How can primary care enhance end-of-life care for liver disease?

Qualitative study of general practitioners’ perceptions and experiences | BMJ Open

Liver disease is the third most common cause of premature death in the UK. The symptoms of terminal liver disease are often difficult to treat, but very few patients see a palliative care specialist and a high proportion die in hospital. Primary care has been identified as a setting where knowledge and awareness of liver disease is poor. Little is known about general practitioners’ (GPs) perceptions of their role in managing end-stage liver disease.

GPs expressed a desire to be more closely involved in end-of-life care for patients with liver disease but identified a number of factors that constrained their ability to contribute. These fell into three main areas; those relating directly to the condition, (symptom management and the need to combine a palliative care approach with ongoing medical interventions); issues arising from patients’ social circumstances (stigma, social isolation and the social consequences of liver disease) and deficiencies in the organisation and delivery of services. Collaborative working with support from specialist hospital clinicians was regarded as essential, with GPs acknowledging their lack of experience and expertise in this area.

Full reference: Standing, H. et al. (2017) How can primary care enhance end-of-life care for liver disease? Qualitative study of general practitioners’ perceptions and experiences. BMJ Open. 7:e017106.

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How well do we currently care for our dying patients in acute hospitals

The aim of this study was to evaluate quality of care provided to dying patients and their families in acute hospitals from the perspective of bereaved relatives | BMJ Supportive & Palliative Care

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Background: The National Care of the Dying Audit—Hospitals (NCDAH) is used as a method to evaluate care for dying patients in England. An additional component to the 2013/2014 audit was the Local Survey of Bereaved Relatives Views using the ‘Care Of the Dying Evaluation’ (CODE) questionnaire.

Conclusions: Adopting a postbereavement survey to NCDAH appears to be feasible, acceptable and a valuable addition. On the whole, the majority of participants reported good or excellent care. A small but significant minority, however, perceived poor quality of patient care with clear and timely communication urgently needed.

Full reference: Mayland, C.R. et al. (2017) How well do we currently care for our dying patients in acute hospitals: the views of the bereaved relatives? BMJ Supportive & Palliative Care. Vol. 07 (Issue 03) pp. 316-325.

Marie Curie Research Conference Abstracts 2017

Selected abstracts from the conference:

  • 14 Managing uncertainty in care for people with dementia at the end of life: the use of heuristics

Do Not Attempt Resuscitation Orders(DNAR) and their contemporary counterparts are cornerstones of End of Life care and as such, of importance within medical education. Previous research indicates the need for a better understanding of patient and physicians perceptions of DNAR topics.

Davies, N. et al. (2017) 14 Managing uncertainty in care for people with dementia at the end of life: the use of heuristics. BMJ Supportive & Palliative Care. Vol. 07 (Issue 03) p. A352.

  • 21 Exploring the effectiveness of a mindfulness-based intervention for staff in a palliative care setting

Palliative care staff engage in emotional and stressful work; however, research is yet to offer any insights as to what types of psychosocial intervention can effectively improve staff psychological well-being (Hill, Dempster, Donnelly, & McCorry, 2016). This research aims to evaluate the effectiveness of a Mindfulness-Based Intervention (MBI), which was condensed to make it more feasible for staff to attend, to improve the psychological well-being of palliative care staff.

Hill, R.C. et al. (2017) 21 Exploring the effectiveness of a mindfulness-based intervention for staff in a palliative care setting. BMJ Supportive & Palliative Care. Vol. 07 (Issue 03) pp. A354-A355.

  • 28 Do not attempt resuscitation: university of aberdeen student perspectives

Do Not Attempt Resuscitation Orders(DNAR) and their contemporary counterparts are cornerstones of End of Life care and as such, of importance within medical education. Previous research indicates the need for a better understanding of patient and physicians perceptions of DNAR topics.

Koshias, A. et al. (2017) 28 Do not attempt resuscitation: university of aberdeen student perspectives. BMJ Supportive & Palliative Care. Vol. 07 (Issue 03) pp. A357-A358

 

 

 

 

Can the ‘surprise question‘ be used to correctly identify people nearing the end of life?

The surprise question (SQ) (“Would you be surprised if this patient died within the next χ months?”) offers an alternative to standard prognostic estimates | BMJ Supportive & Palliative Care

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Methods: We searched numerous databases, including: Medline, Embase, CINAHL, AMED. Studies were included if they reported the SQ and were written in English.

