Publications by authors named "Jennifer Philip"

135 Publications

Chronic breathlessness in advanced cardiorespiratory disease: patient perceptions of opioid use.

BMJ Support Palliat Care 2021 Apr 9. Epub 2021 Apr 9.

The University of Melbourne Faculty of Medicine, Dentistry and Health Sciences, Melbourne, Victoria, Australia

Objective: Low-dose oral opioids may improve severe chronic breathlessness in advanced cardiorespiratory diseases. Prescription of opioids for breathlessness occurs infrequently however, with little known about patients' attitudes towards their use in this setting. The aim of this qualitative study was to explore patients' perceptions regarding opioids for the management of severe chronic breathlessness in people with advanced cardiorespiratory disease.

Methods: A cross-sectional, qualitative study was undertaken using outpatients with severe chronic breathlessness due to either severe chronic obstructive pulmonary disease (COPD) or chronic heart failure (CHF). Indepth, semistructured interviews were audio-recorded, transcribed verbatim and coded. Thematic analysis was undertaken to extrapolate recurring ideas from the data.

Results: Twenty-four participants were purposively sampled from three different groups: opioid-naïve patients with COPD (n=7), opioid-naïve patients with CHF (n=7) and patients with COPD using opioids currently or previously for severe chronic breathlessness (n=10). Four major themes were shared by both the and cohorts: (1) stigmatised attitudes and beliefs regarding opioids, (2) limited knowledge and information-seeking behaviour regarding opioids, (3) the impact of the relationships with health professionals and continuity of care, and (4) the significance of past experiences with opioids. An additional theme that was unique to the opioid-experienced cohort was (5) the perception of benefit and improved quality of life.

Conclusion: Lack of knowledge regarding the role of opioids in managing severe chronic breathlessness, opioid misinformation and social stigmas are major barriers to opioid therapy that may be overcome by accurate information from trusted health professionals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjspcare-2020-002853DOI Listing
April 2021

COVID-19 End-of-life Care: Symptoms and Supportive Therapy Use in an Australian Hospital.

Intern Med J 2021 Mar 23. Epub 2021 Mar 23.

The Royal Melbourne Hospital, 300 Grattan St, Parkville, Victoria, Australia, 3050.

Background: Descriptions of symptoms and medication use at end-of-life in COVID-19 are limited to small cross-sectional studies, with no Australian longitudinal data.

Aims: To describe end-of-life symptoms and care needs of people dying of COVID-19.

Methods: This retrospective cohort study included consecutive admitted patients who died at a Victorian tertiary referral hospital from 1 January to 30 September directly due to COVID-19. Clinical characteristics, symptoms, and use of supportive therapies including medications and non-pharmacological interventions in the last three days of life were extracted.

Results: The cohort comprised 58 patients (median age 87 years IQR 81, 90) predominantly admitted from home (n = 30), who died after a median of 11 days (IQR 6, 28) in the acute medical (n = 31) or aged care (n = 27) wards of the hospital. The median Charlson Comorbidity Score was 7 (IQR 5,8). Breathlessness (n = 42), agitation (n = 36) and pain (n = 33) were the most frequent clinician-reported symptoms in the final three days of life, with most requiring opioids (n = 52), midazolam (n = 40), with dose escalation commonly being required. While oxygen therapy was commonly used (n = 47), few (n = 13) required an anti-secretory agent.

Conclusions: This study presents one of the first and largest Australian report of the end of life and symptom experience of people dying of COVID-19. This information should help clinicians to anticipate palliative care needs of these patients, for example recognising that higher starting doses of opioids and sedatives may help reduce prevalence and severity of breathlessness and agitation near death. This article is protected by copyright. All rights reserved.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/imj.15300DOI Listing
March 2021

Referral criteria to palliative care for patients with respiratory disease: a systematic review.

Eur Respir J 2021 Mar 18. Epub 2021 Mar 18.

Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX, USA.

Background: Advanced non-malignant respiratory diseases are associated with significant patient morbidity, yet access to palliative care occurs late, if at all.

Aim: To examine referral criteria for palliative care among patients with advanced non-malignant respiratory disease, with a view to developing a standardised set of referral criteria.

Design: Systematic review of all studies reporting on referral criteria to palliative care in advanced non-malignant respiratory disease, with a focus on chronic obstructive pulmonary disease and interstitial lung disease.

Data Sources: A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed).

Results: Searches yielded 2052 unique titles, which were screened for eligibility resulting in 62 studies addressing referral criteria to palliative care in advanced non-malignant respiratory disease. Of 18 categories put forward for referral to palliative care, the most commonly discussed factors were hospital use (69% of papers), indicators of poor respiratory status (47%), physical and emotional symptoms (37%), functional decline (29%), need for advanced respiratory therapies (27%), and disease progression (26%).

Conclusion: Clinicians consider referral to specialist palliative care for a wide range of disease- and needs-based criteria. Our findings highlight the need to standardise palliative care access by developing consensus referral criteria for patients with advanced non-malignant respiratory illnesses.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1183/13993003.04307-2020DOI Listing
March 2021

Referral criteria to specialist palliative care for patients with dementia: A systematic review.

J Am Geriatr Soc 2021 Mar 2. Epub 2021 Mar 2.

Department of Palliative Care, Rehabilitation and Integrative Medicine, University of Texas MD Anderson Cancer Center, Houston, Texas, USA.

Background: Patients with dementia often have significant symptom burden and a progressive course of functional deterioration. Specialist palliative care referral may be helpful, but it is unclear who and when patients should be referred. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with dementia.

Methods: We searched Ovid MEDLINE, Ovid Embase, Ovid PsycInfo, Cochrane Library, PubMed, and CINAHL databases for articles from inception to December 3, 2019, related to specialist palliative care referral for dementia. Two investigators independently reviewed the citations for inclusion, extracted the referral criteria, and categorized them thematically.

Results: Of the 1788 citations, 59 articles were included in the final sample. We identified 13 categories of referral criteria, including 6 disease-based and 7 needs-based criteria. The most commonly discussed criterion was "dementia stage" (n = 43, 73%), followed by "new diagnosis of dementia" (n = 17, 29%), "medical complications of dementia" (n = 12, 20%), "prognosis" (n = 11, 19%), and "physical symptoms" (n = 11, 19%). Under dementia stage, 37/44 (84%) articles recommended a palliative care referral for advanced dementia. Pneumonia (n = 6, 10%), fall/fracture (n = 4, 7%), and decubitus ulcers (n = 4, 7%) were most commonly discussed complications to trigger a referral. Under prognosis, the time frame for referral varied from <2 years of life expectancy to <6 months. 3 (5%) of articles recommended "surprise question" as a potential trigger.

