Evidence for improving palliative care at the end of life: a systematic review
Humans; Caregivers/psychology; referral and consultation; Palliative Care/standards; social support; RDF Project; Continuity of Patient Care/standards; Pain/therapy; Patient Care Team/standards; Advance Care Planning/standards; Depression/therapy; Dyspnea/therapy
BACKGROUND: Many persons and their families are burdened by serious chronic illness in late life. How to best support quality of life is an important consideration for care. PURPOSE: To assess evidence about interventions to improve palliative and end-of-life care. DATA SOURCES: English-language citations (January 1990 to November 2005) from MEDLINE, the Database of Abstracts of Reviews of Effects, the National Consensus Project for Quality Palliative Care bibliography, and November 2005 to January 2007 updates from expert reviews and literature surveillance. STUDY SELECTION: Systematic reviews that addressed "end of life," including terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia), and intervention studies (randomized and nonrandomized designs) that addressed pain, dyspnea, depression, advance care planning, continuity, and caregiving. DATA EXTRACTION: Single reviewers screened 24,423 titles to find 6381 relevant abstracts and reviewed 1274 articles in detail to identify 33 high-quality systematic reviews and 89 relevant intervention studies. They synthesized the evidence by using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) classification. DATA SYNTHESIS: Strong evidence supports treating cancer pain with opioids, nonsteroidals, radionuclides, and radiotherapy; dyspnea from chronic lung disease with short-term opioids; and cancer-associated depression with psychotherapy, tricyclics, and selective serotonin reuptake inhibitors. Strong evidence supports multi component interventions to improve continuity in heart failure. Moderate evidence supports advance care planning led by skilled facilitators who engage key decision makers and interventions to alleviate caregiver burden. Weak evidence addresses cancer-related dyspnea management, and no evidence addresses noncancer pain, symptomatic dyspnea management in advanced heart failure, or short-acting antidepressants in terminal illness. No direct evidence addresses improving continuity for patients with dementia. Evidence was weak for improving caregiver burdens in cancer and was absent for heart failure. LIMITATIONS: Variable literature indexing for advanced chronic illness and end of life limited the comprehensiveness of searches, and heterogeneity was too great to do meta-analysis. CONCLUSION: Strong to moderate evidence supports interventions to improve important aspects of end-of-life care. Future research should quantify these effects and address the generalizability of insights across the conditions and settings of the last part of life. Many critical issues lack high-quality evidence.
2008
Lorenz KA; Lynn J; Dy SM; Shugarman LR; Wilkinson A; Mularski RA; Morton SC; Hughes RG; Hilton LK; Maglione M; Rhodes SL; Rolon C; Sun VC; Shekelle PG
Annals Of Internal Medicine
2008
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Journal Article
<a href="http://doi.org/10.7326/0003-4819-148-2-200801150-00010" target="_blank" rel="noreferrer">10.7326/0003-4819-148-2-200801150-00010</a>
The benefits of a hospital-based inpatient palliative care consultation service: preliminary outcome data
Female; Humans; Male; Adult; Aged; Middle Aged; Respiration; Outcome Assessment (Health Care); Cost-Benefit Analysis; Consumer Satisfaction; Hospitals; Hospital Charges; Case-Control Studies; adolescent; 80 and over; Palliative Care/organization & administration; referral and consultation; New York City; Artificial/economics; Contract Services
This report describes the multiple complementary analytic methods used to create a composite evaluation of the benefits of a hospital-based inpatient palliative care consultation service at Montefiore Medical Center in its preliminary phase. We evaluated data regarding 592 consecutive patients consulted by the palliative care service between November 2000, through March 2002. Standardized medical record reviews indicated that over 90% of interventions recommended by the palliative care team were accepted and acted on by the primary team; audit of the medical records of 368 patients confirmed that pain and other symptoms improved in 87% of patients after palliative care intervention. Ninety-five percent of respondents to a telephone survey of family caregivers described themselves as likely to recommend the service to others. High levels of referring provider satisfaction were evidenced by a Likert- scale provider satisfaction survey and an increase in the rate of referral for palliative care consultation from 2% to 21% of all patients dying at our medical center during the study period. There were also significant reductions in charges for ancillary tests and ventilator charges after palliative care consultation. A matched case control study of mechanically ventilated patients demonstrated significant savings in hospital charges (n = 160 pairs). Length of stay was significantly reduced for patients referred for hospice (n = 112). This type of multifaceted approach is necessary for the evaluation of a service with multiple components that would be difficult to capture with a single analytic approach. This report suggests efficacy of our palliative care service in terms of patient outcomes, provider satisfaction, caregiver satisfaction, and cost savings.
