Hospital Palliative Care Team Consultations For Patients With Advanced Cancer: Too few, too late?

Palliative care is an approach that improves quality of life of patients and families facing a life-threatening illness. In hospitals, specialist palliative care is often provided by palliative care teams (PCTs). In the Netherlands, the number of PCTs has increased rapidly over the past years. The aim of this thesis was to investigate characteristics of palliative care team consultations for hospitalized patients with incurable cancer and their effect on quality of life, quality of dying and (costs of) care. Furthermore, additional research studies on consultation in palliative and end-of-life-care are described including a study on the developments in end-of-life decision making practices, a study on a specific type consultation, namely consultation of SCEN physicians in case of euthanasia requests and a systematic review on the effects of advance care planning. The thesis concludes with recommendations for clinical practice, policy and future research

Involvement of supportive care professionals in patient care in the last month of life

Background: In the last month of life, many patients suffer from multiple symptoms and problems. Professional supportive care involvement may help to alleviate patients’ suffering and provide them with an optimal last phase of life. Purpose: We investigated how often palliative care consultants, pain specialists, psychological experts and spiritual caregivers are involved in caring for patients in the last month of life, and which factors are associated with their involvement. Methods: Questionnaires were mailed to physicians who had attended the death of a patient from a stratified sample of 8496 deaths that had occurred in 2010 in the Netherlands. The response rate was 74 % (n = 6263). Results: A palliative care team or consultant had been involved in the last month of life in 12 % of all patients for whom death was expected; this percentage was 3 % for pain specialists, 6 % for psychologists or psychiatrists and 13 % for spiritual caregivers. Involvement of palliative care or pain specialists was most common in younger patients, in patients with cancer and in patients who died at home. Involvement of psychological or spiritual caregivers was most common in older patients, in females, in patients with dementia and in patients who died in a nursing home. Involvement of supportive caregivers was also associated with the use of morphine and end-of-life decisions. Conclusion: Supportive care professionals are involved in end-of-life care in about a quarter of all non-suddenly dying patients. Their involvement is related to the setting where patients die, to the patient’s characteristics and to complex ethical decision-making

Palliative care in Dutch hospitals: A rapid increase in the number of expert teams, a limited number of referrals

Background: Palliative care expert teams in hospitals have positive effects on the quality of life and satisfaction with care of patients with advanced disease. Involvement of these teams in medical care is also associated with substantial cost savings. In the Netherlands, professional standards state that each hospital should have a palliative care team by 2017. We studied the number of hospitals that have a palliative care team and the characteristics of these teams. Methods: In April 2015, questionnaires were mailed to key palliative care professionals in all general, teaching and academic hospitals in the Netherlands. Out of 92 hospitals, 74 responded (80 %). Results: Seventy-seven percent of all participating hospitals had a palliative care team. Other services, such as outpatient clinics (22 %), palliative care inpatient units (7 %), and palliative day care facilities (4 %) were relatively scarce. The mean number of disciplines that were represented in the teams was 6,5. The most common disciplines were nurses (72 %) and nurse practitioners (54 %), physicians specialized in internal medicine (90 %) or anaesthesiology (75 %), and spiritual caregivers (65 %). In most cases, the physicians did not have labeled hours available for their work as palliative care consultant, whereas nurses and nurse practitioners did. Most teams (77 %) were only available during office hours. Twenty-six percent of the teams could not only be consulted by healthcare professionals but also by patients or relatives. The annual number of consultations for inpatients per year ranged from 2 to 680 (median: 77). On average, teams were consulted for 0.6 % of all patients admitted to the hospitals. Conclusion: The number of Dutch hospitals with a palliative care team is rapidly increasing. There are substantial differences between teams regarding the disciplines represented in the teams, the procedures and the number of consultations. The development of quality standards and adequate staffing of the teams could improve the quality and effectiveness of the teams

Palliative care consultation services in hospitals in the Netherlands: The design of the COMPASS study