Conclusions: This systematic review highlighted the lack of consensus regarding referral criteria for palliative care in patients with dementia and the need to identify timely triggers to standardize referral.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jgs.17070DOI Listing
March 2021

End of life in hospitalised prisoners: a group comparison of palliative medicine and hospital use.

BMJ Support Palliat Care 2021 Feb 18. Epub 2021 Feb 18.

Palliative Nexus, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Victoria, Australia.

Background: Providing optimal palliative and end-of-life care for people in prison with advanced progressive disease is a growing challenge. This study aimed to examine hospital and palliative care utilisation for people in prison who are hospitalised during the final 3 months of life and to compare with a disease-matched non-incarcerated patient cohort.

Methods: A retrospective cohort study of people in prison who died between 2009 and 2019 in an Australian public hospital that provides tertiary-level healthcare for 18% of Australia's prison population. Demographic, clinical and service use data were extracted from medical records of eligible patients experiencing incarceration (prison group) and a disease-matched, non-incarcerated patient comparator group (comparator group).

Results: At the time of death, patients in the prison group were aged a median of 20 years younger than the comparator group (median age 58 vs 78 years, p<0.01). The prison group experienced more than double the mean length of acute care hospital stay at the end of life. A higher proportion of patients in the prison group experienced an intensive care unit episode (22% vs 12%). More than two-thirds (71%) of the prison group patients were seen by palliative care prior to death, similar to the comparator group (p=0.44). Those transferred to the palliative care unit had a shorter length of stay and were admitted later, just prior to death (median 5 vs 8 days).

Conclusions: People in prison have prolonged acute care public hospital stays and are more likely to experience escalation of care at the end of life. Future opportunity may exist for increased access to formal subacute care settings for people in prison with life-limiting illness to receive optimal palliative and end-of-life care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjspcare-2020-002703DOI Listing
February 2021

Validation of the responding to urgency of need in palliative care (RUN-PC) triage tool.

Palliat Med 2021 Apr 21;35(4):759-767. Epub 2021 Jan 21.

Department of Public Health, La Trobe University, Melbourne, VIC, Australia.

Background: The Responding to Urgency of Need in Palliative Care (RUN-PC) Triage Tool is a novel, evidence-based tool by which specialist palliative care services can manage waiting lists and workflow by prioritising access to care for those patients with the most pressing needs in an equitable, efficient and transparent manner.

Aim: This study aimed to establish the intra- and inter-rater reliability, and convergent validity of the RUN-PC Triage Tool and generate recommended response times.

Design: An online survey of palliative care intake officers applying the RUN-PC Triage Tool to a series of 49 real clinical vignettes was assessed against a reference standard: a postal survey of expert palliative care clinicians ranking the same vignettes in order of urgency.

Setting/participants: Intake officers ( = 28) with a minimum of 2 years palliative care experience and expert clinicians ( = 32) with a minimum of 10 years palliative care experience were recruited from inpatient, hospital consultation and community palliative care services across metropolitan and regional Victoria, Australia.

Results: The RUN-PC Triage Tool has good intra- and inter-rater reliability in inpatient, hospital consultation and community palliative care settings (Intraclass Correlation Coefficients ranged from 0.61 to 0.74), and moderate to good correlation to expert opinion used as a reference standard (Kendall's Tau rank correlation coefficients ranged from 0.68 to 0.83).

Conclusion: The RUN-PC Triage Tool appears to be a reliable and valid tool for the prioritisation of patients referred to specialist inpatient, hospital consultation and community palliative care services.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0269216320986730DOI Listing
April 2021

An exploration of the perceptions, experience and practice of cancer clinicians in caring for patients with cancer who are also parents of dependent-age children.

Support Care Cancer 2021 Jan 2. Epub 2021 Jan 2.

Department of Medical Oncology, St Vincent's Hospital, Fitzroy, Victoria, Australia.

Background: Being a parent alongside a cancer diagnosis presents unique challenges. It is unclear to what degree parenting considerations feature in routine care and how doctors approach treatment decision discussions.

Objective: To explore doctor perspectives regarding patients with cancer who have dependent children.

Methodology: Focus groups and interviews conducted to ascertain doctor views. Responses were audio-recorded, transcribed and thematically analysed.

Results: Twenty-eight doctors participated: medical oncology (7), haematology (10), palliative care (8), and psycho-oncology (3). Participants observed cancer impacted upon parenting across several domains: psycho-social, practical, and family implications. Having dependent children was perceived to influence the patient experience and decision-making by patients and clinicians. Participants identified this cohort as emotionally demanding to care for with a range of psychological effects identified for doctors, particularly in highly challenging circumstances (single-parent and non-English speaking families, scenarios involving communication difficulties).

Conclusion: Participants recognised the presence of dependent children to profoundly influence the experience of being both a parent and a patient with cancer. Identifying patients with parental responsibilities was noted as relevant for management at diagnosis through to death. Greater understanding of doctors' experiences providing care for this cohort may inform the development of resources to assist doctors and their patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00520-020-05969-xDOI Listing
January 2021

The impact of public health palliative care interventions on health system outcomes: A systematic review.

Palliat Med 2021 Mar 23;35(3):473-485. Epub 2020 Dec 23.

Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, VIC, Australia.

Background: Public health palliative care interventions are increasingly implemented, with growing recognition of the importance of building evidence to support their utility in end-of-life care. Previous efforts have focused on community outcomes.

Aim: To examine the impact of public health palliative care on patterns of health service use at the end of life (primary) and explore which outcomes are being measured within this field of research (secondary).

Design: Systematic review of studies reporting qualitative and quantitative data, analysed with a narrative synthesis method.

Data Sources: A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using six electronic databases (MEDLINE, CINAHL, EMBASE, PsycINFO, INFORMIT and COCHRANE) up to February 2020.

Results: Searches yielded 2622 unique titles screened for eligibility, resulting in 35 studies measuring outcomes from a public health palliative care approach. Five (14%) studies assessed health system outcomes, and three reported some mixed evidence of impact, including reduced hospital emergency admissions, hospital bed days, hospital costs and increased home deaths. Most studies (86%) instead reported on conceptual (49%), knowledge (40%), programme participation (37%) and/or individual health outcomes (29%).