2005
O'Mahony S; Blank AE; Zallman L; Selwyn PA
Journal Of Palliative Medicine
2005
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Journal Article
<a href="http://doi.org/10.1089/jpm.2005.8.1033" target="_blank" rel="noreferrer">10.1089/jpm.2005.8.1033</a>
The impact of a palliative medicine consultation service in medical oncology.
Female; Humans; Male; Adult; Prognosis; Eligibility Determination; Prospective Studies; Aged; Middle Aged; Resuscitation Orders; Health Status; adolescent; 80 and over; social support; DNAR; hospice care; Pain/dt [Drug Therapy]; Medical Oncology; Neoplasms/th [Therapy]; Palliative Care/ut [Utilization]; referral and consultation; Pain/et [Etiology]; Palliative Care/og [Organization & Administration]
This prospective study of consecutive patients describes the palliative medicine consult service in a tertiary level cancer center and its impact on patient care. All inpatients/outpatients referred to the Palliative Medicine Program in a 4-month period were enrolled. Data were collected at the initial consultation using standardized forms with spaces for: reason for the consultation, referring service, demographics and history, ECOG performance status, symptoms, prognosis and diagnostic tests, treatment, and care plan. In all, 240 patients were seen: 79% were referred for symptom management; 53% were referred from medical oncology; and 50% were women. Median patient age was 67 years (range 18-96). Median performance status was 2 (1-4). Most (84%) of the patients had cancer. The cancer sites were: lung in 26% of cases, colorectal in 8%, and breast in 7%. Inpatients accounted for 53% and outpatients, for 47% of the study population. The median number of symptoms per patient was 13 (2-30). The estimated survival was <2 weeks in 15%, 2-8 weeks in 38%, 2-6 months in 37%, and >6 months in 10%. The patients' goals were: improve symptoms for 84%, return home for 55%, and no further admissions for 5%. The support systems named by patients were: family in 89%, friends in 13%, and the community in 5%. Hospice care was discussed at the consultation with 38% of the patients, would have been inappropriate for 31%, was not discussed with 22%, and had been discussed before with 9%. In response to questions about psychosocial care, a caregiver was identified by 78%, a spokesperson by 75%, and durable power of attorney was referred to by 21%. The DNR status was discussed on consult by 57%, had already been discussed with 30%, and was not discussed with 13%. Plan of care foresaw outpatient follow-up for 40%, inpatient follow-up for 32%, and transfer to palliative medicine for 27%. In 39% of cases the consults were considered late referrals. New medications suggested were opioids for 46% of patients, antiemetics for 28%, a bowel regimen for 24%, steroids for 15%, and others for 51%. (1) Palliative medicine consultation involves common complex medical, psychological, and social problems. (2) Complex symptomatology in this population is confirmed. (3) Multiple interventions were suggested even at the initial consultation. (4) Important issues such as DNR (do not resuscitate) status, support system, treatment goals, and eligibility for hospice care had often not been addressed.
2002
Homsi J; Walsh D; Nelson KA; LeGrand SB; Davis M; Khawam E; Nouneh C
Supportive Care In Cancer : Official Journal Of The Multinational Association Of Supportive Care In Cancer
2002
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Journal Article
<a href="http://doi.org/10.1007/s00520-002-0341-8" target="_blank" rel="noreferrer">10.1007/s00520-002-0341-8</a>
Open lung biopsy in neonatal and paediatric patients referred for extracorporeal membrane oxygenation (ECMO)
Child; Humans; infant; Extracorporeal Membrane Oxygenation; infant; referral and consultation; Newborn; retrospective studies; Heart Defects; Safety; Biopsy/methods; Congenital/pathology; Hyperplasia/pathology; Lung/pathology; Respiratory Insufficiency/pathology/surgery/therapy; Thoracotomy/methods
BACKGROUND: This study was undertaken to determine the usefulness, safety, and most appropriate timing of open lung biopsy in infants and children considered for and on extracorporeal membrane oxygenation (ECMO) for respiratory failure. METHODS: A retrospective review of children referred for consideration of and placed on ECMO in our institution in the period 1996-2002. RESULTS: 506 patients were referred, 15 (3%) of whom underwent antemortem open lung biopsy (eight neonatal, four paediatric, and three cardiac patients). In the neonatal group open lung biopsy contributed to clinical decision making in all patients. Four neonates had a fatal lung dysplasia (three alveolar capillary dysplasia and one surfactant protein B deficiency) and treatment was withdrawn. Of the other four neonates, two had pulmonary hypoplasia, one had pulmonary lymphangiectasia, and one had meconium aspiration with mild barotrauma. Treatment was continued in these four patients and two survived. In the paediatric group the biopsies were of clinical relevance in two infants with pertussis who had lung infarction on biopsy in whom treatment was withdrawn. In the other two paediatric patients the biopsies were equivocal, treatment was continued, but both patients died. In the cardiac group, who presented perioperatively with pulmonary hypertension, the biopsies excluded a fatal lung dysplasia and severe pulmonary vascular disease but all three infants died. One patient had non-fatal bleeding complications. CONCLUSION: Open lung biopsy is clinically most useful when performed to diagnose fatal lung dysplasias in neonates and to confirm the presence of viable lung tissue in patients with acute lung injury due to pertussis infection.
