Trends in Palliative Care Research During the COVID-19 Pandemic.

To demonstrate the trends and variety of research on palliative care during the COVID-19 pandemic. A systematic search of the Web of Science database. Since the outbroke of the COVID-19 pandemic, the adjustment of palliative care systems is warranted to maintain a high quality of care. The COVID-19 -related palliative care studies account for approximately 4% of all publications on palliative care. However, there is a dearth of research investigating the nature of these studies. A total of 293 studies were included. Of the included studies, those related to system improvement were the most common (181/293, 61.8%), followed by those related to patient care (79/293, 27.0%), bereavement support for patients or family members (19/293, 6.5%), and the mental health of frontline practitioners (14/293, 4.8%). From these studies, 82, 137, and 74 studies were published in 2020, 2021, and 2022 (until August 1), respectively. The research trends of palliative care demonstrate the flexibility and rapid response of the global palliative care system to the COVID-19 pandemic and show how the palliative care system is evolving. While most studies are interested in system improvement, patient care, and bereavement support, the mental health of frontline practitioners has received less attention. Our findings provide palliative care practitioners with current valuable information and highlight possible future trends.

Análisis de la producción científica internacional sobre cuidados paliativos: estudio bibliométrico sobre la base de datos bibliográfica Scopus / Analysis of international scientific production on palliative care: bibliometric study on the Scopus bibliographic database

Objetivo: analizar la producción científica internacional sobre cuidados paliativos tomando como fuente de obtención de los datos la base de datos bibliográfica Scopus.Método:Estudio descriptivo transversal. Los datos se obtuvieron de la base de datos Scopus, interrogando mediante el término “Palliative Care” en los campos de título, resumen y palabras clave. El periodo estudiado fue desde el inicio de la indización en esta base de datos hasta el 31 de diciembre de 2021.Resultados:Evolución de la producción científica creciente (R2 = 0,75). El número de originales fue de 55376 (69,73%), siendo la frecuencia y porcentaje de los artículos citables 66781 (84,09%). La obsolescencia fue de 37 ± 2,52 años con Índice de Price del 6,67%. El idioma de publicación predominante fue el inglés, en 66539 (83,79%) referencias y el país más productor Estados Unidos de América 22482 (28,31%) documentos.Conclusiones:Los indicadores métricos obtenidos estuvieron en línea con otras áreas de conocimiento relacionadas con las ciencias de la salud. Si bien, los resultados sobre obsolescencia fueron superiores a lo esperado. La producción científica presentó un adecuado incremento lineal sin alcanzar el modelo exponencial. El predominio del idioma inglés y de las publicaciones mainstream confirman la tendencia a publicar en las revistas con mayores indicadores de impacto. (AU)

Objective: To analyze the international scientific production on palliative care using the Scopus database as the source for obtaining the data.Method:Cross-sectional descriptive study. The data was obtained from the Scopus database, using the term “Palliative care” in the title, abstract and keyword fields. The period studied was from the beginning of indexing in this database until December 31, 2021.Results:Evolution of growing scientific production (R2 = 0.75). The number of originals was 55,376 (69.73%), with the frequency and percentage of citable articles being 66,781 (84.09%). Obsolescence was 37 ± 2.52 years with a Price Index of 6.67%. The predominant language of publication was English, in 66,539 (83.79%) references and the most producing country, the United States of America, 22,482 (28.31%) documents.Conclusions:The metric indicators obtained were in line with other areas of knowledge related to health sciences. Although, the results on obsolescence were higher than expected. The scientific production presented an adequate linear increase without reaching the exponential model. The predominance of the English language and mainstream publications confirm the tendency to publish in the journals with the highest impact indicators. (AU)

Utilization of Palliative Care for Patients with COVID-19 and Acute Kidney Injury during a COVID-19 Surge.