Background: Patients with an advanced incurable disease are often hospitalised for some time during the last phase of life. Care in hospitals is generally focussed at curing disease and prolonging life and may therefore not in all cases adequately address the needs of such patients. We present the COMPASS study, a study on the effects and costs of consultation teams for palliative care in hospitals. This observational study aims to investigate the use, effects and costs of PCT consultation services for hospitalized patients with incurable cancer in the Netherlands. Methods/design: The study consists of 3 parts: 1. A questionnaire, interviews and a focus group discussion to investigate the characteristics of PCT consultation in 12 hospitals. PCTs will register their activities to calculate the costs of PCT consultation. 2. Cancer patients for whom the attending physician would not be surprised that they would die within 12 month will be included in a medical file search in three hospitals. Medical records will be investigated to compare care, treatment and hospital costs between patients with and patients without PCT consultation. 3. In the other nine hospitals, we will perform a longitudinal study, and compare quality of life between 100 patients for whom a PCT was consulted with 200 patients without PCT consultation. Propensity score matching will be used to adjust for differences between both patient groups. Patients will be followed for three months after inclusion. Quality of life will be assessed with the Palliative Outcome Scale, the EuroQol-5d and the EORTC-QLQ-C15 PAL. Satisfaction with care in the hospital is measured with the IN-PATSAT32. The cost impact of PCT consultation will also be explored. Discussion: This is the first multicenter study on PCT consultation in the Netherlands. The study will give valuable insight in the process, effects and costs of PCT consultation in hospitals. It is anticipated that PCT consultation has a positive effect on patients' quality of life and satisfaction with care and will lead to less hospital care costs

Satisfaction with care of hospitalised patients with advanced cancer in the Netherlands

Abstract We aimed to assess the level of satisfaction with hospital care of patients with advanced cancer and its association with quality of life and other patient characteristics. Eligible patients were asked to fill out the EORTC INPATSAT‐32 questionnaire, measuring patient satisfaction, and the EORTC QLQ‐C15‐PAL, measuring quality of life. Factor analysis was performed to identify underlying patterns in satisfaction. Multivariable regression analyses were used to assess associations of quality of life and other patient characteristics with satisfaction. A total of 105 patients participated in the study. The mean general satisfaction score was 72 (SD 21). Factor analysis identified three underlying dimensions: satisfaction with nurses (explaining 62.1% of the total variance), satisfaction with physicians (7.7%) and satisfaction with hospital services (5.3%). Associations were found between global health and general satisfaction (β = 0.35, p = 0.01), and between emotional functioning and satisfaction with hospital services (β = 0.016, p < 0.01). Further, diagnosis of breast cancer was associated with satisfaction with physicians (β = 1.06, p < 0.01) and dyspnoea with satisfaction with hospital services (β = 0.007, p = 0.03). Patients with advanced cancer are reasonably satisfied with hospital care. The INPATSAT‐32 mainly measures satisfaction with nurses. Satisfaction with care and quality of life seems to represent distinct outcomes of hospital care in patients with advanced cancer

Palliative care team consultation and quality of death and dying in a university hospital: A secondary analysis of a prospective study

Purpose Involvement of palliative care experts improves the quality of life and satisfaction with care of patients who are in the last stage of life. However, little is known about the relation between palliative care expert involvement and quality of dying (QOD) in the hospital. We studied the association between palliative care team (PCT) consultation and QOD in the hospital as experienced by relatives. Methods We conducted a secondary analysis of data from a prospective study among relatives of patients who died from cancer in a university hospital and compared characteristics and QOD of patients for whom the PCT was or was not consulted. Results 175 out of 343 (51%) relatives responded to the questionnaire. In multivariable linear regression PCT was associated with a 1.0 point better QOD (95% CI 0.07–1.96). In most of the subdomains of QOD, we found a non-significant trend towards a more favorable outcome for patients for whom the PCT was consulted. Patients for whom the PCT was consulted had more often discussed their preferences for medical treatment, had more often been aware of their imminent death and had more often been at peace with their imminent death. Further, patients for whom the PCT was consulted and their relatives had more often been able to say goodbye. Relatives had also more often been present at the moment of death when a PCT had been consulted. Conclusion For patients dying in the hospital, palliative care consultation is associated with a favorable QOD

