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Simple Summary
Timely palliative care is palliative care personalized based on patients’ needs and delivered at the optimal time and setting. It involves a systematic process to identify patients with high supportive care needs and referring these individuals to specialist palliative care in a timely manner based on standardized referral criteria....
Contexts in source publication
Context 1
... lack of consensual referral criteria in the past partly explained the heterogenous pattern of referral. Several referral criteria for outpatient palliative care have been proposed since ( Table 2). ...Context 2
... 2017, we conducted a Delphi study to identify consensual referral criteria for outpatient palliative care among 60 international experts [66]. Panelists reached consensus on 11 major criteria for referral (Table 2)-the presence of any criterion would be sufficient reason for a patient to be referred. Importantly, 9 of these 11 criteria were needs-based instead of time-based. ...Context 3
... the referral criteria need to be followed strictly? The referral criteria in Table 2 provide a starting point for some key triggers to an outpatient palliative care referral. However, the specific criteria set and cutoff should be tailored to each institution based on discussions between the oncology and palliative care teams. ...Similar publications
Background:
Most efforts to identify caregivers for research use passive approaches such as self-nomination. We describe an approach in which electronic health records (EHRs) can help identify, recruit, and increase diverse representations of family and other unpaid caregivers.
Objective:
Few health systems have implemented systematic processes...
Citations
... Certainly, there can be a stigma associated with palliative care to include "end-of-life care" which may delay referral, and other reservations about initiating referral to avoid reducing hope for patients and families. A model of timely palliative referral considers four elements: establishment of institution-speci c criteria, system triggers for referral, routine screening for supportive care needs, and availability of outpatient palliative care resources [29]. This model is cited as being used for oncology care but can be applied appropriately to cardiac patients as well. ...
Background
Evidence suggests that pediatric palliative care (PPC) is beneficial to medically complex patients. Historically, PPC involvement has been overlooked or delayed and varies by institution but PPC awareness has increased in cardiovascular ICUs (CVICU) and so we investigated frequency and timeliness of PPC referral for patients dying in ICU.
Methods
Retrospective study of pediatric cardiac patients experiencing death in ICU to review PPC presence and timing of initial PPC, most recent PPC, and interventions, therapies, CPR, and presence of do-not-resuscitate DNR discussion.
Results
Fifty-four patients died during a 5-year period aged 11d – 17y (54% male). PPC consultation occurred in 74%. Retroactive application of Center to Advance Palliative Care (CAPC) guidelines, revealed 79% of patients without PPC would have qualified for consultation. Of eligible patients, 67% had PPC within 7 days of death (DOD). Of PPC patients, 50% had PPC on DOD, however for 10% this was their initial PPC. DNR discussion was more likely in PPC patients (63% vs 14%; p = 0.0011), though often only on DOD. Comparing prior to DOD, PPC patients were still more likely to have DNR discussion (55% vs 0%; p = 0.0003). PPC patients were no less likely to have CPR on DOD (28% vs 43%, p = 0.29).
Conclusions
PPC occurred frequently in patients experiencing death in CVICU. However, frequently the initial PPC occurred within a week or day of death. Patients without PPC would often qualify under published guidelines. Standardization, timing, and patient identification for PPC will expand efficacy in CVICU.
... These preliminary findings suggest that palliative care case conferences are promising for this group of patients, but that the timing of the intervention may be critical to its success [19,32]. While research has been investigating the early versus timely onset of palliative care, there is large evidence for the benefit of palliative care services [33]. Nevertheless, studies with interventions focusing on integrating non-cancer patients into SPHC have been scarce. ...
Background
Patients with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and dementia are underrepresented in specialist palliative home care (SPHC). However, the complexity of their conditions requires collaboration between general practitioners (GPs) and SPHC teams and timely integration into SPHC to effectively meet their needs.
Objective
To facilitate joint palliative care planning and the timely transfer of patients with advanced chronic non-malignant conditions to SPHC.