2004
Inwald D; Brown K; Gensini F; Malone M; Goldman A
Thorax
2004
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Journal Article
<a href="http://doi.org/10.1136/thx.2003.010793" target="_blank" rel="noreferrer">10.1136/thx.2003.010793</a>
Hospital charges for a community inpatient palliative care program
Female; Humans; Male; Adult; Aged; Middle Aged; Time Factors; Hospitals; Chi-Square Distribution; Tennessee; 80 and over; Comparative Study; referral and consultation; Palliative Care/economics/organization & administration/utilization; Cost Control; Hospital Costs/statistics & numerical data; Community/economics/utilization; Hospital Charges/statistics & numerical data; Length of Stay/economics/statistics & numerical data; Patient Admission/economics; Patient Discharge/economics
Defining financial parameters of palliative care (PC) is important for providing sustainable programming. In our study, we evaluated hospital length of stay (LOS) and charges for the first 164 inpatient PC consultations performed by the Advanced Illness Assistance (AIA) team at Blount Memorial Hospital (BMH). These AIA patients had a median LOS of 11 days (range, 3-114 days), mean total charges per patient of 65,795 dollars, and mean daily charges of 3,809 dollars. Higher mean daily charges (p = 2.74 E-08, chi-square) were associated with patients who received consultation because of nonphysical symptom reasons. Patients were followed in PC consultation (AIA follow-up days) for a median of five days (range, 1-48), and had mean daily charges of 3,117 dollars. These mean daily charges were 414 dollars less than the charges for the five days prior to PC consultation (pre-AIA days) (p = 0.04, t-test). There was a significant decrease in laboratory and imaging charges during AIA follow-up (p = 0.04, t-test). The study included a reference group of patients whose information was obtained retrospectively from the BMH Atlas (MediQual, Marlborough, MA) database. These reference group patients were hospitalized at BMH during the same time, but they were not seen by the AIA team. The reference group was matched by Diagnosis Related Group (DRG), Admission Severity Grade (ASG), and disposition to the AIA patients. The Atlas patients had a shorter median LOS of six days (range, 1-105 days), and significantly greater mean daily charges of 4,105 dollars (p = 0.006, t-test) compared with AIA patients. Mean daily charges decreased for Atlas patients, as their day of discharge approached (p < 0.001). Estimates of potential charge savings were calculated in two ways: 1) by evaluating the effect of decreasing the LOS of Atlas patients with long LOS (more than seven days) to the level of AIA patients with long LOS, and 2) by comparing the actual mean patient charges during AIA follow-up with using the pre-AIA mean daily charges during the AIA follow-up period and correcting for the effect of decreasing charges that occurred as discharge approached. The estimated savings achieved by decreasing long LOS were more than 100,000 dollars per year, and estimated savings achieved using AIA follow-up charges were more than 1,801,930 dollars per year.
2004
Cowan JD
The American Journal Of Hospice & Palliative Care
2004
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Journal Article
<a href="http://doi.org/10.1177/104990910402100306" target="_blank" rel="noreferrer">10.1177/104990910402100306</a>
New guidelines for the management of migraine in primary care
Humans; Questionnaires; Medical History Taking; Primary Health Care; Non-U.S. Gov't; Research Support; patient care team; referral and consultation; algorithms; Diagnosis; Differential; Patient Education; Migraine Disorders/diagnosis/prevention & control/therapy
Despite repeated initiatives over the past decade, migraine remains under-recognised, under-diagnosed and under-treated in everyday clinical practice. The Migraine in Primary Care Advisors (MIPCA) group has produced new guidelines for migraine management to attempt to rectify this situation. MIPCA is a group of physicians, nurses, pharmacists and other healthcare professionals dedicated to the improvement of headache management in primary care, who have also worked closely with the Migraine Action Association (the UK patients' group) in the development of these guidelines. The principles of the new MIPCA guidelines are: To arrange specific consultations for headache. To institute a system of detailed history taking, patient education and buy-in at the outset of the consultation. To utilise a new screening algorithm for the differential diagnosis of headache, which can be confirmed by further questioning, if necessary. To institute a process of management that is individualised for each patient, using a new algorithm. Assessing the impact on the patient's daily life is a key aspect of diagnosis and management. To prescribe only treatments that have objective evidence of favourable efficacy and tolerability. To utilise prospective follow-up procedures to monitor the success of treatment. To organise a team approach to headache management in primary care.