Conclusion: The impact of public health palliative care is an evolving area of empirical inquiry with currently only limited evidence that it improves healthcare utilisation outcomes at the end of life, and limited focus on measurement of these outcomes. Further empirical studies are needed to support the reorientation of health services, which remains an important component in realising 'whole of system change' to bring about quality end-of-life care for all.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0269216320981722DOI Listing
March 2021

Barriers and enablers to the implementation of protocol-based imaging in pancreatic cancer: A qualitative study using the theoretical domains framework.

PLoS One 2020 17;15(12):e0243312. Epub 2020 Dec 17.

School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.

Background: Accurate pre-operative imaging plays a vital role in patient selection for surgery and in allocating stage-appropriate therapies to patients diagnosed with pancreatic cancer (PC). This study aims to: (1) understand the current diagnosis and staging practices for PC; and (2) explore the factors (barriers and enablers) that influence the use of a pancreatic protocol computed tomography (PPCT) or magnetic resonance imaging (MRI) to confirm diagnosis and/or accurately stage PC.

Methods: Semi-structured interviews were conducted with radiologists, surgeons, gastroenterologists, medical and radiation oncologists from the states of New South Wales (NSW) and Victoria, Australia. Interviews were conducted either in person or via video conferencing. All interviews were recorded, transcribed verbatim, de-identified and data were thematically coded according to the 12 domains explored within the Theoretical Domains Framework (TDF). Common belief statements were generated to compare the variation between participant responses.

Findings: In total, 21 clinicians (5 radiologists, 10 surgeons, 2 gastroenterologists, 4 medical and radiation oncologists) were interviewed over a four-month-period. Belief statements relevant to the TDF domains were generated. Across the 11 relevant domains, 20 themes and 30 specific beliefs were identified. All TDF domains, with the exception of social influences were identified by participants as relevant to protocol-based imaging using either a PPCT or MRI, with the domains of knowledge, skills and environmental context and resources being offered by most participants as being relevant in influencing their decisions.

Conclusions: To maximise outcomes and personalise therapy it is imperative that diagnosis and staging investigations using the most appropriate imaging modalities are conducted in a timely, efficient and effective manner. The results provide an understanding of specialists' opinion and behaviour in relation to a PPCT or MRI and should be used to inform the design of future interventions to improve compliance with this practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243312PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7746147PMC
January 2021

Australian recommendations for the management of hepatocellular carcinoma: a consensus statement.

Med J Aust 2020 Dec 13. Epub 2020 Dec 13.

University of New South Wales, Sydney, NSW.

Introduction: Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths both globally and in Australia. Surveillance for HCC in at-risk populations allows diagnosis at an early stage, when potentially curable. However, most Australians diagnosed with HCC die of the cancer or of liver disease. In the changing landscape of HCC management, unique challenges may lead to clinical practice variation. As a result, there is a need to identify best practice management of HCC in an Australian context. This consensus statement has been developed for health professionals involved in the care of adult patients with HCC in Australia. It is applicable to specialists, general medical practitioners, nurses, health coordinators and hospital administrators.

Methods And Recommendations: This statement has been developed by specialists in hepatology, radiology, surgery, oncology, palliative care, and primary care, including medical practitioners and nurses. The statement addresses four main areas relevant to HCC management: epidemiology and incidence, diagnosis, treatment, and patient management. A modified Delphi process was used to reach consensus on 31 recommendations. Principal recommendations include the adoption of surveillance strategies, use of multidisciplinary meetings, diagnosis, treatment options and patient management.

Changes In Management As A Result Of This Statement: This consensus statement will simplify HCC patient management and reduce clinical variation. Ultimately, this should result in better outcomes for patients with HCC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5694/mja2.50885DOI Listing
December 2020

Barriers and enablers to the implementation of multidisciplinary team meetings: a qualitative study using the theoretical domains framework.

BMJ Qual Saf 2020 Nov 27. Epub 2020 Nov 27.

Monash University Faculty of Medicine, Nursing and Health Sciences, Melbourne, Victoria, Australia

Background: Evidence-based clinical practice guidelines recommend discussion by a multidisciplinary team (MDT) to review and plan the management of patients for a variety of cancers. However, not all patients diagnosed with cancer are presented at an MDT.

Objectives: (1) To identify the factors (barriers and enablers) influencing presentation of all patients to, and the perceived value of, MDT meetings in the management of patients with pancreatic cancer and; (2) to identify potential interventions that could overcome modifiable barriers and enhance enablers using the theoretical domains framework (TDF).

Methods: Semistructured interviews were conducted with radiologists, surgeons, medical and radiation oncologists, gastroenterologists, palliative care specialists and nurse specialists based in New South Wales and Victoria, Australia. Interviews were conducted either in person or via videoconferencing. All interviews were recorded, transcribed verbatim, deidentified and data were thematically coded according to the 12 domains explored within the TDF. Common belief statements were generated to compare the variation between participant responses.

Results: In total, 29 specialists were interviewed over a 4-month period. Twenty-two themes and 40 belief statements relevant to all the TDF domains were generated. Key enablers influencing MDT practices included a strong organisational focus (), beliefs about the benefits of an MDT discussion (), the use of technology, for example, videoconferencing (), the motivation to provide good quality care () and collegiality (). Barriers included: absence of palliative care representation (), the number of MDT meetings (), the cumulative cost of staff time (), the lack of capacity to discuss all patients within the allotted time () and reduced confidence to participate in discussions ().

Conclusions: The internal and external organisational structures surrounding MDT meetings ideally need to be strengthened with the development of agreed evidence-based protocols and referral pathways, a focus on resource allocation and capabilities, and a culture that fosters widespread collaboration for all stages of pancreatic cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjqs-2020-011793DOI Listing
November 2020

Healthcare Professionals' Views of Working with Medical Interpreters in a Cancer Setting: an Exploratory Study.

J Cancer Educ 2020 Nov 23. Epub 2020 Nov 23.

Department of Medical Oncology, St Vincent's Hospital, 41 Victoria Pde, Fitzroy, Victoria, 3065, Australia.