Methods
A two-arm, unblinded, cluster-randomised controlled trial. 49 GP practices in northern Germany were randomised using web-based block randomisation. We included patients with advanced CHF, COPD and/or dementia. The KOPAL intervention consisted of a SPHC nurse–patient consultation followed by an interprofessional telephone case conference between SPHC team and GP. The primary outcome was the number of hospital admissions 48 weeks after baseline. Secondary analyses examined the effects on health-related quality of life and self-rated health status, as measured by the EuroQol 5D scale.
Results
A total of 172 patients were included in the analyses. 80.4% of GP practices had worked with SHPC before, most of them exclusively for cancer patients. At baseline, patients reported a mean EQ-VAS of 48.4, a mean quality of life index (EQ-5D-5L) of 0.63 and an average of 0.80 hospital admissions in the previous year. The intervention did not significantly reduce hospital admissions (incidence rate ratio = 0.79, 95%CI: [0.49, 1.26], P = 0.31) or the number of days spent in hospital (incidence rate ratio = 0.65, 95%CI: [0.28, 1.49], P = 0.29). There was also no significant effect on quality of life (∆ = −0.02, 95%CI: [−0.09, 0.05], P = 0.53) or self-rated health (∆ = −2.48, 95%CI: [−9.95, 4.99], P = 0.51).
Conclusions
The study did not show the hypothesised effect on hospitalisations and health-related quality of life. Future research should focus on refining this approach, with particular emphasis on optimising the timing of case conferences and implementing discussed changes to treatment plans, to improve collaboration between GPs and SPHC teams.
... Another consequence of using active treatment in the last months of life is delayed referral for palliative care in situations where early palliative care is not the standard approach, owing to misconceptions about its appropriate integration in the management of patients with advanced breast cancer [23]. Indeed, we found concerning evidence of insufficient access to palliative care, which confirms findings from previous Italian reports [5,24]. Palliative home care was provided to just over half of the patients (52%), and palliative care evaluations were performed in 13.9% of the patients. ...
Objectives
To better understand the type of care offered to Italian patients with advanced breast cancer at the End-of-Life (EoL), we conducted a retrospective observational study. EoL was defined as the period of six months before death.
Methods
One hundred and twenty-one patients with advanced breast cancer (ABC) treated at IRCCS San Martino Policlinic Hospital who died between 2017 and 2021 were included. Data about patient, disease, and treatment characteristics from breast cancer diagnosis to death, along with information about comorbidities, medications, imaging, specialist evaluations, hospitalization, palliative care and home care, hospice admissions, and site of death were collected.
Results
98.3% of the patients received at least one line of active treatment at EoL; 52.8% were hospitalized during the selected period. Palliative (13.9%), psychological (7.4%), and nutritional evaluations (8.2%) were underutilized. Palliative home care was provided to 52% of the patients. Most of the patients died at home (66.1%) and fewer than one out of five (18.2%) died at the hospital. Among the patients who died at home, 27.3% had no palliative support.
Conclusions
Our findings indicate that palliative care in EoL breast cancer patients is still inadequate. Only a minority of patients had psychological and nutritional support While low nutritional support may be explained by the fact that typical symptoms of ABC do not involve the gastrointestinal tract, the lack of psychological support suggests that significant barriers still exist. Data on the site of death are encouraging, indicating that EoL management is increasingly home centered in Italy.
... Our findings resonate with evidence from other research and suggest that there is a need to improve education and knowledge about palliative care and hospice care among patients and families. In addition, superior support from senior medical officers also greatly promoted the occurrence of referrals, as a previous study found that implementation of timely palliative care at each institution requires oncology leadership support(Hui et al., 2022). Our research shows that collaboration between healthcare providers is important for early palliative care intervention and smooth referral. ...
... Facilitated communication among professionals from different medical institutions helps to initiate palliative care referral early(Schenker et al., 2014). study also incorporated factors perceived by healthcare providers, namely perceived behavioural control, including palliative care resources and systems, disease trajectory and culture and bias.Hui et al. (2022) found that adequate palliative care infrastructure, integration of electronic health record and customization of referral criteria serve as facilitators for palliative care referrals. Currently, the lack of palliative care education and training among professionals is the primary reason for the insufficient palliative care resources and ...
