Palliative care initiated in the emergency department is associated with improved quality of life

A palliative care consultation initiated in the emergency department (ED) for patients with advanced cancer was associated with improved quality of life and did not seem to shorten survival, according to an article published online by JAMA Oncology.

Visits to the ED are common for patients with advanced cancer and it is during these visits that decisions are often made about the intensity of care. Although the availability of palliative care services continues to increase, consultation typically does not happen until a week into a patient’s hospital stay. A consultation initiated from the ED may be an opportunity to ensure that care is congruent with a patient’s wishes and to interrupt the cascade of intensive, end-of-life care that may be a marker of low-quality care.

Corita R. Grudzen, M.D., M.S.H.S., of New York University, and coauthors conducted a randomized clinical trial to compare quality of life, depression, health care utilization and survival in ED patients with advanced cancer randomly assigned to an intervention with an ED-initiated palliative care consultation vs. usual care.

The study included 136 patients: 69 in the palliative care consultation intervention and 67 in usual care, who also may have received a palliative care consultation if it was requested by the admitting team or an oncologist. Among the 69 patients in the intervention, 41 died by the one-year mark, as did 44 of the 67 patients who received usual care.

The authors report that the palliative care consultation intervention was associated with increased quality-of-life scores from study enrollment to week 12 (average increase of 5.91 points in the intervention vs an increase of 1.08 in the usual care group).

Median survival was longer for patients in the intervention (289 days) compared with the usual care group (132 days), although the difference was not statistically significant. The lack of statistical significance was due to the highly variable length of survival in the study group, the authors note.
The authors found no statistically significant differences in depression, admission to the intensive care unit and discharge to hospice. The authors suggest the impact of palliative care on health care utilization was “more nuanced” in their study.

Emergency department-initiated palliative care consultation improved QOL [quality of life] in patients with advanced cancer and does not seem to shorten survival; the impact on health care utilization and depression is less clear and warrants further study,” the study concludes.

Grudzen et al. Emergency Department–Initiated Palliative Care in Advanced Cancer: A Randomized Clinical Trial. JAMA Oncol. Published online January 14, 2016. doi:10.1001/jamaoncol.2015.5252 [Article]

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Patients with advanced, incurable cancer denied palliative care

Many patients with advanced, incurable cancer do not receive any palliative care, reveals new research to be presented later this month at the ESMO 2014 Congress in Madrid, Spain, 26-30 September. The findings are astonishing as they come at the same time as 15 new oncology centres in Europe, Canada, South America and Africa are being awarded the prestigious title of ‘ESMO Designated Centre of Integrated Oncology and Palliative Care.’

Dr Alexandru Grigorescu, medical oncology consultant at the Institute of Oncology Bucharest, Romania, member of the ESMO Palliative Care Working Group, said: “The integration of palliative care in oncology is a challenge. This is especially the case for countries with few resources, where the healthcare budget is low, with insufficient palliative care specialists and some drugs are unavailable as hospitals do not have the funds to buy them.”

ESMO brings a new approach to palliative care, namely by integrating it with specific anticancer treatment conducted in medical oncology departments,” continued Grigorescu. “In this context, we conducted a study to assess palliative care needs and delivery in patients with advanced, incurable cancer.”

The research was conducted in five Romanian and one Swiss institutes. It found that 17% of patients received no palliative care interventions and 26% did not have their symptoms addressed. One-fifth of patients wanted to discuss end-of-life issues with a healthcare professional, but it occurred in just 15% of cases. Only 10% of patients had a care plan.

Grigorescu said: “Our study shows that there are significant gaps in the delivery of palliative care for patients with advanced, incurable cancer. Our findings argue for healthcare decision-makers to increase the budget for palliative care. We hope the study will make a point about the importance of treating patients during this period. In Romania we do not have an independent speciality of palliative care, so it should be the responsibility of medical oncologists.”

ESMO promotes good practice in palliative care for cancer patients through –among others– the ESMO Designated Centres of Integrated Oncology and Palliative Care accreditation programme. The designation recognises that centres have achieved a high standard of integration of medical oncology and palliative care and is valid for three years.