Palliative care team consultation and quality of death and dying in a university hospital: a secondary analysis of a prospective study

PURPOSE: Involvement of palliative care experts improves the quality of life and satisfaction with care of patients who are in the last stage of life. However, little is known about the relation between palliative care expert involvement and quality of dying (QOD) in the hospital. We studied the association between palliative care team (PCT) consultation and QOD in the hospital as experienced by relatives. METHODS: We conducted a secondary analysis of data from a prospective study among relatives of patients who died from cancer in a university hospital and compared characteristics and QOD of patients for whom the PCT was or was not consulted. RESULTS: 175 out of 343 (51%) relatives responded to the questionnaire. In multivariable linear regression PCT was associated with a 1.0 point better QOD (95% CI 0.07-1.96). In most of the subdomains of QOD, we found a non-significant trend towards a more favorable outcome for patients for whom the PCT was consulted. Patients for whom the PCT was consulted had more often discussed their preferences for medical treatment, had more often been aware of their imminent death and had more often been at peace with their imminent death. Further, patients for whom the PCT was consulted and their relatives had more often been able to say goodbye. Relatives had also more often been present at the moment of death when a PCT had been consulted. CONCLUSION: For patients dying in the hospital, palliative care consultation is associated with a favorable QOD

The incidence and impact of implantable cardioverter defibrillator shocks in the last phase of life: An integrated review

Background: Although the implantable cardioverter defibrillator is successful in terminating life

Trends in time in the management of the implantable cardioverter defibrillator in the last phase of life: a retrospective study of medical records

Background: The implantable cardioverter defibrillator (ICD) might give unwanted shocks in the last month of life. Guidelines recommend deactivation of the ICD prior to death. Aims: The aims of this study were to examine trends in time (2007–2016) in how and when decisions are made about ICD deactivation, and to examine patient- and disease-related factors which may have influenced these decisions. In addition, care and ICD shock frequency in the last month of life of ICD patients are described. Methods: Medical records of a sample of deceased patients who had their ICD implanted in 1999–2015 in a Dutch university (n = 308) or general (n = 72) hospital were examined. Results: Median age at death was 71 years, and 88% were male. ICD deactivation discussions increased from 6% for patients who had died between 2007 and 2009 to 35% for patients who had died between 2013 and 2016. ICD deactivation rates increased in these periods from 16% to 42%. Presence of do-not-resuscitate (DNR) orders increased from 9% to 46%. Palliative care consultations increased from 0% to 9%. When the ICD remained active, shocks were reported for 7% of patients in the last month of life. Predictors of ICD deactivation were the occurrence of ICD deactivation discussions after implantation (OR 69.30, CI 26.45–181.59), DNR order (OR 6.83, CI 4.19–11.12), do-notintubate order (OR 6.41, CI 3.75–10.96), and palliative care consultations (OR 8.67, CI 2.76–27.21) Conclusion: ICD deactivation discussions and deactivation rates have increased since 2007. Nevertheless, ICDs remain active in the majority of patients at the end of life, some of whom experience shocks

Implantable cardioverter defibrillator deactivation and advance care planning: A focus group study

Objective: Implantable cardioverter defibrillators can treat life-threatening arrhythmias, but may negatively influence the last phase of life if not deactivated. Advance care planning conversations can prepare patients for future decision-making about implantable cardioverter defibrillator deactivation. This study aimed at gaining insight in the experiences of patients with advance care planning conversations about implantable cardioverter defibrillator deactivation. Methods: In this qualitative study, we held five focus groups with 41 patients in total. Focus groups were audio-recorded and transcribed. Transcripts were analysed thematically, using the constant comparative method, whereby themes emerging from the data are compared with previously emerged themes. Results: Most patients could imagine deciding to have their implantable cardioverter def