2002
Dowson AJ; Lipscombe S; Sender J; Rees T; Watson D; Migraine In Primary Care Advisors (MIPCA) - Migraine Guidelines Development Group
Current Medical Research And Opinion
2002
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Journal Article
<a href="http://doi.org/10.1185/030079902125001164" target="_blank" rel="noreferrer">10.1185/030079902125001164</a>
Differences in understanding of specialist palliative care amongst service providers and commissioners in South London
Humans; Attitude of Health Personnel; Non-U.S. Gov't; Research Support; Palliative Care/organization & administration; referral and consultation; Neoplasms/therapy; Delivery of Health Care/organization & administration; London; Terminology
This paper describes a study that sought to identify service providers' and commissioners' understanding of specialist palliative care within the context of changing service provision in one area of South London. Using a formative evaluation framework, we examined the views of 44 providers and commissioners from statutory and voluntary health and social care services about their understanding of specialist palliative care services and, in particular, the remit of current service provision delivered by a Marie Curie Centre. Face-to-face audiotaped semi-structured interviews were conducted. A qualitative thematic analysis highlighted a number of issues including a lack of consensus about definitions of palliative care, ambivalence about referral procedures, and a lack of role clarity between specialist and generalist palliative care providers. The study took place within the real world context of changing services and economic pressures. This raises methodological issues about how services are evaluated and what terminology is used to describe end-of-life care. The study findings confirm that confusion about terminology and referral criteria remain major issues for clinical workers and organizations seeking to access services.
2002
Payne S; Sheldon F; Jarrett N; Large S; Smith P; Davis CL; Turner P; George S
Palliative Medicine
2002
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Journal Article
<a href="http://doi.org/10.1191/0269216302pm572oa" target="_blank" rel="noreferrer">10.1191/0269216302pm572oa</a>
Continuity of care: an approach to measurement
Hospitalization; Humans; Questionnaires; Follow-Up Studies; Prospective Studies; Communication; Psychotherapy; Comprehensive Health Care; Medical Records; Ambulatory Care; Models; referral and consultation; Theoretical; Community Mental Health Services; Evaluation Studies as Topic; Community Psychiatry; Day Care; Mental Disorders/therapy; Transfer Agreement
1972
Bass RD; Windle C
The American Journal Of Psychiatry
1972
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Journal Article
<a href="http://doi.org/10.1176/ajp.129.2.196" target="_blank" rel="noreferrer">10.1176/ajp.129.2.196</a>
The consultant and the patient-physician relationship. A trilateral deliberative model
Humans; United States; Physician-Patient Relations; Family; Communication; Physicians; Physician's Role; Interprofessional Relations; Continuity of Patient Care; Primary Health Care; Professional Patient Relationship; Psychological; Analytical Approach; Models; referral and consultation
1994
Emanuel LL; Richter J
Archives Of Internal Medicine
1994
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Journal Article
<a href="http://doi.org/10.1001/archinte.1994.00420160016003" target="_blank" rel="noreferrer">10.1001/archinte.1994.00420160016003</a>
Experience with neonatal palliative care consultation at the Medical College of Wisconsin-Children's Hospital of Wisconsin
Humans; infant; Intensive Care Units; Palliative Care; Hospitals; Wisconsin; Neonatology; Neonatal; Pediatric; referral and consultation; Newborn; retrospective studies
At Children's Hospital of Wisconsin there is a pediatric palliative care consultation service that serves a diverse patient population, including infants. However, the value of a palliative care consultation for infants has not been well evaluated. We performed a retrospective, case series, descriptive chart review of infants in our neonatal intensive care unit (NICU) who received palliative care consults between January 1996 and June 1998. We specifically looked at their diagnoses, the timing of consults, reasons that consultations were ordered, what recommendations were made, and the subsequent outcomes. During the series period there were 898 admissions to the NICU, 51 neonatal deaths, and 12 neonatal palliative care consultations. The diagnostic categories for those with a palliative care referral included prematurity, lethal anomalies, and catastrophic or overwhelming illness. Reasons for the consultations were organization of home hospice, facilitation of medical options, such as do-not-resuscitate (DNR) orders and treatment withdrawal, facilitation of comfort measures, and grief/loss issues. Recommendations that the palliative care staff made fell into four categories: advance directive planning, the optimal environment for supporting neonatal death, comfort and medical care, and psychosocial support. This series is a description of what a palliative care service can offer for terminally ill infants in an NICU. We speculate that such consults can more consistently and comprehensively provide appropriate end-of-life care for these patients and their families.