Prof Nathan Cherny, former chair of the ESMO Palliative Care Working Group and initiator of the Designated Centres programme, said: “The ESMO Designated Centres programme is the premier initiative worldwide for providing incentives and a structured model to enable centres to develop integrated programmes in oncology and palliative care. The ESMO designation is widely recognised and indicates that the centre has made philosophical and infrastructural commitments to meet the physical and psychological challenges of patients and families with advanced cancers.

Cherny, an oncologist and palliative medicine specialist who is chair of humanistic medicine at Shaare Zedek Medical Centre, Jerusalem, Israel, added: “The designation also indicates that the centre is not only providing a clinical service but that it has programmes developed both to push the boundaries of knowledge through research and to teach the essential skills required for the provision of palliative care to cancer patients.”

Since the programme began in 2003, the Designated Centre accolade has been awarded to 175 centres, of which 25 are in resource and/or regulation restrictive countries. In addition to the 15 new centres joining the prestigious group this year, 44 centres have achieved reaccreditation.

Commenting on ESMO’s activities in the field of palliative care, Cherny said: “ESMO has a 15 year history of a commitment to the improvement of the quality of palliative care for cancer patients in Europe and around the world. ESMO was the first major oncology organisation to develop a dedicated working group to this task, and to develop policies for individual clinicians, for cancer centres and for the training of oncologists. ESMO has researched its own membership to identify deficits in knowledge and practice and has developed educational tools to address the shortcomings that were identified.”

ESMO has been a leading player in identifying barriers to the availability and accessibility of essential pain relieving medication in Europe and in the developing world. Cherny said: “The findings from the Global Opioid Policy Initiative (GOPI) study have major policy implications that are relevant to over five billion of the world’s population. We are working with our partners to promote legislative reforms to guarantee that all patients have access to affordable, effective pain medication to relieve the tragedy of needless suffering caused by undertreated cancer pain.”

To promote better care for patients with advanced cancer ESMO published a guide for patients and their families and a companion volume for oncologists. The ESMO Guidelines Working Group is developing evidence-based clinical practice guidelines to assist oncologists in the provision of palliative care. This month three new guidelines have been published. Cherny said: “Together these publications help patients with advanced and incurable cancer ask appropriate questions and have meaningful discussions with their oncologist that lead to coordinated and holistic care. The patient book has been translated into 11 languages and is an invaluable resource.”

With its strong commitment to research, best practice and palliative care, ESMO has become a key partner in palliative care initiatives,” added Rolf A. Stahel, ESMO President.

Cherny concluded: “Palliative care has been a central part of ESMO’s work in research, education and public health policy initiatives both in Europe and around the world. This year’s new and reaccredited ESMO Designated Centres will ensure that more patients with cancer receive appropriate, high quality palliative care along with the best of their cancer care – and this makes a difference.

ESMO 2014 Congress in Madrid, Spain, 26-30 September.

Further Information 

A guide for patients with advanced cancer: Getting the most out of your oncologist: http://www.esmo.org/Patients/Getting-the-Most-out-of-Your-Oncologist

User’s manual for oncology clinicians: http://oncologypro.esmo.org/Publications/User-s-Manual-for-Oncology-Clinicians

Many patients in cancer centers may not experience a dignified death

A new study that surveyed physicians and nurses in hospitals within cancer centers in Germany suggests that many patients there do not experience a dignified death. Published early online in Cancer, a peer-reviewed journal of the American Cancer Society, the study indicates the need for cancer centers to invest more in palliative care services, adequate rooms for dying patients, staff training in end-of-life care, and advance-care-planning standards.

Previous research has shown that hospitals are often ill-prepared to provide care for dying patients. To investigate whether the circumstances for dying on cancer center wards allow for a dignified death, Karin Jors, MA, of the University Medical Center Freiburg, and her colleagues surveyed physicians and nurses in 16 hospitals belonging to 10 cancer centers in Baden-Württemberg, Germany. The survey addressed topics regarding end-of-life care including structural conditions such as rooms and staff, education/training, working environment, family/caregivers, medical treatment, communication with patients, and dignified death.

Among 1131 survey respondents, 57 percent believed that patients could die with dignity on their ward. Half of the survey staff members indicated that they rarely have enough time to care for dying patients, and 55 percent found the rooms available for dying patients unsatisfactory. Only 19 percent of respondents felt that they had been well-prepared to care for dying patients (and only 6 percent of physicians felt so). Palliative care staff reported much better conditions for dying patients than staff from other wards, with 95 percent of palliative care staff indicating that patients die with dignity on their wards. Generally, physicians perceived the circumstances for dying patients much more positively than nurses, especially regarding communication and life-prolonging measures. While 72 percent of physicians reported that patients can usually die a dignified death on their ward, only 52 percent of nurses shared this opinion.