Australia, like many other nations, continues to become more culturally and linguistically diverse. Medical interpreters play a key role in bridging the linguistic gap between healthcare professionals (HCPs) and patients. Little research exists from the HCP's perspective about working with interpreters. This study aimed to explore the views of HCPs regarding working with interpreters in a cancer setting. This exploratory study utilised a cross-sectional, qualitative design, involving focus groups and semi-structured interviews. HCPs from the Oncology and Palliative Care units were invited to participate and were asked about their experiences of working with interpreters in a cancer setting. Interviews were audio-recorded and transcribed. An inductive thematic analysis of qualitative data derived an understanding of attitudes and beliefs which may affect the way in which HCPs interact with interpreters and patients. Twenty-five participants were recruited. Five key themes emerged from the data: (1) communication practices and preferences, (2) training and supports, (3) alternative methods for translation, (4) challenges faced by HCPs and interpreters, and (5) limitations of translation. Communication with non-English-speaking patients using interpreters could be significantly improved with further training and support for both HCPs and interpreters, and a greater appreciation for the challenges each party faces.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13187-020-01927-7DOI Listing
November 2020

Do family meetings for hospitalised palliative care patients improve outcomes and reduce health care costs? A cluster randomised trial.

Palliat Med 2021 Jan 31;35(1):188-199. Epub 2020 Oct 31.

Austin Health, Heidelberg, Victoria, Australia.

Background: Family meetings facilitate the exploration of issues and goals of care however, there has been minimal research to determine the benefits and cost implications.

Aims: To determine: (1) if family caregivers of hospitalised patients referred to palliative care who receive a structured family meeting report lower psychological distress (primary outcome), fewer unmet needs, improved quality of life; feel more prepared for the caregiving role; and receive better quality of end-of-life care; (2) if outcomes vary dependant upon site of care and; (3) the cost-benefit of implementing meetings into routine practice.

Design: Pragmatic cluster randomised trial involving palliative care patients and their primary family caregivers at three Australian hospitals. Participants completed measures upon admission (Time 1); 10 days later (Time 2) and two months after the patient died (Time 3). Regression analyses, health utilisation and process evaluation were conducted.

Results: 297 dyads recruited; control ( = 153) and intervention ( = 144). The intervention group demonstrated significantly lower psychological distress (Diff: -1.68,  < 0.01) and higher preparedness (Diff: 3.48,  = 0.001) at Time 2. No differences were identified based on quality of end of life care or health utilisation measures.

Conclusions: Family meetings may be helpful in reducing family caregiver distress and enhancing their preparedness for the caregiving role and it appears they may be conducted without increased hospital health utilisation impacts; although opportunity costs need to be considered in order to routinely offer these as a standardised intervention. Additional health economic examination is also advocated to comprehensively understand the cost-benefit implications.

Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12615000200583.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0269216320967282DOI Listing
January 2021

The Development of the Australian National Palliative Care Clinical Studies Collaborative "Integrating Qualitative Research into Clinical Trials Framework".

J Palliat Med 2021 Mar 20;24(3):331-337. Epub 2020 Oct 20.

IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.

Qualitative methodologies have multiple contributions to health research, including improving baseline understanding in new areas of enquiry; questioning existing assumptions; understanding viewpoints of specific subgroups; and offering complex, contextual information. While the role of qualitative research within mixed methods approaches is well documented, the contribution to clinical trial design and conduct is less well recognized. The Australian Palliative Care Clinical Studies Collaborative and Cancer Symptom Trials have developed a framework to detail how qualitative research might contribute to each key aspect of clinical trials. This practical framework provides real-world examples, including sample qualitative questions, to consider at each phase of controlled clinical trial development. As the number of randomized clinical trials in palliative care increases, a readily accessible approach to integrating qualitative research into clinical trial design and conduct is needed so that its full potential for improving study recruitment, conduct, outcomes, interpretation, and implementation may be realized.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/jpm.2020.0480DOI Listing
March 2021

Estrogen receptor-α prevents right ventricular diastolic dysfunction and fibrosis in female rats.

Am J Physiol Heart Circ Physiol 2020 12 16;319(6):H1459-H1473. Epub 2020 Oct 16.

Department of Biomedical Engineering, University of Wisconsin-Madison, Madison, Wisconsin.

Although women are more susceptible to pulmonary arterial hypertension (PAH) than men, their right ventricular (RV) function is better preserved. Estrogen receptor-α (ERα) has been identified as a likely mediator for estrogen protection in the RV. However, the role of ERα in preserving RV function and remodeling during pressure overload remains poorly understood. We hypothesized that loss of functional ERα removes female protection from adverse remodeling and is permissive for the development of a maladapted RV phenotype. Male and female rats with a loss-of-function mutation in ERα (ERαMut) and wild-type (WT) littermates underwent RV pressure overload by pulmonary artery banding (PAB). At 10 wk post-PAB, WT and ERαMut demonstrated RV hypertrophy. Analysis of RV pressure waveforms demonstrated RV-pulmonary vascular uncoupling and diastolic dysfunction in female, but not male, ERαMut PAB rats. Similarly, female, but not male, ERαMut exhibited increased RV fibrosis, comprised primarily of thick collagen fibers. There was an increased protein expression ratio of TIMP metallopeptidase inhibitor 1 (Timp1) to matrix metalloproteinase 9 (Mmp9) in female ERαMut compared with WT PAB rats, suggesting less collagen degradation. RNA-sequencing in female WT and ERαMut RV revealed kallikrein-related peptidase 10 (Klk10) and Jun Proto-Oncogene (Jun) as possible mediators of female RV protection during PAB. In summary, ERα in females is protective against RV-pulmonary vascular uncoupling, diastolic dysfunction, and fibrosis in response to pressure overload. ERα appears to be dispensable for RV adaptation in males. ERα may be a mediator of superior RV adaptation in female patients with PAH. Using a novel loss-of-function mutation in estrogen receptor-α (ERα), we demonstrate that female, but not male, ERα mutant rats display right ventricular (RV)-vascular uncoupling, diastolic dysfunction, and fibrosis following pressure overload, indicating a sex-dependent role of ERα in protecting against adverse RV remodeling. TIMP metallopeptidase inhibitor 1 (Timp1), matrix metalloproteinase 9 (Mmp9), kallikrein-related peptidase 10 (), and Jun Proto-Oncogene () were identified as potential mediators in ERα-regulated pathways in RV pressure overload.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1152/ajpheart.00247.2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7792707PMC
December 2020

Renal supportive care, palliative care and end-of-life care: Perceptions of similarities, differences and challenges across Australia and New Zealand.