BACKGROUND AND OBJECTIVES: AKI is a common complication of coronavirus disease 2019 (COVID-19) and is associated with high mortality. Palliative care, a specialty that supports patients with serious illness, is valuable for these patients but is historically underutilized in AKI. The objectives of this paper are to describe the use of palliative care in patients with AKI and COVID-19 and their subsequent health care utilization. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a retrospective analysis of New York University Langone Health electronic health data of COVID-19 hospitalizations between March 2, 2020 and August 25, 2020. Regression models were used to examine characteristics associated with receiving a palliative care consult. RESULTS: Among patients with COVID-19 (n=4276; 40%), those with AKI (n=1310; 31%) were more likely than those without AKI (n=2966; 69%) to receive palliative care (AKI without KRT: adjusted odds ratio, 1.81; 95% confidence interval, 1.40 to 2.33; P<0.001; AKI with KRT: adjusted odds ratio, 2.45; 95% confidence interval, 1.52 to 3.97; P<0.001), even after controlling for markers of critical illness (admission to intensive care units, mechanical ventilation, or modified sequential organ failure assessment score); however, consults came significantly later (10 days from admission versus 5 days; P<0.001). Similarly, 66% of patients initiated on KRT received palliative care versus 37% (P<0.001) of those with AKI not receiving KRT, and timing was also later (12 days from admission versus 9 days; P=0.002). Despite greater use of palliative care, patients with AKI had a significantly longer length of stay, more intensive care unit admissions, and more use of mechanical ventilation. Those with AKI did have a higher frequency of discharges to inpatient hospice (6% versus 3%) and change in code status (34% versus 7%) than those without AKI. CONCLUSIONS: Palliative care was utilized more frequently for patients with AKI and COVID-19 than historically reported in AKI. Despite high mortality, consultation occurred late in the hospital course and was not associated with reduced initiation of life-sustaining interventions. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_02_24_CJN11030821.mp3.

Análise da evolução histórica do conceito de cuidados paliativos: revisão de escopo / Análisis de la evolución histórica del concepto de cuidados paliativos: revisión de alcance / Analysis of the historical evolution of the concept of palliative care: a scoping review

Resumo Objetivo Analisar a evolução histórica do conceito de cuidados paliativos e identificar seus elementos essenciais. Métodos Revisão de escopo fundamentada no manual do Joanna Briggs Institute Reviewer's que incluiu as definições de cuidados paliativos oriundos de artigos científicos selecionados de bases e portais da saúde. Foram selecionados 21 estudos para análise. Utilizou-se o software IRaMuTeQ® para agrupamento dos dados. Resultados De 1993 a 2020 a definição de cuidados paliativos mais citada foi a da World Health Organization; a abordagem paliativa foi implementada nas esferas físicas, biopsicossociais e espirituais, a pacientes com enfermidades agudas ou crônicas para promover conforto, dignidade e qualidade de vida. Os elementos essenciais identificados nas definições foram: vida, cuidado, qualidade, família, equipe multidisciplinar, conforto e alívio. Conclusão Constatou-se amadurecimento na definição de cuidados paliativos, ao agregar elementos para garantia de qualidade de vida digna, independentemente do tipo de doença, e integrar família e equipe interprofissional nesse processo.

Resumen Objetivo Analizar la evolución histórica del concepto de cuidados paliativos e identificar sus elementos esenciales. Métodos Revisión de alcance fundamentada en el manual del Joanna Briggs Institute Reviewer's que incluyó las definiciones de cuidados paliativos provenientes de artículos científicos seleccionados de bases y portales de salud. Se seleccionaron 21 estudios para el análisis. Se utilizó el software IRaMuTeQ® para la agrupación de datos. Resultados De 1993 a 2020 la definición de cuidados paliativos más citada fue la de la World Health Organization. El enfoque paliativo fue implementado en la esfera física, biopsicosocial y espiritual a pacientes con enfermedades agudas o crónicas para promover bienestar, dignidad y calidad de vida. Los elementos esenciales identificados en las definiciones fueron: vida, cuidado, calidad, familia, equipo multidisciplinario, bienestar y alivio. Conclusión Se constató la maduración de la definición de cuidados paliativos al agregar elementos para garantizar la calidad de vida digna, independientemente del tipo de enfermedad, e integrar la familia y el equipo interprofesional en ese proceso.

