Early integration of palliative care in hospitals: A systematic review on methods, barriers, and outcome.

OBJECTIVE: According to the World Health Organization (WHO), palliative care (PC) should be available to everyone suffering from life-threatening diseases and should be started early on in the illness trajectory. However, PC is often initiated much later and is restricted to cancer patients. There is a need for more knowledge about how early PC can be implemented in clinical practice. The purpose of our study was to document the best evidence on methods for early identification (EI) of palliative trajectories in cancer, chronic heart failure (CHF), and chronic obstructive pulmonary disease (COPD) populations, and to identify preconditions for early integration of general PC in hospitals and outcomes for patients and relatives. METHOD: A comprehensive systematic review of methods, preconditions, and outcomes was conducted via an electronic literature search of publications between 2002 and September 2012. A final sample of 44 papers was reviewed in detail. RESULTS: Our study identified disease-specific and general methods for EI of patients who might benefit from PC. Prognostication of end-stage disease based on (holistic) clinical judgment, prognostic factors, and/or care needs are the most frequently recommended methods. A number of interacting disease-, staff-, user-, and organization-specific barriers need to be overcome in order to implement early integration of PC in clinical practice. Early integration of PC may lead to better symptom management, prolonged survival, and better quality of life. SIGNIFICANCE OF RESULTS: No methods can be recommended for routine clinical practice without further validation. There is an urgent need to develop and evaluate methods based on the holistic assessment of symptoms or needs. The barriers to early integration of PC are most extensive with regard to CHF and COPD. Professional training and education are recommended to facilitate early implementation of PC. The evidence about outcome is sparse and mostly relates to cancer populations receiving specialized PC.

Identifying transitions in terminal illness trajectories: a critical factor in hospital-based palliative care.

This article describes the significance of the identification and explicit communication of the different clinical phases in incurable illness trajectories in a hospital setting. The article is part of a qualitative study carried out in a Danish haematology department. The data were obtained through a total of 157 hours of participant observation and informal interviews with patients, families, doctors and nurses and four focus group interviews with doctors and nursing staff. Grounded theory was applied for the data analysis. The findings outline how the unpredictability of certain haematological malignancies and barriers in professional practice tended to postpone identifications of transitions between clinical phases. The study has identified ten barriers including personal, professional, time-related, cultural and organizational-for an open dialogue between staff, patients and families about illness progression. The quality of palliative care was affected as different clinical phases require different treatment and care strategies. Complex intervention is called for.

The relevance of time in palliative care nursing practice.

This article describes time as a contextual factor in palliative caring practices and contributes to an understanding of the connections between time and the quality of palliative care. The article is based on an explorative and qualitative research study inspired by grounded theory. The empirical data of the study were obtained through field studies and interview. The interpretation is indebted to a philosophical interpretation that assumes time to be consciously organised into two categories: an objective clock time and a subjective personal time. Two scenarios are presented: one in which clock time is insufficient and another in which clock time is sufficient. Each scenario outlines how nurses relate to time in different ways according to whether clock time is insufficient or sufficient, respectively. It is found that the two scenarios have different implications for palliative care, nurses' personal time, and nurses' opportunities for reflection and professional development.