2001
Leuthner SR; Pierucci R
Journal Of Palliative Medicine
2001
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Journal Article
<a href="http://doi.org/10.1089/109662101300051960" target="_blank" rel="noreferrer">10.1089/109662101300051960</a>
Continuity of care: influence of general practitioners' knowledge about their patients on use of resources in consultations.
Child; Cross-Sectional Studies; Female; Humans; Male; Adult; Aged; Middle Aged; Physicians; Time Factors; adolescent; Preschool; infant; referral and consultation; Norway; Continuity of Patient Care; Drug Prescriptions; Family/psychology; Health Resources/utilization; Physician-Patient Relations
OBJECTIVE--To examine the relation between general practitioners' knowledge about their patients and the use of resources in consultations. DESIGN--A cross sectional evaluation of consultations. SETTING AND SUBJECTS--A representative sample of 133 Norwegian general practitioners were each asked to record 30 consecutive consultations. 131 did so, and of 3990 possible registrations, 3918 (98%) were evaluated. MAIN OUTCOME MEASURES--The influence, as assessed by the doctor, of accumulated knowledge on the use of laboratory tests, expectant management, prescriptions, sickness certification, referrals, and time spent in the consultation. RESULTS--Accumulated knowledge was a substantial factor in saving time, especially in consultations with children, the elderly, patients with psychosocial problems, and those with chronic diseases. It also influenced the overall use of laboratory tests, expectant management, sickness certification, and referrals, and to a lesser degree the use of medication. CONCLUSION--The findings imply strong but complex associations between accumulated knowledge and the use of resources in the consultation.
1991
Hjortdahl P; Borchgrevink CF
British Medical Journal
1991
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Journal Article
<a href="http://doi.org/10.1136/bmj.303.6811.1181" target="_blank" rel="noreferrer">10.1136/bmj.303.6811.1181</a>
Palliative medicine consultation impacts DNR designation and length of stay for terminal medical MICU patients.
Female; Humans; Male; Medical Futility; Aged; referral and consultation; Costs and Cost Analysis; retrospective studies; DNAR; Resuscitation Orders; Palliative Care; DNAR Outcomes; APACHE; Hospital Mortality/td [Trends]; Intensive Care Units/statistics & numerical data; Length of Stay/sn [Statistics & Numerical Data]; Acute physiology and chronic health evaluation; Do not resuscitate; Length of Stay/td [Trends]; Medical intensive care; Palliative medicine consultation
OBJECTIVE: The purpose of this study was to assess the impact of a palliative medicine consultation on medical intensive care unit (MICU) and hospital length of stay, Do Not Resuscitate (DNR) designation, and location of death for MICU patients who died during hospitalization., METHOD: A comparison of two retrospective cohorts in a 17-bed MICU in a tertiary care university-affiliated hospital was conducted. Patients admitted to the MICU between January 1, 2003 and June 30, 2004 (N = 515) were compared to MICU patients who had had a palliative medicine consultation between January 1, 2005 and June 1, 2009 (N = 693). To control for disease severity, only patients in both cohorts who died during their hospitalization were considered for this study., RESULTS: Palliative medicine consultation reduced time until death during the entire hospitalization (log-rank test, p < 0.01). Time from MICU admission until death was also reduced (log-rank test, p < 0.01), further demonstrating the impact of the palliative care consultation on the duration of dying for hospitalized patients. The intervention group contained a significantly higher percentage of patients with a DNR designation at death than did the control group (86% vs. 68%, chi2 test, p < 0.0001)., SIGNIFICANCE OF RESULTS: Palliative medicine consultation is associated with an increased rate of DNR designation and reduced time until death. Patients in the intervention group were also more likely to die outside the MICU as compared to controls in the usual care group.