Abstract Objective To analyze the historical evolution of the concept of palliative care and identify its essential elements. Methods This is a scope review based on the Joanna Briggs Institute Reviewer's manual, which included the definitions of palliative care from scientific articles selected from health databases and portals. Twenty-one studies were selected for analysis. The IRaMuTeQ® software was used to group the data. Results From 1993 to 2020, the most cited definition of palliative care was that of the World Health Organization. The palliative approach was implemented in the physical, biopsychosocial and spiritual spheres for patients with acute or chronic illnesses to promote comfort, dignity and quality of life. The essential elements identified in the definitions were life, care, quality, family, multidisciplinary team, comfort, and relief. Conclusion It was found that the definition of palliative care has matured, by adding elements to guarantee a dignified quality of life, regardless of type of disease, and integrating family and interprofessional team in this process.

Cuidados paliativos aplicados em idosos no domicílio / Palliative care applied to the elderly at home / Cuidados paliativos aplicados a ancianos en el hogar

Objetivo: analisar evidências científicas sobre a utilização de cuidados paliativos aplicados em idosos no domicílio. Métodos: trata-se de uma revisão sistemática de literatura, realizada em janeiro de 2020, utilizando os descritores: "cuidados paliativos/Paliative care" AND "saúde do idoso/heal thof the elderly" AND "assistência domiciliar/home care". Resultados: foram selecionados sete artigos, que emergiram as categorias: Assistência domiciliar adaptada as necessidades dos pacientes de acordo com seus recursos disponíveis; Ampliação dos resultados através do empoderamento e autonomia na participação do cuidado familiar no domicílio; Os cuidados paliativos contribuem para a melhoria dos fatores psicológicos e emocionais, enfrentamento positivo e aceitação do tratamento. Conclusão: a literatura traz uma aplicabilidade geral sem estudos que tratem de forma específica a situação do idoso. Demonstra também um aumento deliberado da necessidade de assistência permanente a estas pessoas com doenças incuráveis, necessitando de apoio holístico

Objective: to analyze scientific evidence on the use of palliative care applied to elderly people at home. Methods: this is a systematic literature review, conducted in January 2020, using the descriptors: "palliative care / Palliative care" AND "health of the elderly / heal thof the elderly" AND "home care / home care". Results: seven articles were selected, which emerged in the categories: Home care adapted to the needs of patients according to their available resources; Expansion of results through empowerment and autonomy in the participation of family care at home; Palliative care contributes to the improvement of psychological and emotional factors, positive coping and treatment acceptance. Conclusion: the literature has a general applicability without studies that specifically address the situation of the elderly. It also demonstrates a delibeate increase in the need for permanent assistance to these people with incurable diseases, requiring holistic support

Objetivo: analizar la evidencia científica sobre el uso de cuidados paliativos aplicados a personas mayores en el hogar. Métodos: esta es una revisión sistemática de la literatura, realizada en enero de 2020, utilizando los descriptores: "cuidados paliativos / cuidados paliativos" Y "salud de los ancianos / curar a los ancianos" Y "cuidado en el hogar / cuidado en el hogar". Resultados: se seleccionaron siete artículos, que surgieron en las categorías: Atención domiciliaria adaptada a las necesidades de los pacientes de acuerdo con sus recursos disponibles; Expansión de resultados a través del empoderamiento y la autonomía en la participación del cuidado familiar en el hogar; Los cuidados paliativos contribuyen a la mejora de los factores psicológicos y emocionales, el afrontamiento positivo y la aceptación del tratamiento. Conclusión: la literatura tiene una aplicabilidad general sin estudios que aborden específicamente la situación de las personas mayores. También demuestra un aumento deliberado en la necesidad de asistencia permanente a estas personas con enfermedades incurables, que requieren un apoyo integral

"Withstanding ambivalence is of particular importance"-Controversies among experts on dealing with desire to die in palliative care.