Background:
Early referral to palliative care has been viewed as providing opportunity for accomplishing end-of-life care goals of life closure, comfortable dying and effective grieving. However, previous studies have shown that palliative care referrals are being made too late. Healthcare providers play important role in helping terminally ill patients to early access and being referred to palliative care. It is necessary to understand healthcare providers' attitudes on palliative care referral and associated factors regarding referrals.
Objectives:
This review aimed to identify and synthesise healthcare providers' attitudes and associated factors on palliative care referrals systematically.
Design:
A systematic review of qualitative evidence and meta-aggregation was conducted and guided according to PRISMA guideline.
Data sources:
PubMed, CINAHL, PsycINFO, EMBASE, Web of Science and Cochrane databases from inception to 24 October 2022.
Results:
Database searches yielded 5856 references. Twenty-two studies met eligibility criteria and of moderate to high methodological quality were included. Studies occurred in USA, UK, Australia and France with 716 healthcare providers participants were included. A total of 378 codings were finally extracted and integrated into 41 categories, forming three synthesised findings: (1) Healthcare providers' attitudes towards palliative care referrals, (2) the influence of subjective norms on palliative care referral behaviour and (3) perceived behavioural control on palliative care referral behaviour.
Conclusion:
This review demonstrates a series of factors that affect the palliative care referrals, including the attitudes of healthcare providers, the participation of patients and families, the support of colleagues and supervisors, inter-professional collaboration, the availability of hospice resource, disease trajectory and socio-economic factors. Further research that addresses these factors and design relevant trainings on improving healthcare providers' attitudes, enhancing patient and family engagement, strengthening support networks and optimising resource allocation may aid to meet increasing demands of patients.
Relevance to clinical practice:
This review not only guides healthcare providers in making better decisions about patient referrals by identifying and addressing barriers but also aids in the development of effective interventions that facilitate the early initiation of referrals.
Patient or public contribution:
No patient or public contribution.
... Furthermore with the increase in the numbers of people living with chronic illness globally [49] arguably the formal adoption of palliative care needs screening in all health care settings may not only reduce patient distress but may assist health care managers and policy makers to more appropriately plan services [50]. Identifying needs early in the illness trajectory may allow appropriate personalised care and services to be provided in a timely and cost effective manner thus avoiding health crises at the end of life [51]. ...
... The SPICT™ has scope to be tested in other patient cohorts. Specifically more work is required to extend and test its use in acute care settings where the demand for palliative care is rising and appropriate timely referrals to specialist palliative care are vital to avoid unnecessary distress [51]. Similarly, there are research opportunities such as reliability and validity testing in relation to the SPICT-4ALL™ version which has been specifically designed to be used by family and informal carers. ...
Background
In order to mitigate the distress associated with life limiting conditions it is essential for all health professionals not just palliative care specialists to identify people with deteriorating health and unmet palliative care needs and to plan care. The SPICT™ tool was designed to assist with this.
Aim
The aim was to examine the impact of the SPICT™ on advance care planning conversations and the extent of its use in advance care planning for adults with chronic life-limiting illness.
Methods
In this scoping review records published between 2010 and 2024 reporting the use of the SPICT™, were included unless the study aim was to evaluate the tool for prognostication purposes. Databases searched were EBSCO Medline, PubMed, EBSCO CINAHL, APA Psych Info, ProQuest One Theses and Dissertations Global.
Results
From the search results 26 records were reviewed, including two systematic review, two theses and 22 primary research studies. Much of the research was derived from primary care settings. There was evidence that the SPICT™ assists conversations about advance care planning specifically discussion and documentation of advance care directives, resuscitation plans and preferred place of death. The SPICT™ is available in at least eight languages (many versions have been validated) and used in many countries.
Conclusions
Use of the SPICT™ appears to assist advance care planning. It has yet to be widely used in acute care settings and has had limited use in countries beyond Europe. There is a need for further research to validate the tool in different languages.
... Policy formulation is essential for guiding the acceptance process and ensuring transparency and consistency in referrals [9]. Defining specific criteria for patient acceptance based on various programs and specialties directs patients to the most appropriate care setting [3]. ...
... This ensures improved accessibility for external parties and demonstrates an acknowledgment of the contemporary digital landscape in which we operate. This aligns with trends in the digitalization of healthcare and the empowerment of patients through online resources [9,10,15,16]. The development of informative and userfriendly orientation materials is a significant improvement. ...