Lustbader DR; Pekmezaris R; Frankenthaler M; Walia R; Smith F; Hussain E; Napolitano B; Lesser M
Palliative & Supportive Care
2011
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Journal Article
<a href="http://doi.org/10.1017/s1478951511000423" target="_blank" rel="noreferrer">10.1017/s1478951511000423</a>
Care goals and decisions for children referred to a pediatric palliative care program
Child; Female; Humans; infant; Male; Young Adult; Palliative Care; Pediatrics; Goals; Health Status; quality of life; adolescent; Preschool; decision making; infant; referral and consultation; Newborn; care goals; Life-limiting conditions; Therapeutic Processes; treatment decision making
OBJECTIVE: To describe goals of care for children with complex, life-limiting conditions and to assess the variables that may influence these goals. METHODS: Goals of care were elicited from the parents and children with complex, life-limiting conditions during initial palliative care consultation. Data abstracted included: diagnoses, demographics, time from diagnosis until initial palliative care consult, spirituality status, resuscitative status, and disposition at discharge. Goals of care were categorized into one of four quality-of-life domains: 1) physical health and independence, 2) psychological and spiritual, 3) social, and 4) environment. Summary statistics were prepared and comparisons were made between the four categories of goals. Descriptive statistics were utilized to explore potential associations with a decision to pursue full medical support. RESULTS: One hundred and forty goals of care were obtained from 50 patients/parents. The median patient age was 4.6 years. Thirty-seven patients had significant cognitive delay/impairment. Neuromuscular disorders accounted for more than half of the diagnoses. Forty-nine patients identified at least one goal pertaining to physical health and independence. This was significantly more than any other category (p < 0.0001). Thirty-three of the 50 patients (66%) opted for full medical support at the time of initial consult. CONCLUSIONS: Children with complex, life-limiting conditions and their families referred to a palliative care service commonly verbalize goals related to health maintenance and independence. Anticipating this expectation may foster communication and improve patient care.
Tamburro R F; Shaffer ML; Hahnlen NC; Felker P; Ceneviva GD
Journal Of Palliative Medicine
2011
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Journal Article
<a href="http://doi.org/10.1089/jpm.2010.0450" target="_blank" rel="noreferrer">10.1089/jpm.2010.0450</a>
Quality of life for children with life-limiting and life-threatening illnesses: description and evaluation of a regional, collaborative model for pediatric palliative care
adolescent; Child; Female; Humans; infant; Male; Palliative Care; Terminal Care; referral and consultation; Pediatrics; Health Personnel; Program Evaluation; Continuity of Patient Care; Biomedical Research; Inservice Training; District of Columbia; quality of life; Preschool; Newborn; PEDI Study; Quality of Health Care
The care of children in the U.S. with life-limiting illnesses is inadequate. Misallocated resources, flawed assumptions and models of care, and a lack of appropriate professional education foster a costly, inefficient system that falls short of its true potential. This article details the evolution of a regional, shared approach to address these issues, the District of Columbia Pediatric Palliative Care Collaboration (DCPPCC), and includes its evolution, preliminary clinical results, and assessment of barriers encountered.
Rogers SK; Gomez CF; Carpenter P; Farley J; Holson D; Markowitz M; Rood B; Smith K; Nigra Peter
The American Journal Of Hospice & Palliative Care
2011
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Journal Article
<a href="http://doi.org/10.1177/1049909110380594" target="_blank" rel="noreferrer">10.1177/1049909110380594</a>
Palliative medicine consultation for preparedness planning in patients receiving left ventricular assist devices as destination therapy.
Female; Humans; Male; Family; Withholding Treatment; Aged; Middle Aged; Interdisciplinary Communication; Severity of Illness Index; patient care team; decision making; retrospective studies; advance care planning; DNAR; quality of life; DNAR Outcomes; referral and consultation; Advance Directives; Palliative Care/mt [Methods]; Heart Failure/th [Therapy]; Heart-Assist Devices; Left/th [Therapy]; Right/th [Therapy]; Ventricular Dysfunction
OBJECTIVE: To assess the benefit of proactive palliative medicine consultation for delineation of goals of care and quality-of-life preferences before implantation of left ventricular assist devices as destination therapy (DT)., PATIENTS AND METHODS: We retrospectively reviewed the cases of patients who received DT between January 15, 2009, and January 1, 2010., RESULTS: Of 19 patients identified, 13 (68%) received proactive palliative medicine consultation. Median time of palliative medicine consultation was 1 day before DT implantation (range, 5 days before to 16 days after). Thirteen patients (68%) completed advance directives. The DT implantation team and families reported that preimplantation discussions and goals of care planning made postoperative care more clear and that adverse events were handled more effectively. Currently, palliative medicine involvement in patients receiving DT is viewed as routine by cardiac care specialists., CONCLUSION: Proactive palliative medicine consultation for patients being considered for or being treated with DT improves advance care planning and thus contributes to better overall care of these patients. Our experience highlights focused advance care planning, thorough exploration of goals of care, and expert symptom management and end-of-life care when appropriate.