In order to investigate controversies surrounding the desire to die phenomenon in palliative care by analyzing expert opinions on the topic, we carried out a secondary qualitative data analysis of free text comments collected during a Delphi survey that was designed to develop a conversation aid for dealing with desire to die in everyday clinical practice. Between 01/2018 and 03/2018, a two-round Delphi survey was carried out with national (German) and international palliative care experts. Free text comments were reinvestigated to identify controversies surrounding the desire to die phenomenon. An additional in-depth analysis focused on statements expressing attitudes towards proactively addressing (potential) desires to die. Within the Delphi survey, 103 of 149 multi-professional participants (almost all of them with practical and only six with exclusively theoretical expertise in palliative care) generated 444 free text comments. Thereof, we identified three main categories related to dealing with desire to die: "outer framework", "extended care system" and "health-professional-patient-relationship". Ambivalences, taboos and uncertainties surrounding desire to die in palliative care became apparent. Experts are divided concerning the practice of proactively addressing desire to die. Even if these conversations-especially the proactive approach-are also viewed critically, we conclude that open-ended and respectful communication about desire to die between health professionals and patients can be understood as an eligible intervention in palliative care. Proactively addressing the topic is a possible way to open up such conversations.

Análisis bibliométrico de la producción científica sobre cuidados paliativos en Scopus / Bibliometric analysis of the scientific production on palliative care in Scopus

Introducción y objetivo: Los cuidados paliativos son un enfoque que mejora la calidad de vida de los pacientes terminales. En los siguientes años habrá una gran necesidad de este servicio debido al aumento de la población de edad avanzada y de las enfermedades que afectan a este grupo. No todos los países de Latinoamérica y el Caribe tienen políticas nacionales de cuidados paliativos. El objetivo de este estudio es describir la producción científica sobre cuidados paliativos en Latinoamérica y el Caribe. Métodos: Se realizó un estudio bibliométrico sobre cuidados paliativos en la base de datos Scopus entre 1990 y 2019 cuyos autores tengan al menos una filiación de Latinoamérica y el Caribe. Resultados: Se obtuvo un total de 2030 documentos, observándose un crecimiento sostenido desde el año 2000. Los países con la mayor cantidad de artículos publicados fueron Brasil con 948 (45,65 %), México con 373 (18,36 %) y Argentina con 274 (13,48 %). El conglomerado por palabras clave nos mostró la formación de 3 grupos: terapia paliativa, terapia paliativa en cáncer y grupo etario. Discusión: Si bien en los últimos años ha habido un aumento en el número de artículos publicados, el aporte de cada país es desigual; los 3 primeros países aportan más del 75 % del total de las publicaciones. Se debe promover las políticas nacionales y la investigación en cuidados paliativos con el objetivo de encontrar otros enfoques y terapias para pacientes que requieran cuidados paliativos. (AU)

Introduction and objective: Palliative care is an approach that improves the quality of life in terminally ill patients. In the coming years, there will be a great need for this service due to an increase in the elderly population and in the diseases that affect this age group. Not all Latin American and Caribbean countries have national palliative care policies. The aim of this study was to describe the scientific production on palliative care in Latin America and the Caribbean. Methods: A bibliometric study on palliative care was conducted in the Scopus database between 1990 and 2019, focusing on papers whose authors had at least one affiliation from Latin America and the Caribbean. Results: A total of 2030 documents were obtained, showing a sustained growth since 2000. The countries with the highest number of published articles were Brazil with 948 (45.65 %), Mexico with 373 (18.36 %), and Argentina with 274 (13.48 %). Clustering by keywords showed the formation of 3 groups: palliative therapy, palliative therapy in cancer, and age group. Discussion: Although there has been an increase in the number of articles published in recent years, the contribution of each country is unequal, with the first 3 countries accounting for more than 75 % of the total number of publications. National policies and research in palliative care should be promoted with the aim of finding other approaches and therapies for patients requiring palliative care. (AU)

Nutritional Support Indications in Gastroesophageal Cancer Patients: From Perioperative to Palliative Systemic Therapy. A Comprehensive Review of the Last Decade.