... The proposed strategy aims to enhance referral efficiency by implementing standardized procedures, which can reduce errors, minimize delays, and improve overall effectiveness. This mirrors the quality improvement strategies frequently recommended in healthcare literature, with the objective of optimizing patient care pathways [20,3,9]. ...
Objective:
This study aimed to enhance the efficiency of the referral system at the Sultan Qaboos Comprehensive Cancer Care and Research Centre (SQCCCRC) in Muscat, Oman by reducing the average time for new patients' acceptance and the delay between patient acceptance and their first appointment.
Methods:
A one-group pretest-posttest quasi-experimental project was conducted from Quarter 2 of 2022 to Quarter 2 of 2023. Data collected during the pretest and posttest phases were compared to evaluate the impact of interventions on the average days for patient acceptance and the time to first appointment after acceptance. The intervention involved developing a comprehensive referral system incorporating technology development, improved accessibility, orientation materials, internal training, policy formulation, criteria definition, and tailoring acceptance criteria to specialty programs. Awareness campaigns were also conducted to educate patients about the referral process and available transportation options. The project followed the FOCUS PDCA (Find, Organize, Clarify, Understand, Select, Plan, Do, Check, Act) approach for implementation.
Result:
Significant improvements were observed in the oncology referral process, with the average days for patient acceptance decreasing from 4.3 days to 1.3 days post-implementation. Statistical analysis confirmed the significance of this change (F-value = 46.25, p < .0001). Similarly, the average days to first visit appointment after acceptance decreased from 8.6 days to 4.0 days, with statistical support (F-value = 6.29, p < .0).
Conclusion:
This study represents a significant advancement in optimizing the oncology referral process. When considered in conjunction with previous research findings, it underscores the importance of ongoing efforts to enhance efficiency in patient referrals.
... At present, the model considered optimal by most authors is targeted referral. It is based on the consensus of the criteria of referral to EPC, which prioritizes early care for patients with PC needs of greater complexity [26][27][28]. ...
... In a context in which healthcare resources are not unlimited, a controversial point is the model of referral to EPC (systematic, on-demand or targeted). At present, many experts consider that the targeted referral model based on systematic evaluation of the specific needs of each patient is the most appropriate [26][27][28]. Targeted referral is based on criteria of consensus among the referent teams and of EPC, the goal of which is to ensure that all patients receive PC that is adapted to their needs and avoid unnecessary activation of specialized PC resources in cases of low complexity. One indispensable condition of the targeted referral model is that the reference healthcare teams must maintain and promote the basic competencies of PC. ...
... Secondary PC is provided by specialized professionals, which in this case are from Oncology, in which basic PC is added to the advanced competencies in the evolutionary complications of cancer and the toxicity of the treatments [16,57,58]. Lastly, tertiary PC is provided by multidisciplinary teams specialized in EPC that support the Primary Care and specialized teams in a model of shared care focused on cases with greater needs [26][27][28][59][60][61][62]. It is reasonable to think that the identification of patient profiles based on PC complexity may be of great utility as a criterion of targeted referral and for the management of the intensity of care shared among the referent and specialized teams. ...
Simple Summary
The World Health Organisation (WHO) has urged all health organizations to develop programs specifically aimed at integrating palliative care (PC) into existing services, based on a model of shared care from the time of diagnosis and alongside life-prolonging treatments. In a context where the resources of multidisciplinary teams specialized in early palliative care (EPC) are not unlimited, it is very important to reach a consensus on appropriate referral criteria so that all patients who need it receive adequate support in terms of quality and intensity, and that specialized resources are not disproportionately used for those cases with less need. Therefore, in the shared care model proposed by the WHO, identifying the complexity of PC needs is a key aspect in defining the appropriate referral criteria. The PALCOM scale is a five-domain multidimensional assessment tool specifically designed and validated to identify the complexity of the needs of patients with advanced cancer. The study we now present, based on pooled data from the development and validation cohorts, confirms the high predictive ability of the PALCOM scale to identify the level of complexity of needs. The data from this study show that higher levels of complexity are significantly associated with greater instability, healthcare resource use and mortality. This study also highlights the importance of identifying the complexity profiles to optimize the targeted referral and management of the intervention intensity by EPC teams.
