Our hospital is committed to assisting clinicians to provide quality care by improving conversations about EOL care. On the basis of a synthesis of existing literature, we describe the importance of and the ideal process for having EOL conversations in patients about ICD deactivation at the EOL.

Evaluating the Pharmacological Management of Terminal Delirium in Imminently Dying Patients With and Without the Comfort Measure Order Set.

Terminal delirium is a distressing irreversible process that occurs frequently in the dying phase, often misdiagnosed and undertreated. A previous study in our organization revealed that terminal delirium was a poorly managed symptom at end of life. Pharmacological options are available in an existing order set to manage this symptom. The management plans of 41 patients identified as having terminal delirium were further evaluated. Elements extracted included medications prescribed to manage terminal delirium, whether medication changes occurred, and whether they were administered and effective. Patients with the order set were more comfortable as compared with the group without. Both groups had several changes made by the palliative care team. Nurses did not administer prescribed as-needed medication to more than one-third of patients. Modifications will be made to the existing order set, and additional education for staff will be organized.

The Role of Spiritual Care with the Introduction of an End of Life Order Set.

Delivering comprehensive end-of-life care to dying patients must involve addressing physical symptoms and psychosocial concerns. Care pathways have been introduced to support health care teams in delivering this care. This retrospective chart review explores the contributions of the Spiritual Care Team in the care of dying patients. They offer a range of interventions which include supportive care, religious and spiritual support. This study was one step towards appreciating the contributions of the Spiritual Care Team.

Exploration of Families' Experiences Caring for Loved Ones With Advanced Ovarian Cancer.

Ovarian cancer is challenging, both physically and psychologically, because of the advanced nature of the disease at diagnosis, adverse effects of the disease and treatment, and impact on roles and responsibilities. The family plays an integral role in promoting and maintaining the health of family caregivers, as well as providing physical and emotional support. The purpose of this study was to explore the experience of family caregivers caring for their loved ones with advanced ovarian cancer. Thirteen family caregivers were interviewed. The analysis of the data revealed 4 significant challenges that characterized the caregiving experience over time: confronting the initial diagnosis, dealing with fluctuations in physical status, confronting a turning point, and facing decline and death. Woven throughout these challenges, family caregivers routinely described difficulties in accessing information and navigating the health care system, which caused them added concern and frustration.

The Comfort Measures Order Set at a Tertiary Care Academic Hospital: Is There a Comparable Difference in End-of-Life Care Between Patients Dying in Acute Care When CMOS Is Utilized?

BACKGROUND: Standardized protocols have been previously shown to be helpful in managing end-of-life (EOL) care in hospital. The comfort measures order set (CMOS), a standardized framework for assessing imminently dying patients' symptoms and needs, was implemented at a tertiary academic hospital. OBJECTIVE: We assessed whether there were comparable differences in the care of a dying patient when the CMOS was utilized and when it was not. METHODS: A retrospective chart review was completed on patients admitted under oncology and general internal medicine, who were referred to the inpatient palliative care team for "EOL care" between February 2015 and March 2016. RESULTS: Of 83 patients, 56 (67%) received intiation of the CMOS and 27 (33%) did not for EOL care. There was significant involvement of spiritual care with the CMOS (66%), as compared to the group without CMOS (19%), P < .05. The use of CMOS resulted in 1.7 adjustments to symptom management per patient by palliative care, which was significantly less than the number of symptom management adjustments per patient when CMOS was not used (3.3), P < .05. However, initiating CMOS did not result in a signficant difference in patient distress around the time of death ( P = .11). Dyspnea was the most frequently identified symptom causing distress in actively dying patients. CONCLUSIONS: Implementation of the CMOS is helpful in providing a foundation to a comfort approach in imminently dying patients. However, more education on its utility as a framework for EOL care and assessment across the organization is still required.

Improving end-of-life care through quality improvement.