Gastric cancer treatments are rapidly evolving, leading to significant survival benefit. Recent evidence provided by clinical trials strongly encouraged the use of perioperative chemotherapy as standard treatment for the localized disease, whereas in the advanced disease setting, molecular characterization has improved patients' selection for tailored therapeutic approaches, including molecular targeted therapy and immunotherapy. The role of nutritional therapy is widely recognized, with oncologic treatment's tolerance and response being better in well-nourished patients. In this review, literature data on strategies or nutritional interventions will be critically examined, with particular regard to different treatment phases (perioperative, metastatic, and palliative settings), with the aim to draw practical indications for an adequate nutritional support of gastric cancer patients and provide an insight on future directions in nutritional strategies. We extensively analyzed the last 10 years of literature, in order to provide evidence that may fit current clinical practice both in terms of nutritional interventions and oncological treatment. Overall, 137 works were selected: 34 Randomized Clinical Trials (RCTs), 12 meta-analysis, 9 reviews, and the most relevant prospective, retrospective and cross-sectional studies in this setting. Eleven ongoing trials have been selected from clinicaltrial.gov as representative of current research. One limitation of our work lies in the heterogeneity of the described studies, in terms of sample size, study procedures, and both nutritional and clinical outcomes. Indeed, to date, there are no specific evidence-based guidelines in this fields, therefore we proposed a clinical algorithm with the aim to indicate an appropriate nutritional strategy for gastric cancer patients.

Underutilization of Palliative Care for Patients with Advanced Peripheral Arterial Disease.

BACKGROUND: Advanced peripheral arterial disease is associated with an overall annual mortality between 20-40%. Amputees are at particularly high risk for perioperative and long-term mortality and may benefit from palliative care programs to improve quality of life and to align medical treatments with their goals of care. As studies of palliative care in vascular patients are scarce, we sought to examine palliative care utilization using below knee amputation (BKA) as a surrogate for advanced peripheral arterial disease. METHODS: All patients who underwent below knee amputation over a 5-year period at a single large academic medical center were identified through chart review. Demographics, preoperative conditions, intraoperative factors, and perioperative outcomes were recorded. The primary outcome was palliative care consultation at the time of the amputation. The secondary outcomes included one-year mortality and palliative care consultation prior to death. RESULTS: The cohort comprised 111 patients (76 men, 35 women) who received BKA for chronic limb threatening ischemia. Three patients (2.7%) received palliative care consultations at the time of their amputation. Of these, one had been obtained remotely for an oncologic condition and the others for surgical decision-making. Follow-up was available for 73 patients. One-year mortality was 21.9% (n = 16) at a mean of 102 ± 86 days after BKA. Among patients who died within 1 year of their amputation, 37.5% (n = 6) received palliative care consultations prior to their death. The median interval between amputation and palliative consultation was 26 (IQR 14-81) days. The median interval between palliative consultation and death was 9 (IQR 4-39) days. CONCLUSION: Palliative care services were rarely provided to patients with advanced peripheral arterial disease. When obtained, consultations occurred closer to death than to amputation suggesting a missed opportunity to receive the benefits of early evaluation. Future studies can be aimed at identifying a cohort of vascular patients who would most benefit from early palliative evaluation and determining if palliative consultations alter health care utilization patterns and outcomes for vascular patients.