Abstract
Introduction: Identifying the complexity of palliative care needs is a key aspect of referral to specialized multidisciplinary early palliative care (EPC) teams. The PALCOM scale is an instrument consisting of five multidimensional assessment domains developed in 2018 and validated in 2023 to identify the level of complexity in patients with advanced cancer. (1) Objectives: The main objective of this study was to determine the degree of instability (likelihood of level change or death), health resource consumption and the survival of patients according to the level of palliative complexity assigned at the baseline visit during a 6-month follow-up. (2) Method: An observational, prospective, multicenter study was conducted using pooled data from the development and validation cohort of the PALCOM scale. The main outcome variables were as follows: (a) instability ratio (IR), defined as the probability of level change or death; (b) emergency department visits; (c) days of hospitalization; (d) hospital death; (e) survival. All the variables were analyzed monthly according to the level of complexity assigned at the baseline visit. (3) Results: A total of 607 patients with advanced cancer were enrolled. According to the PALCOM scale, 20% of patients were classified as low complexity, 50% as medium and 30% as high complexity. The overall IR was 45% in the low complexity group, 68% in the medium complexity group and 78% in the high complexity group (p < 0.001). No significant differences in mean monthly emergency department visits (0.2 visits/ patient/month) were observed between the different levels of complexity. The mean number of days spent in hospital per month was 1.5 in the low complexity group, 1.8 in the medium complexity group and 3.2 in the high complexity group (p < 0.001). The likelihood of in-hospital death was significantly higher in the high complexity group (29%) compared to the medium (16%) and low (8%) complexity groups (p < 0.001). Six-month survival was significantly lower in the high complexity group (24%) compared to the medium (37%) and low (57%) complexity groups (p < 0.001). Conclusion: According to the PALCOM scale, more complex cases are associated with greater instability and use of hospital resources and lower survival. The data also confirm that the PALCOM scale is a consistent and useful tool for describing complexity profiles, targeting referrals to the EPC and managing the intensity of shared care.
... 7 Some signs and symptoms of compassion fatigue are exhaustion, anger, irritability, negative coping behaviors, alcohol and drug use, decreased job satisfaction, absenteeism, difficulty in decision-making in caring for others (it could be negligent), 8 alterations in professional's ability to empathize, dissociative behaviors, and constant psychological distress, 5 and avoidance behaviors. 9 Furthermore, compassion fatigue can contribute to an increase in medical mistakes, hinder effective communication within the healthcare team, 7 and act as a barrier to providing proper PC. 10 Empathy, resilience, and hope are personal protective factors against compassion fatigue. 5 Providers who empathize with patients and develop strong relationships perceive their work as more meaningful. ...
Objective
To explore the experiences that significantly impact the professional quality of life of people providing palliative care (PC) in Ecuador.
Design
Observational cross-sectional qualitative research.
Methods
In September 2022, 10 focus groups were carried out in four cities in Ecuador; each group lasted from 1 to 2 h, was audio recorded, and transcribed verbatim. Recruitment was conducted through convenience sampling, and a total of 71 individuals (15 students, 50 professionals, and 6 volunteers) linked to PC participated. Content analysis with a phenomenological and inductive approach was used to analyze the data.
Results
People recognized their experiences in PC as having positive and negative impacts on their professional quality of life. Experiences were mapped as affecting them at individual, relational, and contextual levels. These experiences included personal growth, opportunity to provide care, teamwork, death-related issues, inability to deal with work-related stress, social acceptance of PC, and dealing with inefficient health systems, among others.
Conclusion
Despite the positive emotions that arise with caring for others, individuals working and volunteering in PC experience situations that influence their professional quality of life. Addressing these factors to increase satisfaction and ease the burden of PC work is essential. Undergraduate education, continuous professional training, and PC teams should incorporate actions to address these factors at all levels, such as teaching coping skills, fostering social support, and increasing awareness of PC.
