Palliative Care

Population ageing and the implications these present for care towards the end of life are major public health issues for 21st century. In the line with aging of the population, the pattern of diseases that people suffer and die from is also changing. Palliative care should be an integral part of health care and take place in any setting. Palliative care services are structured in three levels of ascending specialization, referred to the expertise of the staff providing the service: palliative care approach, general palliative care and specialist palliative care. Priority care needs for the three illness trajectories, for short period of evident decline (mostly cancer), for chronic illnesses with intermittent exacerbations and sudden dying (organ system failure), and for slow dwindling (mostly frailty and dementia) are different and specific palliative care services are needed through different length of time

Palliative Care

Population ageing and the implications these present for care towards the end of life are major public health issues for 21st century. In the line with aging of the population, the pattern of diseases that people suffer and die from is also changing. Palliative care should be an integral part of health care and take place in any setting. Palliative care services are structured in three levels of ascending specialization, referred to the expertise of the staff providing the service: palliative care approach, general palliative care and specialist palliative care. Priority care needs for the three illness trajectories, for short period of evident decline (mostly cancer), for chronic illnesses with intermittent exacerbations and sudden dying (organ system failure), and for slow dwindling (mostly frailty and dementia) are different and specific palliative care services are needed through different length of time

Advance care planning, a multi-centre cluster randomised clinical trial: the research protocol of the ACTION study

Background: Awareness of preferences regarding medical care should be a central component of the care of patients with advanced cancer. Open communication can facilitate this but can occur in an ad hoc or variable manner. Advance care planning (ACP) is a formalized process of communication between patients, relatives and professional caregivers about patients’ values and care preferences. It raises awareness of the need to anticipate possible future deterioration of health. ACP has the potential to improve current and future healthcare decision making, provide patients with a sense of control, and improve their quality of life. Methods/Design: We will study the effects of the ACP program Respecting Choices on the quality of life of patients with advanced lung or colorectal cancer. In a phase III multicenter cluster randomised controlled trial, 22 hospitals in 6 countries will be randomised. In the intervention sites, patients will be offered interviews with a trained facilitator. In the control sites, patients will receive care as usual. In total, 1360 patients will be included. All participating patients will be asked to complete questionnaires at inclusion, and again after 2.5 and 4.5 months. If a patient dies within a year after inclusion, a relative will be asked to complete a questionnaire on end-of-life care. Use of medical care will be assessed by checking medical files. The primary endpoint is patients’ quality of life at 2.5 months ost-inclusion. Secondary endpoints are the extent to which care as received is aligned with patients’ preferences, patients’ evaluation of decision-making processes, quality of end-of-life care and cost-effectiveness of the intervention. A complementary qualitative study will be carried out to explore the lived experience of engagement with the Respecting Choices program from the perspectives of patients, their Personal Representatives, healthcare providers and facilitators. Discussion: Transferring the concept of ACP from care of the elderly to patients with advanced cancer, who on average are younger and retain their mental capacity for a larger part of their disease trajectory, is an important next step in an era of increased focus on patient centered healthcare and shared decision-making. Trial registration: International Standard Randomised Controlled Trial Number: ISRCTN63110516. Date of registration: 10/3/2014. Keywords: Advance care planning, Oncology, Quality of life, Medical decision-makin

No Indices of Increased Type 2 Diabetes Risk in Individuals with Reactive Postprandial Hypoglycemia