Nephrology (Carlton) 2021 Jan 21;26(1):15-22. Epub 2020 Oct 21.

Department of Medicine, Melbourne University, Melbourne, Victoria, Australia.

Renal supportive care (RSC) is an approach integrating nephrology and palliative care to improve quality of life for people with chronic kidney disease (CKD). RSC practice varies across services; therefore, understanding clinicians' perspectives is important to the evolution and definition of RSC.

Aim: To understand renal clinicians' views and experiences of RSC, palliative care and end-of-life care.

Method: A cross-sectional online survey was undertaken across Australia and New Zealand between February and May 2018. Participants were asked about end-of-life care, RSC, palliative care and an ideal model of RSC.

Results: Estimated response rate 13% included 382 clinicians; doctors (32%), nurses (68%); of whom 84% access specialist palliative care and 59% RSC. A lack of agreed treatment goals (86%) and late or rushed treatment decision making (85%) was associated with challenging end-of-life experiences. Variable concepts of RSC were described, with RSC being considered the same as: usual care for all CKD patients (40%), conservative (30%) or palliative care (22%). The term RSC was generally distinct from (77%) and more acceptable than palliative care (80%) with preferential RSC referral for symptoms (86% vs 69%, P < .01) and complex treatment decision making (82% vs 58%, P < .01). Aspirations for RSC included improving symptoms and quality of life (89%), with an ideal model comprising: symptom management (98%), improved nephrology and community service integration (96%) and clinician education (94%).

Conclusion: This study revealed challenges for renal clinicians in providing end-of-life care and variation of views and experiences of RSC. It represents opportunities to develop RSC aligned with clinician priorities to improve patient care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/nep.13787DOI Listing
January 2021

Mapping non-malignant respiratory palliative care services in Australia and New Zealand.

Aust Health Rev 2020 Sep;44(5):778-781

Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, 300 Grattan Street, Parkville, Vic. 3050, Australia. Email:

Objective Despite needs, people with advanced non-malignant respiratory disease are infrequently referred to palliative care services. Integrated models of palliative care and respiratory service delivery have been advocated to address this inequity of access. This study mapped current ambulatory palliative care service provision for patients with advanced non-malignant respiratory disease in Australia and New Zealand. Methods An online survey was distributed to the palliative care physician membership of the Australian and New Zealand Society of Palliative Medicine. Information was sought regarding access to specific breathlessness and integrated respiratory and palliative care services, and their operation. Data were described using descriptive statistics. Results In all, 133 respondents (93 from Australia, 40 from New Zealand; representing 55 Australian and 26 New Zealand discrete sites) with complete data were available for analysis. More than half the respondents reported seeing patients with advanced non-malignant respiratory disease frequently (56/97; 58%), and 18 of 81 services (22%) reported having breathlessness or integrated respiratory and palliative care services caring for this patient group. Such services were mostly staffed by respiratory and palliative care doctors and nurses and based in the clinic environment, with limited support available outside this setting. Of the 63 respondents without existing breathlessness or integrated services, 49 (78%) expressed interest in their establishment, with limited resources cited as the most common barrier. Conclusions There is limited availability of integrated respiratory and palliative care or specialised breathlessness services in Australia and New Zealand despite widespread support by palliative care physicians. This study provides a snapshot to inform strategic service development. What is known about the topic? People with advanced respiratory disease have very significant morbidity with complex needs equivalent to, and in many cases more intense than, people with end-stage lung cancer; they also have significant mortality. Yet, these people frequently do not access palliative care services. The establishment of integrated respiratory and palliative care services has been advocated as an effective means to overcome the barriers to palliative care access. Such services have demonstrated improved patient and family-reported outcomes, as well as service-level improvements. What does this paper add? This paper maps the availability of integrated respiratory palliative care services in Australia and New Zealand. We reveal that although most palliative care physicians report seeing patients with advanced respiratory disease in practice, just one-fifth of services report having an integrated service approach. There was high interest and enthusiasm for such services (78%), but resources limited their establishment. What are the implications for practitioners? Palliative care services recognise the needs of patients with advanced respiratory disease and the benefits of integrated respiratory and palliative care services to address these needs, but scarcity of resources limits the ability to respond accordingly. This study provides a snapshot of current service level to inform strategic development.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1071/AH19206DOI Listing
September 2020

Referral Criteria to Palliative Care for Patients With Heart Failure: A Systematic Review.

Circ Heart Fail 2020 09 9;13(9):e006881. Epub 2020 Sep 9.

Department of Palliative Care, Rehabilitation and Integrative Medicine (Y.K.C., H.K., L.M., D.H.), The University of Texas MD Anderson Cancer Center, Houston, TX.

Background: Patients with heart failure have significant symptom burden, care needs, and often a progressive course to end-stage disease. Palliative care referrals may be helpful but it is currently unclear when patients should be referred and by whom. We conducted a systematic review of the literature to examine referral criteria for palliative care among patients with heart failure.

Methods: We searched Ovid, MEDLINE, Ovid Embase, and PubMed databases for articles in the English language from the inception of databases to January 17, 2019 related to palliative care referral in patients with heart failure. Two investigators independently reviewed each citation for inclusion and then extracted the referral criteria. Referral criteria were then categorized thematically.

Results: Of the 1199 citations in our initial search, 102 articles were included in the final sample. We identified 18 categories of referral criteria, including 7 needs-based criteria and 10 disease-based criteria. The most commonly discussed criterion was physical or emotional symptoms (n=51 [50%]), followed by cardiac stage (n=46 [45%]), hospital utilization (n=38 [37%]), prognosis (n=37 [36%]), and advanced cardiac therapies (n=36 [35%]). Under cardiac stage, 31 (30%) articles suggested New York Heart Association functional class ≥III and 12 (12%) recommended New York Heart Association class ≥IV as cutoffs for referral. Prognosis of ≤1 year was mentioned in 21 (21%) articles as a potential trigger; few other criteria had specific cutoffs.

Conclusions: This systematic review highlighted the lack of consensus regarding referral criteria for the involvement of palliative care in patients with heart failure. Further research is needed to identify appropriate and timely triggers for palliative care referral.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCHEARTFAILURE.120.006881DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7494548PMC
September 2020

Systems of Care in Crisis: The Changing Nature of Palliative Care During COVID-19.

J Bioeth Inq 2020 Dec 25;17(4):761-765. Epub 2020 Aug 25.