Although end of life (EoL) care has been identified as an area for quality improvement in hospitals, the quality of care Canadian patients receive at the end of life is not well-evidenced. National statistics indicate that Canadians would prefer to die at home, yet more than 50% die in acute care hospital settings. Busy and often highly specialised acute care units may be perceived as a distressing place of death for both patients and their families. Furthermore, many clinicians are not trained in diagnosing imminent dying, managing symptoms at the end of life or supporting dying patients and their families. As such, to improve the experience of EoL care, a corporate, institution-wide strategy entitled the Quality Dying Initiative was introduced and implemented across a tertiary care academic teaching hospital. A primary focus of this initiative was the implementation of a comprehensive Comfort Measures Strategy. This strategy involved the development of an evidence-based order set, which included elements of symptom assessment and management, patient and family education, and spiritual and emotional support. Staff education and mentoring was also a critical element of the larger Comfort Measures Strategy, as well as an evaluative component.

An interprofessional education programme for medical learners during a one-month palliative care rotation.

Interprofessional education in health care and in palliative care has been the focus of increasing attention in recent years. For health professionals to provide and deliver high-quality palliative care, collaboration and teamwork is required. Palliative care is the ideal service to introduce interprofessional teamwork to medical learners early on in their training. During a 1-month palliative care rotation in Ontario, Canada, medical learners completed a questionnaire seeking their feedback on the interprofessional team model. This article will highlight the results of the questionnaire, how the team promotes a culture of interprofessional collaborative practice, and the supportive structures that foster collaboration among professionals.

Enhancing communication in end-of-life care: a clinical tool translating between the Clinical Frailty Scale and the Palliative Performance Scale.

OBJECTIVES: To create a clinical tool to translate between the Clinical Frailty Scale (CFS), which geriatrics teams use, and Palliative Performance Scale (PPS), which palliative care teams use, to create a common language and help improve communication between geriatric and palliative care teams. DESIGN: Cross-sectional. SETTINGS: Two academic health centers: inpatient palliative care and chronic care units, an outpatient geriatric clinic, and inpatient referrals to a palliative care consultation service. PARTICIPANTS: Older adults (≥65) aged 80.9±8.0, with malignant (51%) and nonmalignant (49%) terminal diagnoses (N=120). MEASUREMENTS: Each participant was assigned four scores: a CFS score each from a geriatric physician and nurse and a PPS score each from a palliative care physician and nurse. Interrater reliability of each measure was calculated using kappa coefficients. For each measure, the mean of physician and nurse scores was used to calculate every possible combination of CFS and PPS scores to determine the combination with maximum agreement. RESULTS: Interrater reliability of each measure was very high for the CFS (weighted κ=0.92) and PPS (weighted κ=0.80). The CFS-PPS score matching that achieved maximum agreement (weighted κ=0.71) was used to create a conversion chart between the two measures. CONCLUSION: This conversion chart is a reliable means of translating scores between the CFS and PPS and is useful for geriatric and palliative care teams collaborating in the care of elderly adults.

Nurses' experiences caring for patients and families dealing with malignant bowel obstruction.

Malignant bowel obstruction (MBO) is a well-recognised complication of advanced abdominal and pelvic cancers. Often surgical intervention is not feasible, resulting in complex symptoms and an unpredictable course. Although symptom management is a crucial part of nursing care, psychosocial and emotional issues frequently emerge for patients and families. This qualitative study explored the perspectives of nurses from a palliative care unit, in-patient acute care oncology units, ambulatory cancer setting, and the community on their experiences of caring for patients with MBO and their families. Six individual interviews and two focus groups were conducted. Eight overarching messages were identified related to nurses' experiences. Highlights include aspects of patients' and families' emotional distress, and the nurse-patient relationship in relieving suffering. Nurses have an important and privileged role that involves identifying MBO signs and symptoms, having knowledge of treatment and symptom management options, and helping patients transition from a curative to a palliative philosophy of care.

Exploring the leadership role of the clinical nurse specialist on an inpatient palliative care consulting team.

Demand for palliative care services in Canada will increase owing to an aging population and the evolving role of palliative care in non-malignant illness. Increasing healthcare demands continue to shape the clinical nurse specialist (CNS) role, especially in the area of palliative care. Clinical nurse specialists bring specialized knowledge, skills and leadership to the clinical setting to enhance patient and family care. This paper highlights the clinical leadership role of the CNS as triage leader for a hospital-based palliative care consulting team. Changes to the team's referral and triage processes are emphasized as key improvements to team efficiency and timely access to care for patients and families.