Reactive postprandial hypoglycemia (RPH) is an understudied condition that lacks clinical definition, knowledge of future health implications, and an understanding of precise underlying mechanisms. Therefore, our study aimed to assess the glycemic response after glucose ingestion in individuals several years after the initial evaluation of RPH and to compare glucose regulation in individuals with RPH vs. healthy volunteers. We assessed the inter- and intra-individual differences in glucose, insulin, and C-peptide concentrations during 5-h oral glucose tolerance tests (OGTTs); the surrogate markers of insulin resistance (HOMA-IR and Matsuda index); and beta-cell function (distribution index and insulinogenic index). The study included 29 subjects with RPH (all females, aged 39 (28, 46) years) and 11 sex-, age-, and body mass index (BMI)-matched controls. No biochemical deterioration of beta-cell secretory capacity and no progression to dysglycemia after 6.4 ± 4.2 years of follow-up were detected. RPH subjects were not insulin resistant, and their insulin sensitivity did not deteriorate. RPH subjects exhibited no differences in concentrations or in the shape of the glucose-insulin curves during the 5-h OGTTs compared to age- and BMI-matched controls. No increased incident type 2 diabetes risk indices were evident in individuals with RPH. This dictates the need for further research to investigate the magnitude of future diabetes risk in individuals experiencing RPH

Development of an international Core Outcome Set (COS) for best care for the dying person : study protocol

Background: In contrast to typical measures employed to assess outcomes in healthcare such as mortality or recovery rates, it is difficult to define which specific outcomes of care are the most important in caring for dying individuals. Despite a variety of tools employed to assess different dimensions of palliative care, there is no consensus on a set of core outcomes to be measured in the last days of life. In order to optimise decision making in clinical practice and comparability of interventional studies, we aim to identify and propose a set of core outcomes for the care of the dying person. Methods: Following the COMET initiative approach, the proposed study will proceed through four stages to develop a set of core outcomes: In stage 1, a systematic review of the literature will identify outcomes measured in existing peer reviewed literature, as well as outcomes derived through qualitative studies. Grey literature, will also be included. Stage 2 will allow for the identification and determination of patient and proxy defined outcomes of care at the end of life via quantitative and qualitative methods at an international level. In stage 3, from a list of salient outcomes identified through stages 1 and 2, international experts, family members, patients, and patient advocates will be asked to score the importance of the preselected outcomes through a Delphi process. Stage 4 consists of a face-to-face consensus meeting of international experts and patient/family representatives in order to define, endorse, and propose the final Core Outcomes Set. Discussion: Core Outcome Sets aim at promoting uniform assessment of care outcomes in clinical practice as well as research. If consistently employed, a robust set of core outcomes for the end of life, and specifically for the dying phase, defined by relevant stakeholders, can ultimately be translated into best care for the dying person. Patient care will be improved by allowing clinicians to choose effective and meaningful treatments, and research impact will be improved by employing internationally agreed clinically relevant endpoints and enabling accurate comparison between studies in systematic reviews and/or in meta-analyses

Content analysis of Advance Directives completed by patients with advanced cancer as part of an Advance Care Planning intervention : insights gained from the ACTION trial

Purpose. Writing an Advance Directive (AD) is often seen as a part of Advance Care Planning (ACP). ADs may include specific preferences regarding future care and treatment and information that provides a context for healthcare professionals and relatives in case they have to make decisions for the patient. The aim of this study was to get insight into the content of ADs as completed by patients with advanced cancer who participated in ACP conversations. Methods. A mixed methods study involving content analysis and descriptive statistics was used to describe the content of completed My Preferences forms, an AD used in the intervention arm of the ACTION trial, testing the effectiveness of the ACTION Respecting Choices ACP intervention. Results. In total, 33% of 442 patients who received the ACTION RC ACP intervention completed a My Preferences form. Document completion varied per country: 10.4% (United Kingdom), 20.6% (Denmark), 29.2% (Belgium), 41.7% (the Netherlands), 61.3% (Italy) and 63.9% (Slovenia). Content analysis showed that \u27maintaining normal life\u27 and \u27experiencing meaningful relationships\u27 were important for patients to live well. Fears and worries mainly concerned disease progression, pain or becoming dependent. Patients hoped for prolongation of life and to be looked after by healthcare professionals. Most patients preferred to be resuscitated and 44% of the patients expressed maximizing comfort as their goal of future care. Most patients preferred \u27home\u27 as final place of care. Conclusions. My Preferences forms provide some insights into patients\u27 perspectives and preferences. However, understanding the reasoning behind preferences requires conversations with patients