Palliative Nexus, University of Melbourne and St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.

Among the far-reaching impacts of COVID-19 is its impact on care systems, the social and other systems that we rely on to maintain and provide care for those with "illness." This paper will examine these impacts through a description of the influence on palliative care systems that have arisen within this pandemic. It will explore the impact on the meaning of care, how care is performed and identified, and the responses of palliative care systems to these challenges. It will also highlight the current and potential future implications of these dynamics within the unfolding crisis of this pandemic.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11673-020-10006-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7445713PMC
December 2020

Palliative care physicians' preparation and planning for the implementation of the Voluntary Assisted Dying Act in Victoria.

Intern Med J 2020 Aug 3. Epub 2020 Aug 3.

Palliative Care Service, Austin Health.

In November 2017, the Victorian Voluntary Assisted Dying (VAD) Act was passed enabling people with a progressive terminal illness to end their life voluntarily. Heated debate abounded including, to some extent within palliative care, which was also challenged with developing processes around the legislation enactment.

Objective: In response, the lead author convened a series of meetings of palliative care physicians: 1. To share ideas about preparations being undertaken within services; and 2. To re-establish professional cohesion following the divide that the legislation had presented.

Design: Setting/Participants: A series of three closed meetings were held between the legislation passage and its implementation, with all Victorian palliative care physicians invited to attend. Meetings were facilitated by an experienced psychiatrist from outside the field.

Results: These meetings proved very valuable as physicians collectively sought to define and respond to challenges, simultaneously reflecting on the personal and professional implications for individuals and the field. Key areas raised including gauging institutional 'readiness' for the legislation through staff surveys; the educational role of palliative care staff of the legislation implications; communication skills training; the role (if any) of palliative care in the processes of VAD; and the perceptions of palliative care itself in health services and the community. It was during the processes of discussing challenges and sharing solutions that the attendees appeared to re-affirm their professional interconnections. A description of the key elements of these discussions may be useful to others who may yet face similar circumstances with the introduction of VAD legislation. This article is protected by copyright. All rights reserved.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/imj.15004DOI Listing
August 2020

A randomised phase II trial testing the acceptability and feasibility of a narrative approach to public health communication to increase community engagement with palliative care.

Palliat Med 2020 09 19;34(8):1108-1117. Epub 2020 Jun 19.

Department of Medicine, St Vincent's Hospital, The University of Melbourne, Fitzroy, VIC, Australia.

Background: Communities have limited understanding of palliative care, creating barriers to informed choice around consideration of a full range of care options in the event of serious illness. Few empirically tested interventions are available to educate community about palliative care, and ultimately improve timely access to these services.

Aim: To test the acceptability (primary outcome), and feasibility of a narrative approach to public health communication seeking to improve attitudes to possible access to palliative care in the event of serious illness.

Design: Randomised phase II trial with six parallel experimental conditions. Outcomes tested included measures of acceptability, feasibility and change in attitudes to possible access to palliative care post-intervention. Contrasts planned for exploratory testing included format, message content and narrator.

Setting/participants: Community-based sample of consecutive English-speaking adults who volunteered their participation in response to a study advertisement distributed online through established community groups.

Results: A narrative approach to public health communication was found to be acceptable to community members, and feasible to deliver online. Exploratory data suggested it immediately improved attitudes towards possible access to palliative care in the event of serious illness, with the narrative detailing a description of the evidence delivered by a healthcare professional appearing to be the most promising strategy.

Conclusions: This study provides preliminary data to inform a future, longitudinal trial evaluating effectiveness and ultimately other evidence-based, public health approaches to improve community engagement with palliative care. Further studies are required to confirm the generalisability of findings to a broader representative sample and other settings including internationally.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0269216320932766DOI Listing
September 2020

The burden of diagnostic investigations at the end of life for people with COPD.

Intern Med J 2020 Jun 16. Epub 2020 Jun 16.

Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Royal Parade, Parkville, Victoria, 3050, Australia.

Background: Chronic obstructive pulmonary disease (COPD) is an incurable, chronic condition that leads to significant morbidity and mortality, with most patients dying in hospital. While diagnostic tests are important for actively managing patients during hospital admissions, the balance between benefit and harm should always be considered. This is particularly important when patients reach the end-of-life, when the focus is to reduce burdensome interventions. This study aimed to examine the use of diagnostic testing in a cohort of people with COPD who died in hospital.

Methods: Retrospective medical record audits were completed at two Australian hospitals (Royal Melbourne Hospital and Northeast Health Wangaratta), with all patients who died from COPD over twelve years between 1/1/2004 and 31/12/2015 included.

Results: Three hundred and forty-three patients were included, with a median of 11 diagnostic testing episodes per patient. Undergoing higher numbers of diagnostic tests was associated with younger age, ICU admission and non-invasive ventilation use. Reduced testing was associated with recent hospital admission for COPD, domiciliary oxygen use and a prior admission with documentation limiting medical treatment. Most patients underwent diagnostic tests in the last two days of life, and 12% of patients had ongoing diagnostic tests performed after a documented decision was made to change the goal of care to provide comfort care only.

Conclusion: There were missed opportunities to reduce the burden of diagnostic tests and focus on comfort at the end of life. Increased physician education regarding communication and end-of-life care, including recognising active dying may address these issues. This article is protected by copyright. All rights reserved.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/imj.14943DOI Listing
June 2020

Complexities and Constraints in End-of-Life Care for Hospitalized Prisoner Patients.

J Pain Symptom Manage 2020 11 25;60(5):984-991.e1. Epub 2020 May 25.

Palliative Nexus, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia; Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia.

Context: Managing the care of an increasing and aging prisoner population, including providing palliative and end-of-life care, is a challenge worldwide. There is little known about the views of health professionals who provide palliative care to hospitalized prisoner patients.

Objectives: To explore experiences and perspectives of health professionals regarding the provision of palliative and end-of-life care for hospitalized prisoner patients.

Methods: A qualitative study involving semistructured focus groups and interviews with 54 medical, nursing, and allied health staff engaged in the care of hospitalized prisoner patients. Purposive sampling from a metropolitan teaching hospital responsible for providing secondary and tertiary health care for prisoners in Victoria, Australia, for 40 years was used to identify and seek perspectives of staff from a variety of clinical disciplines. Inductive thematic analysis was conducted by two researchers.