Swetz K M; Freeman MR; AbouEzzeddine OF; Carter Kari A; Boilson BA; Ottenberg AL; Park Soon J; Mueller PS
Mayo Clinic Proceedings
2011
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Journal Article
<a href="http://doi.org/10.4065/mcp.2010.0747" target="_blank" rel="noreferrer">10.4065/mcp.2010.0747</a>
Pediatric end-of-life decisions when abuse is suspected
Female; Humans; infant; United States; Terminal Care; Parental Consent; referral and consultation; Medical Futility; Withholding Treatment; Life Support Care; Emergency Medical Services; Brain Injuries; Child Abuse; Skull Fractures
Arias JJ; Weise KL
The Virtual Mentor: Vm
2012
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Journal Article
<a href="http://doi.org/10.1001/virtualmentor.2012.14.10.ecas3-1210" target="_blank" rel="noreferrer">10.1001/virtualmentor.2012.14.10.ecas3-1210</a>
A Pilot Study Of The Effectiveness Of Home Teleconsultations In Paediatric Palliative Care
Caregivers/px [psychology]; Palliative Care/mt [methods]; Pediatrics/mt [methods]; Quality Of Life; Remote Consultation/ut [utilization]; Adult; Caregivers; Cohort Studies; Female; Health Services Accessibility; Humans; Male; Middle Aged; Outcome And Process Assessment (health Care); Palliative Care; Palliative Care/st [standards]; Patient Satisfaction; Pediatrics/st [standards]; Pilot Projects; Prospective Studies; Referral And Consultation; Rural Population
We conducted a pilot study to investigate the effectiveness of a home telehealth service for paediatric palliative care consultations. Over a 10 week period, 14 of the 17 caregivers approached to be part of the study agreed to participate. Families were allocated, non-randomly, to a control group (usual care) or an intervention group (usual care with the addition of home telehealth consultations). The primary outcome measure was quality-of-life score. Caregivers were surveyed for up to 99 days following recruitment. A descriptive analysis of the quality-of-life data showed no differences between caregivers in the two groups. However, important lessons were learnt regarding factors which influence the success of studies in this population group, and the domains of caregiver quality-of-life that warrant intervention. Palliative care is complex, and multiple interventions and supports are required if care is to be managed at home. Home telehealth consultations are a feasible and acceptable means of facilitating a palliative care consultation which can reduce the burden on families at a distressing time.
Bradford N; Young J; Armfield NR; Bensink ME; Pedersen LA; Herbert A; Smith AC
Journal Of Telemedicine & Telecare
2012
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
10.1258/jtt.2012.gth103
Trends In Hospital Utilization And Costs Among Pediatric Palliative Care Recipients
Child; Hospital Costs; Hospital Utilization; Only Child; Palliative Care; Pediatric Palliative Care; Referral And Consultation
OBJECTIVE AND BACKGROUND: Few previous studies have explored how pediatric palliative care (PPC) influences hospital utilization. We evaluated this among PPC recipients in a single center. METHODS: This is a retrospective cohort study of 109 patients >/=2 years of age who received PPC consultation at a large quaternary children's hospital from April 2009 to September 2010. We assessed frequencies of hospital admissions and emergency department (ED) visits, use of intensive interventions, and hospital costs. Generalized estimating equations were used to compare outcomes in the two years before and after PPC consultation, stratifying by whether a patient survived two or more years following PPC enrollment. RESULTS: Median age at PPC consultation was 13 years (interquartile range 6-18); 56.0% were male (n = 61), 69.7% white non-Hispanic (n = 76). Fifty-nine percent (n = 64) of patients died during the study period. Overall, annual hospital admission rates decreased from 4.6 (95% confidence interval [CI] 4.0-5.4) before PPC consultation to 3.7 (95% CI 3.4-4.4) after (p = 0.025). Annual ED visits decreased from 0.9 (95% CI 0.7-1.2) to 0.6 (95% CI 0.4-0.8) (p = 0.030). Survivors had significantly decreased hospital admissions [rate ratio (RR) 0.57 (95% CI 0.45-0.73), p < 0.001] and ED visits [RR 0.33 (95% CI 0.20-0.54), p < 0.001]. Decedents had increased intensive care unit use (p = 0.029) but decreased operations (p = 0.002); survivors experienced no change in these outcomes after PPC consultation. Hospital costs remained stable for all (p = 0.929). DISCUSSION: PPC involvement may contribute to decreased hospital and ED use, without escalating costs. These outcomes are most evident in survivors. Hence, PPC may have a measurable long-term impact on hospital use in seriously ill children.