Experiences, challenges and perspectives for ensuring end-of-life patient care: A national online survey with general practitioners in Germany.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic is posing major challenges for health care systems. In Germany, one such challenge has been that adequate palliative care for the severely ill and dying (with and without COVID-19), as well as their loved ones, has not been available at all times and in all settings., the pandemic has underlined the significance of the contribution of general practitioners (GPs) to the care of severely ill and dying patients. OBJECTIVES: To describe GPs' experiences, challenges and perspectives with respect to end-of-life care during the first peak of the pandemic (spring 2020) in Germany. MATERIALS AND METHODS: In November and December 2020, a link to an Unipark online survey was sent to GPs registered on nationwide distribution lists. RESULTS: In total, 410 GPs responded; 61.5% indicated that the quality of their patients' end-of-life care was maintained throughout the pandemic, 36.8% reported a decrease in quality compared to pre-pandemic times. Of the GPs who made home visits to severely ill and dying patients, 61.4% reported a stable number of visits, 28.5% reported fewer visits. 62.7% of the GPs reported increased telephone contact and reduced personal contact with patients; 36.1% offered video consultations in lieu of face-to-face contact. The GPs reported that relatives were restricted (48.5%) or prohibited from visiting (33.4%) patients in nursing homes. They observed a fear of loneliness among patients in nursing homes (91.9%), private homes (87.3%) and hospitals (86.1%). CONCLUSIONS: The present work provides insights into the pandemic management of GPs and supports the development of a national strategy for palliative care during a pandemic. To effectively address end-of-life care, GPs and palliative care specialists should be involved in COVID-19 task forces on micro, meso and macro levels of health care.

Healthcare Utilization for Stroke Patients at the End of Life: Nationally Representative Data.

Objectives Stroke and post-stroke complications are associated with high morbidity, mortality, and cost. Our objective was to examine healthcare utilization and hospice enrollment for stroke patients at the end of life. Materials and methods The 2014 Nationwide Readmissions Database is a national database of > 14 million admissions. We used validated ICD-9 codes to identify fatal ischemic stroke, summarized demographics and hospitalization characteristics, and examined healthcare use within 30 days before fatal stroke admission. We used de-identified 2014 Medicare hospice data to identify stroke and non-stroke patients admitted to hospice. Results Among IS admissions in 2014 (n = 472,969), 22652 (4.8%) had in-hospital death. 28.2% with fatal IS had two or more hospitalizations in 2014. Among those with fatal IS admission, 13.0% were admitted with cerebrovascular disease within 30 days of fatal IS admission. Half of stroke patients discharged to hospice from the Medicare dataset were hospitalized with cerebrovascular disease within the thirty days prior to hospice enrollment. Within the study year, 6.9% of hospice enrollees had one or more emergency room visits, 31.7% had one or more inpatient encounters, and 5.2% had one or more nursing facility encounters (compared to 21.4%, 70.6%, and 27.2% respectively in the 30-day period prior to enrollment). Conclusions High rates of readmission prior to fatal stroke may indicate opportunity for improvement in acute stroke management, secondary prevention, and palliative care involvement as encouraged by AHA/ASA guidelines. For patients who are expected to survive 6 months or less, hospice may offer goal-concordant services for patients and caregivers who desire comfort-focused care.

Projecting palliative and end-of-life care needs in Central Lancashire up to 2040: an integrated palliative care and public health approach.

OBJECTIVES: A collaborative study was undertaken by palliative care and public health on behalf of Chorley & South Ribble and Greater Preston Clinical Commissioning Groups. Going beyond a traditional needs assessment by providing projections of local palliative and end-of-life care needs in all conditions over 20 years, the study will support locality commissioning and development of appropriate health care services. STUDY DESIGN: Population-based needs assessment involving secondary analysis of routinely available regional mortality and population data for Central Lancashire (2017). Palliative care need was estimated using three different recognised methods. METHODS: These estimates were combined with routinely available population and mortality projections and observed trends in palliative care need to provide projections up to 2040. RESULTS: Palliative care need in 2017 in Chorley & South Ribble and Greater Preston is estimated to be between 75% (1292) and 97% (1670), and 74.9% (1337) and 95.7% (1710) of all deaths, respectively. By 2040, the annual need is projected to increase compared with 2017 figures, by 24.2-55.9% (314-729 more deaths) in Chorley & South Ribble and by 13.4-41.4% (180-554 more deaths) in Greater Preston. The numbers of deaths from dementia are forecast to increase by three-fold in both localities. CONCLUSION: This study demonstrates practical application of public health data to support the development of locally responsive palliative care services. Dissemination of findings from this needs assessment on rising palliative care need, including numbers of deaths in different disease groups, provides direction to plan appropriate, equitable and sustainable services. Rapidly growing dementia deaths deserve particular attention in the planning of care. Collaborative work between public health and palliative care in other settings is encouraged, and will likely increase in significance as the full impact of COVID-19 is felt.