Results: Participants described significant constraints in how they provide palliative care to hospitalized prisoners. Key themes emerged describing constraints on prisoner health decisions, provision and place of care, patient advocacy, and how care is delivered in the last days of life. Participants highlighted a deep philosophical tension between prison constraints and the foundational principles of palliative care.

Conclusion: Clarity of correctional service processes, protocols, and aspects of security and related training for health professionals is needed to ensure improved care for prisoners with progressive and life-limiting illness. Further research is required to seek the views of prisoners facing end of life and their families.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpainsymman.2020.05.024DOI Listing
November 2020

Effect of Transfer Status on Outcomes of Emergency General Surgery Patients.

Surgery 2020 08 23;168(2):280-286. Epub 2020 May 23.

Department of Surgery, University of Wisconsin, Madison, WI. Electronic address:

Introduction: Transferred emergency general surgery (EGS) patients are a vulnerable, high acuity population. The outcomes of and health care utilization among transferred (TRAN) as compared to directly admitted (DA) patients have been studied primarily using single institution or hospital system data which limits generalizability. We evaluated these outcomes among EGS patients using a national database.

Methods: We identified encounters of patients aged ≥18 years with a diagnosis of EGS as defined by the American Association for the Surgery of Trauma in the 2008-2011 Nationwide Inpatient Sample (NIS). Multivariable regression analyses determined if transfer status independently predicted in-hospital mortality (logistic regression) and morbidity (presence of any complication among those who survived to discharge; logistic regression), cost (log-linear regression), and duration of stay (among those who survived to discharge; log-linear regression) accounting for the NIS sampling design.

Results: We identified 274,145 TRAN (57,885 unweighted) and 10,456,100 DA (2,187,132 unweighted) encounters. On univariate analysis, TRAN patients were more likely to have greater comorbidity scores, have Medicare insurance, and reside in an area with a lesser median household income compared to DA patients (p<0.0001). Mortality was greater in the TRAN vs DA groups (4.4% vs 1.6%; p<0.0001). Morbidity (presence of any complication) was also greater among TRAN patients (38.8% vs 26.1%; p<0.0001). Morbidity among TRAN patients was primarily due to urinary- (13.7%), gastrointestinal- (12.9%), and pulmonary-related (13.3%) complications. Median duration of hospital stay was 4.3 days for TRAN vs 3.0 days for DA (p<0.0001) patients. Median cost was greater for TRAN patients ($8,935 vs $7,167; p<0.0001). Regression analyses determined that after adjustment, TRAN patients had statistically significantly greater mortality, morbidity, and cost as well as longer durations of stay.

Conclusions: EGS patients who are transferred experience increased in-hospital morbidity and mortality as well as increased durations of stay and cost. As the population and age of patients diagnosed with EGS conditions increase while the EGS workforce decreases, the need for inter-hospital transfers will increase. Identifying risk factors associated with worse outcomes among transferred patients can inform the design of initiatives in performance improvement and direct the finite resources available to this vulnerable patient population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.surg.2020.01.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7390656PMC
August 2020

Mapping the nature of distress raised by patients with high-grade glioma and their family caregivers: a descriptive longitudinal study.

Neurooncol Pract 2020 Jan 3;7(1):103-110. Epub 2019 Jul 3.

Department of Neurosurgery, St Vincent's Hospital, Melbourne, VIC, Australia.

Background: Few supportive and palliative care interventions have been described for people with high-grade glioma (HGG) and their caregivers. A structured intervention, I-CoPE, which includes regular screening of patients' and caregivers' needs, was delivered as a pilot study in a tertiary neuro-oncological unit. This study prospectively described the severity and content of key concerns raised by patients and their caregivers in the 3 months following a diagnosis of HGG.

Methods: Consecutive patients and caregivers were screened for distress longitudinally using the Distress Thermometer at 3 time points. Exploration of the issues raised during screening was undertaken by the care coordinator and the issues documented. This documentation was subsequently audited to map patterns and nature of distress. The key reasons underlying distress and responses offered were grouped thematically and summarized using descriptive statistics.

Results: Thirty-two patients and 31 caregivers were recruited and underwent screening. At diagnosis, 87% of caregivers (n = 27) and 60% of patients (n = 19) reported distress scores meeting clinical significance. The predominant concerns reported by patients during screening related to existential issues such as fear of dying, whereas caregivers were more focused on practical caring responsibilities. Over time, the reasons for distress changed to include more physical health concerns for patients and more psychological concerns for caregivers.

Conclusions: This prospective longitudinal descriptive study revealed that following a new diagnosis of HGG, patients and caregivers had changing needs for support and fluctuating distress, mirroring the illness trajectory. Palliative care needs were apparent from diagnosis, and early integration of palliative care should be considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/nop/npz032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7104884PMC
January 2020

Patterns of opioid use in dialysis access procedures.

J Vasc Surg 2020 09 27;72(3):1018-1024. Epub 2020 Feb 27.

Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisc.

Background: Overprescription of opioids after surgical procedures is recognized as an important contributor to opioid misuse. Dialysis access procedures are commonly performed outpatient operations with few data or guidelines to inform prescription pain management practices. We sought to characterize opioid pain medication use after dialysis access surgery to promote a conservative approach to postoperative opioid prescriptions.

Methods: We performed a retrospective review of patients who underwent surgical dialysis access procedures from August 2018 through January 2019. Patient-reported opioid use information was captured in a brief questionnaire administered during routine follow-up appointments or phone calls and recorded in the electronic medical record. The procedure, type of intraoperative anesthesia or analgesia, postoperative prescription provided, and patient factors (including age, sex, dialysis type, history of chronic pain, and preoperative opioid or benzodiazepine use) were recorded. All procedures were classified by type (arteriovenous fistula or graft with a short incision [AVF-S], arteriovenous fistula or graft with a long incision [AVF-L], or peritoneal dialysis [PD] catheter), and descriptive statistics were performed using R (R Foundation for Statistical Computing, Vienna, Austria).

Results: Eighty-six patients underwent dialysis access procedures in the study time frame, of whom 63 were administered the pain questionnaire and 58 quantified opioid use; 85% of patients received a prescription, but 31% took no opioids and 71% used opioids for ≤2 days. Interquartile ranges (25th-75th percentile) of prescription and consumption quantities for patients who underwent AVF-L procedures were 10 to 28 pills and 2.5 to 20 pills; for patients who underwent AVF-S, quantities were 4.0 to 8.4 pills and 0 to 4.3 pills; and PD quantities were 10 pills and 3.3 to 9 pills. Thirty-one patients (53%) reported receiving more pain medication than they used, which resulted in a median of 8 excess pills per patient with an unused pill interquartile range of 0 to 22 pills for AVF-L procedures, 0 to 4.2 pills for AVF-S procedures, and 1.3 to 6.7 pills for PD procedures. Patients who were prescribed oxycodone or had a repeated operation had significantly increased opioid use.