Results: Out of the 357 studies identified, 22 were included in the review. In these studies, 25 718 estimates were reported. The results showed a wide variation in the reported accuracy of the SQ, with sensitivity ranging from 11.6% to 96.6% and specificity ranging from 13.9% to 78.6%. The AUROC score across the studies ranged from 0.512 to 0.822. Doctors appeared to be more accurate than nurses at recognising people in the last year of life (c-statistic=0.735 vs. 0.688).

Conclusions: The performance of the SQ varied greatly across the studies. Further work is required to understand the processes by which clinicians arrive at their prognostic estimates, to refine the accuracy of the SQ and to compare its performance against other more sophisticated prognostic tools, particularly in populations where a higher proportions of deaths occur.

Full reference: Vickerstaff, V. et al. (2017) 60 Can the ‘surprise question‘ be used to correctly identify people nearing the end of life?: a review. BMJ Supportive & Palliative Care. Vol. 07 (Issue 03) A371.

Developing a model for embedded palliative care in a cancer clinic

Describe the development and key features of a model for embedded palliative care (PC) for patients with advanced kidney cancer or melanoma seen in a cancer clinic | BMJ Supportive & Palliative Care

Methods: Retrospective chart review of patients following an initial phase and then a prospective review following the implementation of a model for embedded PC.

Results: In the initial phase, 18 patients were seen for a total of 53 visits; 78% were seen more than once, with a mean of three visits per patient. In the model phase, 46 patients were seen for a total of 163 visits; 74% were seen more than once, with a mean of 3.5 visits. Demographics were similar between the two groups. Content of the first PC visit in the initial and model phases was symptom management (61% and 57%), psychosocial support/relationship building (28% and 35%) and advance care planning/decision-making support (11% and 8%), respectively.

Conclusions: The initial phase demonstrated acceptability and feasibility of a model for embedded PC for patients and the oncology team. Establishment of specific eligibility criteria and screening to identify eligible patients in the model phase led to an increased uptake of PC for patients with advanced kidney cancer and melanoma in a cancer clinic.

Full reference: DeSanto-Madeya, S. et al. Developing a model for embedded palliative care in a cancer clinic. BMJ Supportive & Palliative Care. Vol. 07 (Issue 03) pp.247-250.

 

Delivering high quality end of life care for people who have a learning disability

This guidance document provide resources and tips for commissioners, service providers and health and social care staff providing, or delivering care to people with a learning disability at the end of their lives | NHS England

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Image source: NHS England

This ‘top tips’ guide aims to support commissioners, providers and clinicians to reduce inequalities in palliative and end of life for people with a learning disability, focusing on ‘The Ambitions for Palliative and End of Life Care’. These six ambitions provide a framework for national and local health and care system leaders to take action to improve palliative and end of life care. Developed by 27 organisations across the palliative and end of life care system, these ambitions set out what high quality palliative
and end of life care looks like. The ambitions call on leaders from every part of the health and caresystem, and the wider community, to put the framework into practice.

This ‘top tips’ guidance has been developed by NHS England in association with the Palliative Care for People with Learning Disabilities (PCPLD) Network. The development process involved consultation with Public Health England and a range of commissioners, providers and professionals working within palliative and end of life care and learning disability settings. People with lived experience have also helped us to develop the guide.

 

Responses to assisted suicide requests

An interview study with Swiss palliative care physicians | BMJ Supportive & Palliative Care

Objectives: Assisted suicide in Switzerland is mainly performed by right-to-die societies. Medical involvement is limited to the prescription of the drug and certification of eligibility. Palliative care has traditionally been perceived as generally opposed to assisted suicide, but little is known about palliative care physicians’ involvement in assisted suicide practices. This paper aims to describe their perspectives and involvement in assisted suicide practices.

 

Conclusions: The Swiss model of assisted suicide gives palliative care physicians opportunities to develop roles which are compatible with each practitioner’s values, but may not correspond to patients’ expectations. Specific education for all palliative care professionals and more structured ways to manage communication about assisted suicide are warranted.

Full reference: Gamondi, C. et al.  (2017) Responses to assisted suicide requests: an interview study with Swiss palliative care physicians. BMJ Supportive & Palliative Care. Published Online: 11 August 2017.