Patterns of Palliative Chemotherapy and Survival in Patients With Pancreatic Cancer Focusing on Age: A Nationwide Real-World Danish Registry Study.

OBJECTIVES: The aim of this study was to identify patterns of palliative chemotherapy (CTh) and the associated overall survival (OS) in patients with pancreatic cancer, with specific focus on age. METHODS: Between May 1, 2011, and April 30, 2016, 4260 patients were registered in the Danish Pancreatic Cancer Database. The 1715 patients receiving palliative CTh were retrieved. Age was grouped into less than 70, 70 to less than 75, and 75 years or more. RESULTS: Of the 1715 patients receiving first-line CTh, 586 (34%) underwent second-line CTh and 151 (9%) third-line CTh. First-line gemcitabine resulted in a significant worse survival compared with combination CTh, hazard ratio 1.51. For combination CTh, OS differed between the age groups, P < 0.01. The median OS in the less than 70 years (n = 547), 70 to less than 75 years (n = 163), and 75 years or more (n = 67) groups were 9.3, 9.6, and 7.2 months, respectively. No differences in survival were observed among patients receiving first-line gemcitabine (P = 0.35). CONCLUSIONS: Our findings are useful in treatment-related decision making in patients with pancreatic cancer. A significant survival benefit was observed for all patients after first-line combination CTh. The effect of combination CTh was most prominent among patients aged less than 75 years. By age, no differences in survival were observed in those receiving gemcitabine.

Lugar de fallecimiento de pacientes con procesos paliativos: ¿podemos invertir la tendencia de fallecer en el hospital? / Place of death of patients receiving palliative care: can we reverse the trend of dying in hospitals?

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How many people will need palliative care in Scotland by 2040? A mixed-method study of projected palliative care need and recommendations for service delivery.

OBJECTIVE: To estimate future palliative care need and complexity of need in Scotland, and to identify priorities for future service delivery. DESIGN: We estimated the prevalence of palliative care need by analysing the proportion of deaths from defined chronic progressive illnesses. We described linear projections up to 2040 using national death registry data and official mortality forecasts. An expert consultation and subsequent online consensus survey generated recommendations on meeting future palliative care need. SETTING: Scotland, population of 5.4 million. PARTICIPANTS: All decedents in Scotland over 11 years (2007 to 2017). The consultation had 34 participants; 24 completed the consensus survey. PRIMARY AND SECONDARY OUTCOMES: Estimates of past and future palliative care need in Scotland from 2007 up to 2040. Multimorbidity was operationalised as two or more registered causes of death from different disease groups (cancer, organ failure, dementia, other). Consultation and survey data were analysed descriptively. RESULTS: We project that by 2040, the number of people requiring palliative care will increase by at least 14%; and by 20% if we factor in multimorbidity. The number of people dying from multiple diseases associated with different disease groups is projected to increase from 27% of all deaths in 2017 to 43% by 2040. To address increased need and complexity, experts prioritised sustained investment in a national digital platform, roll-out of integrated electronic health and social care records; and approaches that remain person-centred. CONCLUSIONS: By 2040 more people in Scotland are projected to die with palliative care needs, and the complexity of need will increase markedly. Service delivery models must adapt to serve growing demand and complexity associated with dying from multiple diseases from different disease groups. We need sustained investment in secure, accessible, integrated and person-centred health and social care digital systems, to improve care coordination and optimise palliative care for people across care settings.