Ananth P; Melvin P; Berry JG; Wolfe J
Journal Of Palliative Medicine
2017
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
<a href="https://doi.org/10.1089/jpm.2016.0496" target="_blank" rel="noreferrer">10.1089/jpm.2016.0496</a>
Advance Care Planning: Outpatient Antenatal Palliative Care Consultation
Outpatients; Referral And Consultation; Adult; Advance Care Planning/organization & Administration; Female; Humans; Infant Newborn; Palliative Care/organization & Administration; Pregnancy; Prenatal Care/organization & Administration
Kukora and colleagues report on their single centre study of antenatal palliative care consultation (APCC) and reveal that this practice—though applied in a limited number of cases—contributed to a greater use of postnatal palliative/comfort care regimens. Additionally, while not altering the ultimate outcome for referred fetuses/ neonates, those who received APCC often died after a shorter in-hospital course. What are we to think of such a practice? How can APCC improve patient, family and staff experiences when a grievous outcome is anticipated?
Carter BS
Archives Of Disease In Childhood. Fetal And Neonatal Edition
2017
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
Affording Opportunities To Discuss Deterioration In Paediatric Palliative Care Consultations: A Conversation Analytic Study
Child; Communication; Family Management; Only Child; Paediatrics; Palliative Care; Prognosis; Referral And Consultation
OBJECTIVE: Discussing the potential deterioration of a child who has a life-limiting condition has recognised benefits for future care, but can be challenging in a clinical context where uncertain illness trajectories are common. Existing research is restricted to indirect forms of evidence such as self-report data from clinicians and families. This study directly explores how discussions about deterioration are managed within actual paediatric palliative care consultations. METHODS: 9 consultations were video recorded in an Australian paediatric palliative care service. Each consultation involved the same paediatric palliative care specialist. Conversation analysis was used to identify and explore recurrent ways in which discussions about deterioration came to be realised. FINDINGS: The study identified two communicative practices used by a paediatric palliative care specialist that afforded opportunities to discuss deterioration: (1) soliciting the family's agenda for the consultation; (2) initiating and maintaining topics where discussing deterioration is a relevant possibility. Across these different practices, a common feature was indirect initiation of discussions about deterioration. This approach made such discussions possible, but without mandating or even suggesting that such discussion must occur. CONCLUSIONS: These communicative practices balance the benefit of discussing deterioration against a recognised importance of allowing discussions to be directed by a child's family. This was achieved by creating opportunities for discussing deterioration, without making such discussions necessary.
Ekberg S; Danby S; Herbert A; Bradford N; Yates P
Bmj Supportive & Palliative Care
2017
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
10.1136/bmjspcare-2016-001130
Screening Criteria Improve Access To Palliative Care In The Picu.
Ipal-icu Project; Unit; Consultation; Pediatrics; Child; Pediatric Intensive-care; Critical Care Medicine; Guidelines; Integrated; Model; Quality Improvement; Delivery Of Healthcare; Intensive Care; Palliative Care; Pediatrics; Referral And Consultation
OBJECTIVES:
To test the ability of palliative care screening criteria to improve access to palliative care services in the PICU and examine the association between palliative care team involvement and ICU and hospital length of stay.
DESIGN:
Prospective interventional quality improvement study.
SETTING:
PICU at a quaternary academic medical center.
PATIENTS:
All patients admitted to the PICU who met criteria for palliative care referral over a 9-month period.
INTERVENTION:
Consensus palliative care consultation criteria were created by pediatric critical care medicine and palliative care providers, and palliative care referral was encouraged for all PICU patients meeting criteria.
MEASUREMENTS AND MAIN RESULTS:
Palliative care referral rates increased significantly after screening criteria implementation. We identified 100 patients who were eligible for palliative care services, and referrals were made for 70 patients (70%). Patients were divided into three groups based on palliative care status: patients new to the palliative care team, patients with an existing palliative care relationship, and patients who did not have a palliative care referral. By the end of study, patients who had an existing relationship with the palliative care team were more likely to still be alive and to have limitations of medical interventions in place, whereas patients who did not have a palliative care referral were more likely to be deceased and to have died in the PICU. After correcting for other factors, including severity of illness, patients who were new to the palliative care team experienced greater delay in palliative care referral and had significantly longer PICU and hospital length of stay than those who were already known to the palliative care team.
CONCLUSIONS:
Palliative care screening criteria are effective tools for improving access to palliative care services in the PICU; however, widespread adoption may produce a significant increase in palliative care demand. The association between an existing palliative care relationship and reduction in resource utilization deserves further investigation as does the perceived benefit of palliative care involvement in the patient, family, and staff experience.
Lutmer JE; Humphrey L; Kempton TM; Moore-Clingenpeel M; Ayad O
Pediatric Critical Care Medicine
2016
Article information provided for research and reference use only. PedPalASCNET does not hold any rights over the resource listed here. All rights are retained by the journal listed under publisher and/or the creator(s).
DOI: 10.1097/PCC.0000000000000848