Conclusions: This investigation of opioid use after surgical dialysis access procedures suggests that most patients use relatively few opioid pills after surgery, which translates into overprescription and leftover medication for >50% of patients. A conservative approach to postoperative prescription guidelines using lower prescription quantities would encourage opioid-related risk reduction while providing adequate postoperative analgesia. Recommended quantities for postoperative prescriptions were generated using the 80th percentile consumed and were 0 to 6 pills for brachiobasilic or brachiocephalic fistulas, 0 to 5 pills for basilic vein transposition, 0 to 5 pills for radiocephalic AVF, 0 to 15 pills for upper arm grafts, and 0 to 10 pills for PD catheter placement.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jvs.2019.12.033DOI Listing
September 2020

Understanding Patients' Attitudes Toward Cancer Multidisciplinary Meetings: A Mixed Methods Study.

JCO Oncol Pract 2020 02 7;16(2):e175-e182. Epub 2020 Jan 7.

Department of Medicine, Eastern Hill Clinical School, University of Melbourne, Melbourne, Victoria, Australia.

Purpose: Multidisciplinary cancer meetings (MDMs) are an integral component of quality care; however, little research exists regarding patients' views on this model of care. We aimed to explore and understand the attitudes of patients toward MDMs.

Methods: A mixed methods exploratory design was used. Qualitative data from patients with a current or previous diagnosis of cancer were collected and analyzed using a grounded theory approach. Results informed the development of a questionnaire survey that was administered to patients with a current or previous diagnosis of cancer. Results were analyzed using descriptive statistics.

Results: Nine patients participated in 3 focus groups, and 152 patients (response rate, 90%) completed the questionnaire. Patients were strongly supportive of MDMs and thought that all patients with cancer should be routinely discussed. More than 90% of surveyed patients believed MDMs were reassuring, meant all treatment modalities were considered, and led to evidence-based treatment recommendations. Patients wanted MDMs to focus on medical treatment planning rather than psychosocial issues, and 87% regarded the meeting as confidential. Patients described a preference for doctor-led decision making, and most (84%) wanted MDM treatment decisions to be discussed with them in a subsequent consultation, with 73% of patients also wanting this in a written format.

Conclusion: Patients strongly endorse MDMs as a means to develop an evidence-based, medical treatment plan agreed to by consensus. They want to be purposely informed of the meeting and its outcomes. Results from this study can help inform future guidelines on the conduct of MDMs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1200/JOP.19.00274DOI Listing
February 2020

Who is asking about medicinal cannabis in palliative care?

Intern Med J 2020 02;50(2):243-246

Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia.

Following legislative changes in the availability and prescribing of medicinal cannabis in Australia, we sought to understand prospectively the nature of information seeking and requests for medicinal cannabis in consultations between palliative care clinicians and patients with cancer. The 104 discussions were overwhelmingly initiated by patients and carers (93%) and were for a variety of symptoms, reflecting high levels of patient interest in the use of medicinal cannabis in cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/imj.14732DOI Listing
February 2020

Prevalence of QTc Prolongation in Patients With Advanced Cancer Receiving Palliative Care-A Cause for Concern?

J Pain Symptom Manage 2020 04 19;59(4):856-863. Epub 2019 Dec 19.

University of Melbourne and St. Vincent's Hospital, Melbourne, Victoria, Australia.

Context: Medications commonly used for symptom control along with other known risk factors have the potential to prolong ventricular repolarization as measured by the QT interval (the time from the start of the Q wave to the end of the T wave) on a standard electrocardiogram (ECG).

Objectives: To document the prevalence of a prolonged QT interval corrected for heart rate (QTc) interval in the palliative/oncology setting, compare automatic ECG QTc measurements with manual readings and identify any correlation between QTc prolongation and the use of drugs or other risk factors.

Methods: A convenience sample of consecutive patients with cancer, admitted under or known to the palliative/supportive care teams in two metropolitan hospitals, and willing to provide an ECG recording and basic demographic information including QTc risk factors were included. Both automated and manually calculated QTc intervals were recorded. Multivariable analysis was used to determine risk factors independently associated with prolonged QTc intervals.

Results: Of the 389 participants, there was a significant difference in mean QTc between sites using automated but not manual calculations. Manual readings were therefore used with predetermined cutoffs of 0.44 seconds (males) and 0.46 seconds (females). Seventy-two (18.5%) of the participants had a prolonged QTc with six (1.5%) having a prolongation of >0.50 seconds. At-risk drugs were being taken by 218 participants (56.0% of total cohort). Factors shown to be associated with QTc prolongation included age, gender, performance status, and hypocalcemia. No specific medication was associated with increased risk.

Conclusion: Although almost 20% of patients receiving palliative care had prolongation of QTc, the possibility of serious consequences appeared to be low despite the frequent occurrence of risk factors.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpainsymman.2019.12.356DOI Listing
April 2020

Moral Distress in Nephrology: Perceived Barriers to Ethical Clinical Care.

Am J Kidney Dis 2020 08 19;76(2):248-254. Epub 2019 Dec 19.

St George Hospital, Kogarah, NSW, Australia.

Moral distress occurs when individuals are unable to act in accordance with what they believe to be ethically correct or just. It results from a discrepancy between a clinician's perception of "the right thing to do" and what is actually happening and is perpetuated by perceived constraints that limit the individual from speaking up or enacting change. Moral distress is reported by many clinicians in caring for patients with serious illness, including chronic kidney disease and kidney failure. If left unidentified, unexpressed, or unaddressed, moral distress may cause burnout, exhaustion, detachment, and ineffectiveness. At an extreme, moral distress may lead to a desire to abandon the speciality entirely. This article offers an international perspective on moral distress in nephrology in diverse contexts and health care systems. We examine and discuss the sociocultural factors that contribute to moral distress in nephrology and offer suggestions for interventions from individual provider, facility, and health care systems perspectives to reduce the impact of moral distress on nephrology providers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.ajkd.2019.09.018DOI Listing
August 2020