In our ageing society, it is predicted that the number of hospital deaths will continue to rise in the coming years, and many of these deaths will be attributable to cancer. For this reason, it is particularly important that cancer centers strive to create a comfortable, dignified experience for dying patients and their families,” said Jors. “Above all, this requires that staff members are provided with the adequate resources to care for these patients.”

The investigators encourage the integration of palliative care into standard oncology care, beginning as early as diagnosis. They also note that physicians and nurses would benefit from increased education and training in end-of-life care. To promote the development of standards for end-of-life care, establish a comprehensive palliative care curriculum for health care staff, and to encourage further research in this field, the Palliative Care Center of Excellence in Baden-Württemberg (KOMPACT) was established in 2014. “This center combines the expertise of five academic, specialist palliative care departments. We believe that this cooperation is a valuable tool for improving patient care in the end-of-life setting,” said Jors.

Jors et al., (2014). Dying in cancer centers: Do the circumstances allow for a dignified death? Cancer, EPub Ahead of Print, DOI: 10.1002/cncr.28702 [Abstract]

Social network may improve care for cancer patients

Several chemotherapy patients at the UC Davis Comprehensive Cancer Center will be invited to use tablets with a unique social networking tool as part of their treatment plan. Researchers at the Betty Irene Moore School of Nursing at UC Davis hope to prove that mobile health technology improves the care experience for patients as well as the quality of care while also reducing cost.

The project is part of a two-year, $199,854 grant from the McKesson Foundation and its national Mobilizing for Health Initiative. Research on mobile health technology in cancer care is new, said Jill Joseph, the associate dean for research at the nursing school. Other cancer-related mobile applications are available, but are limited to education and awareness and don’t provide disease management tools or real-time communication.

We have ample evidence that cancer patients often receive fragmented care, experience significant distress, and may needlessly require care in emergency departments or inpatient settings, particularly during chemotherapy,” Joseph said. “Little research and development has focused on providing novel technologies to support cancer care coordination.

Participating patients will use a tablet device, such as a Google Nexus or iPad, to connect to their unique and private Personal Health Network that includes a nurse coordinator — who manages the their care — along with family, caregivers, clinicians and other desired partners. These people can connect with one another through real-time messaging, video and audio components as well as schedule appointments, assign tasks, store and track information and more.

A nurse coordinator is assigned to support each chemotherapy patient who uses the mobile application. This coordinator monitors the patient’s care plan, triages issues and communicates with caregivers. Unlike electronic health records and other information systems common in hospitals, the social networking platform allows patients, their families and caregivers to not only access information but communicate with another and make decisions about care and health management.

This is a new tool designed with the patient and family at the center of care,” said Katherine Kim, a recent doctoral graduate of the UC Davis nursing school who is now a visiting faculty member and project director.

For example, a chemotherapy patient might message her nurse coordinator that she’s not doing well that day, and feels nauseous and anxious. The nurse can then communicate with the patient to further assess the situation, communicate with other caregivers, and work with the patient to address the issues or take other steps such as reschedule appointments or review current medications.

Developed by private technology partner Tiatros, the social networking platform is different from other social media sites, like Facebook and LinkedIn, because it complies with health privacy laws and operates securely.

I’m excited about bringing nursing research into the Cancer Center. I’m especially excited for our patients to have an opportunity to be part of this project,” said Kerri Stuart, a nurse manager at the Cancer Center. “Learning you have cancer is overwhelming and the thought of chemotherapy is often terrifying. This is a tool that empowers patients and provides access to information when they need it, not just when the clinic is open.

Research team members will interview patients after they have used the program for six months to determine how their health, the delivery of care and their need for emergency or inpatient care was affected. The team includes nursing faculty from the School of Nursing as well as oncology nurses, social workers, and physicians from the UC Davis Comprehensive Cancer Center.

The study is the first funded project resulting from the development of the UC Davis Collaborative Cancer Care Research Group, a multidisciplinary team of experts who hope to develop technology-enabled solutions that improve the quality, accessibility and affordability of cancer care.