... Palliative care requires skilled physicians, nurses, psychologists, and social workers, all of whom form the basis of the palliative team [3], thus providing and incorporating a multidisciplinary and coordinated healthcare plan for the patients in advanced stages of a disease [4]. Its timely initiation is essential to ensure both the quality and accessibility of the palliative cancer care plan, particularly so because it requires speci c conditions that may be dictated by the treatment's environment, i.e. inpatient or outpatient settings [5,6,7]. Therefore, the qualitative aspect and intervention cost-effectiveness depend in great part upon the correct identi cation and prioritization of the necessary care [8][9][10], which may be limited by its scope and availability. ...
Background
The purpose of palliative medicine is to achieve and maintain the best possible quality of life for patients and support their families, relatives, and friends. Therefore, we conducted a case-control observational retrospective study evaluating the economic burden of nutritional intervention during ambulatory palliative oncology care, aiming to implement the obtained data to the quality of healthcare.
Methods
A comparison of total expenses per patient was made between the three groups of patients, i.e., Group A – 256 patients with systematic nutritional intervention during 2020-22, Group B − 1393 patients treated during 2020-22, and Group C – 940 patients without systematic nutritional intervention during in 2017-19. The expense analysis was performed using mixed methods monitoring nutritional intervention, i.e. medical records, laboratory tests, and insurance bills from the palliative oncology clinic. The collected data included four categories (direct and indirect cost): nutritional supplements, other medical expenses, requested care, and other care. The qualitative costs and benefits analyses were done within the CBA method framework, i.e. online interviews of relevant stakeholders who were involved in the process of nutritional measures.
Results
The Mann–Whitney U-test showed significant (P < 0.001) differences between the tested groups, with the lowest median of total expenses in Group B (2,921 CZK) and the highest in Group A (16,692 CZK), demonstrating a significant reduction in total expenses. The same was observed in the comparison between Group C (4,923 CZK) and Group B (2,921 CZK) during 2020-22.
Conclusion
The present study proves that nutritional intervention, and the related modifications in palliative treatment, benefit the patients and reduce the overall costs of healthcare.
... There is increasing demand for primary care practitioners to play a key role in palliative care delivery. Primary care practitioners can facilitate timely and appropriate access to specialized palliative care services, however, the highly individualized and idiosyncratic nature of decision-making around referral to palliative care emphasizes the need for research on how specialists communicate palliative care decisions [20]. ...
... However, there are diverse variables that can impede or promote the referral process. It is, therefore, necessary that continuous research is conducted among physicians to support and educate them for the provision of high-quality palliative and end-of-life care [20,24,25]. ...
... Data was collected using self-administered questionnaires. The questionnaire was developed by the researchers through an extensive review of related literature and modified according to an instrument used in past surveys [20,24,26,27]. The questionnaire sought to elicit responses from physicians who were involved in referrals of any case (including cancers, terminal stages of other non-communicable diseases, tuberculosis, AIDS etc.) for palliative care. ...
Background
The need for primary care physicians to be heavily involved in the provision of palliative care is growing. International agencies and practice standards advocate for early palliative care and the use of specialized palliative care services for patients with life-threatening illnesses. This study was conducted to investigate physicians’ referral practices and perceived barriers to timely referral at the Korle Bu Teaching Hospital.
Methods
A cross-sectional study design was employed using a convenience sampling technique to recruit 153 physicians for the study. Data on socio-demography, referral practices, timing and perceived barriers were collected using a structured questionnaire. Binary Logistic regression using crude and adjusted odds was performed to determine the factors associated with late referral. Significance was set at p < 0.05.
Results
The prevalence of late referral was reported to be 68.0%. There were poor referral practices among physicians to palliative care services, and the major barriers to late referral were attributed to the perception that referring to a palliative care specialist means that the physician has abandoned his patient and family members’ decisions and physicians’ personnel choices or opinions on palliative care.
Conclusion
The healthcare system needs tailored interventions targeted at improving physicians’ knowledge and communication strategies, as well as tackling systemic deficiencies to facilitate early and appropriate palliative care referrals. It is recommended that educational programs be implemented, palliative care training be integrated into medical curricula and culturally sensitive approaches be developed to address misconceptions surrounding end-of-life care.
