Process Evaluation of the Regional Referral Clinical Pathway for Home-Based Palliative Care and Outreach Program: A Questionnaire Survey of the Medical Staff and Bereaved Families.

BACKGROUND: The purpose of this study was to clarify how the Regional Referral Clinical Pathway for Home-based Palliative Care (RRCP-HPC) and an outreach program by a palliative care team (PCT) lead to an improvement in the outcome. DESIGN AND METHODS: We conducted questionnaire surveys using the mailing method involving the regional medical staff involved in cancer patients introduced to the PCT of a single hospital, as well as bereaved families. The questionnaire was prepared through interviews with the medical staff and bereaved families. Subsequently, factor analysis was performed to identify factor structures and calculate the correlation coefficient with each outcome. RESULTS: For the questionnaire survey involving the medical staff, responses were collected from 119 regional medical institutions and 84 regional medical staff. The response rate per institution was 51.3%. Similarly, for the questionnaire survey involving bereaved families, the response rate was 42.4%. For the survey involving the medical staff, 6 factors, such as "improved awareness of an interdisciplinary team," were extracted. For the survey involving the bereaved families, 4 factors, such as "improvement of communications between patients and healthcare professionals," were extracted. There were significant (≥moderate) correlations between these factors and all outcomes. CONCLUSION: In this study, we clarified the process of achieving palliative care until death at home without difficulties using the outreach program and RRCP-HPC. The results suggest the importance of improving communications. The outreach program and RRCP-HPC may have contributed to palliative care at home without difficulties through an improvement in communications.

Impact of a Six-Year Project to Enhance the Awareness of Community-Based Palliative Care on the Place of Death.

OBJECT: To examine the clinical outcomes of a project to enhance the awareness of community-based palliative care (awareness-enhancing project), focusing on home death and care rates in communities. METHODS: A single-center study on community-based intervention was conducted. The awareness-enhancing project, consisting of three intervention approaches (outreach, palliative care education for community-based medical professionals, and information-sharing tool use), was executed, and changes in the home death rate in the community were examined. RESULTS: The home death rate markedly exceeded the national mean from 2010. In 2012-2013, it was as high as 19.9%, greater than the previous 5.9% (p = 0.001). Through multivariate analysis, the participation of home care physicians and visiting nurses in a palliative care education program, and patients' Palliative Prognostic Index values were identified as factors significantly influencing the home death rate. CONCLUSION: The three intervention approaches time dependently increased the home death rate as a clinical outcome in the community, although they targeted limited areas. These approaches may aid in increasing the number of individuals who die in their homes.

Going back to home to die: does it make a difference to patient survival?

BACKGROUND: Many patients wish to stay at home during the terminal stage of cancer. However, there is concern that medical care provided at home may negatively affect survival. This study therefore explored whether the survival duration differed between cancer patients who received inpatient care and those who received home care. METHODS: We retrospectively investigated the place of care/death and survival duration of 190 cancer patients after their referral to a palliative care consultation team in a Japanese general hospital between 2007 and 2012. The patients were classified into a hospital care group consisting of those who received palliative care in the hospital until death, and a home care group including patients who received palliative care at home from doctors in collaboration with the palliative care consultation team. Details of the place of care, survival duration, and patient characteristics (primary site, gender, age, history of chemotherapy, and performance status) were obtained from electronic medical records, and analyzed after propensity score matching in the place of care. RESULTS: Median survival adjusted for propensity score was significantly longer in the home care group (67.0 days, n = 69) than in the hospital care group (33.0 days, n = 69; P = 0.0013). Cox's proportional hazard analysis revealed that the place of care was a significant factor for survival following adjustment for covariates including performance status. CONCLUSIONS: This study suggests that the general concern that home care shortens the survival duration of patients is not based on evidence. A cohort study including more known prognostic factors is necessary to confirm the results.

Evaluation of A Novel Information-Sharing Instrument for Home-Based Palliative Care: A Feasibility Study.

AIM: To examine the feasibility and usefulness of a novel region-based pathway: the Regional Referral Clinical Pathway for Home-Based Palliative Care. METHOD: This was a feasibility study to evaluate the frequency of variances and the perceived usefulness of pathway using in-depth interviews. All patients with cancer referred to the palliative care team between 2011 and 2013 and received home care services were enrolled. RESULT: A total of 44 patients were analyzed, and pathway was completed in all the patients. The target outcome was achieved in 61.4% while some variances occurred in 54.5%. Nine categories were identified as the usefulness of the pathway, such as reviewing and sharing information and promoting communication, education, motivation, and relationships. CONCLUSION: This novel pathway is feasible and seems to be useful.

[Use of orally disintegrating olanzapine tablet for patients with cancerous peritonitis and postoperative gastric cancer receiving home palliative care].

In May, 2009, a man in his 30s presented to the department of outpatient palliative care of this hospital. His chief complaints were of severe nausea and abdominal fullness associated with cancerous peritonitis following surgery for gastric cancer. Abdominal fullness was reduced after the initiation of a continued subcutaneous administration of octreotide acetate, but combination therapy with metoclopramide and domperidone did not relieve nausea. The administration of olanzapine orally disintegrating tables (OLZ-ODT) at a dose of 10 mg twice daily was associated with the tendency to reduce nausea. As the symptoms were relieved, palliative care at his home was initiated. The patient's self-discontinuation of OLZ-ODT because the nausea was relieved resulted in its aggravation, but it was relieved again when the administration was resumed. Subsequently, home care was possible for approximately two and half a months without aggravation. Maintaining nausea control well leads to higher-quality care. OLZ-ODT appears to not only be effective for relieving nausea associated with cancerous peritonitis, but is also important for disseminating palliative care at home.

[A case report of a patient treatable by home palliative care, administered zoledronic acid used for bladder cancer with hypercalcemia].

We experienced a case in which zoledronate was effective for alleviating gastrointestinal symptoms arising from urinary bladder cancer-associated hypercalcemia, and long-term palliative home care was feasible by continuation of the administration. A female in her eighties was found to have bladder cancer. After transurethral resection of the bladder tumor, part of it was left unresected. Since dizziness, appetite loss, and general fatigue became severer, blood tests were carried out and hypercalcemia was observed. Then, zoledronate was administered and clinical symptoms quickly improved. After discussion with her and her family, palliative home care was selected. Home care was possible for about six months by continuation of zoledronate administration. In conclusion, it was suggested that careful continuous administration of zoledronate was also useful for symptom control in the palliative home care, and that it would potentially be a key drug for promotion of palliative home care.