Impact of a Palliative Care Nurse Practitioner in an Oncology Clinic: A Quality Improvement Effort

2021 ◽  
Author(s):  
Sarah F. D'Ambruoso ◽  
John A. Glaspy ◽  
Sara A. Hurvitz ◽  
Neil S. Wenger ◽  
Christopher Pietras ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advanced Cancer ◽  
Advance Care Planning ◽  
Nurse Practitioner ◽  
Care Delivery ◽  
Skills Training ◽  
Care Planning ◽  
Care Nurse ◽  
Advance Care

PURPOSE: Guidelines support early integration of palliative care (PC) into standard oncology practice; however, little is known as to whether outcomes can be improved by modifying health care delivery in a real-world setting. METHODS: We report our 6-year experience of embedding a nurse practitioner in an oncology clinic (March 2014-March 2020) to integrate early, concurrent advance care planning and PC. RESULTS: Compared with patients with advanced cancer not enrolled in the palliative care nurse practitioner program, in March 2020, patients who are enrolled are more likely to have higher quality of PC (eg, goals of care note documentation [82% v 15%; P < .01], referral to the psychosocial oncology program [67% v 37%; P < .01], and referral to hospice [61% v 34%; P < .01]) and less inpatient utilization in the last 6 months of life (eg, hospital days [12 v 18; P < .01] and intensive care unit days [1.2 v 2.3; P < .01]). The program expanded over time with the support of faculty skills training for advance care planning and PC, supporting a shared mental model of PC delivery within the oncology clinic. CONCLUSION: Embedding a trained palliative care nurse practitioner in oncology clinics to deliver early integrated PC can lead to improved quality of care for patients with advanced cancer.

scholarly journals Effect and Efficiency of an Embedded Palliative Care Nurse Practitioner in an Oncology Clinic

2017 ◽  
Vol 13 (9) ◽  
pp. e792-e799 ◽  
Author(s):  
Anne M. Walling ◽  
Sarah F. D’Ambruoso ◽  
Jennifer L. Malin ◽  
Sara Hurvitz ◽  
Ann Zisser ◽  
...  
Keyword(s):  
Palliative Care ◽  
Advanced Cancer ◽  
Advance Care Planning ◽  
Nurse Practitioner ◽  
Implementation Strategies ◽  
Care Planning ◽  
Care Nurse ◽  
Time Motion ◽  
Symptom Screening ◽  
Advance Care

Purpose: To test a simultaneous care model for palliative care for patients with advanced cancer by embedding a palliative care nurse practitioner (NP) in an oncology clinic. Methods: We evaluated the effect of the intervention in two oncologists’ clinics beginning March 2014 by using implementation strategies, including use of a structured referral mechanism, routine symptom screening, integration of a psychology-based cancer supportive care center, implementation team meetings, team training, and a metrics dashboard for continuous quality improvement. After 1 year of implementation, we evaluated key process and outcome measures for supportive oncology and efficiency of the model by documenting tasks completed by the NP during a subset of patient visits and time-motion studies. Results: Of approximately 10,000 patients with active cancer treated in the health system, 2,829 patients had advanced cancer and were treated by 42 oncologists. Documentation of advance care planning increased for patients of the two intervention oncologists compared with patients of the other oncologists. Hospice referral before death was not different at baseline, but was significantly higher for patients of intervention oncologists compared with patients of control oncologists (53% v 23%; P = .02) over the intervention period. Efficiency evaluation revealed that approximately half the time spent by the embedded NP potentially could have been completed by other staff (eg, a nurse, a social worker, or administrative staff). Conclusion: An embedded palliative care NP model using scalable implementation strategies can improve advance care planning and hospice use among patients with advanced cancer.

scholarly journals Perceptions of involvement in advance care planning and emotional functioning in patients with advanced cancer

2021 ◽  
Author(s):  
Lente L. Kroon ◽  
◽  
Janneke van Roij ◽  
Ida J. Korfage ◽  
An K. L. Reyners ◽  
...  
Keyword(s):  
Quality Of Care ◽  
Medical Treatment ◽  
Advanced Cancer ◽  
Advance Care Planning ◽  
Emotional Functioning ◽  
Solid Cancer ◽  
Care Planning ◽  
Advance Care ◽  
Prospective Longitudinal

Abstract Purpose Advance Care Planning (ACP) is positively associated with the quality of care, but its impact on emotional functioning is ambiguous. This study investigated the association between perceptions of ACP involvement and emotional functioning in patients with advanced cancer. Methods This study analyzed baseline data of 1,001 patients of the eQuiPe study, a prospective, longitudinal, multicenter, observational study on quality of care and quality of life in patients with advanced cancer in the Netherlands. Patients with metastatic solid cancer were asked to participate between November 2017 and January 2020. Patients’ perceptions of ACP involvement were measured by three self-administered statements. Emotional functioning was measured by the EORTC-QLQ-C30. A linear multivariable regression analysis was performed while taking gender, age, migrant background, education, marital status, and symptom burden into account. Results The majority of patients (87%) reported that they were as much involved as they wanted to be in decisions about their future medical treatment and care. Most patients felt that their relatives (81%) and physicians (75%) were familiar with their preferences for future medical treatment and care. A positive association was found between patients’ perceptions of ACP involvement and their emotional functioning (b=0.162, p<0.001, 95%CI[0.095;0.229]) while controlling for relevant confounders. Conclusions Perceptions of involvement in ACP are positively associated with emotional functioning in patients with advanced cancer. Future studies are needed to further investigate the effect of ACP on emotional functioning. Trial registration number NTR6584 Date of registration: 30 June 2017 Implications for Cancer Survivors Patients’ emotional functioning might improve from routine discussions regarding goals of future care. Therefore, integration of ACP into palliative might be promising.

scholarly journals Palliative Care and Advance Care Planning in Pulmonary Hypertension

2018 ◽  
Vol 17 (1) ◽  
pp. 15-19 ◽  
Author(s):  
Charles L. Rhee ◽  
Michael Cuttica
Keyword(s):  
Palliative Care ◽  
Pulmonary Hypertension ◽  
Advance Care Planning ◽  
End Of Life Care ◽  
Progressive Disease ◽  
Care Planning ◽  
Care Providers ◽  
Advance Care

Pulmonary hypertension (PH) is a progressive disease with high associated morbidity and mortality despite the development of novel therapies. Palliative care is a multidisciplinary field focused on optimization of quality of life and overall supportive care for patients and their families in the setting of life-limiting illness. Although the benefits of palliative care in oncology are well described, there are few studies regarding the timing and involvement of palliative care in PH patients. In this paper, we describe the importance of longitudinal advance care planning, including suggestions for addressing difficult topics such as end-of-life care, and the role of palliative care providers in helping guide these discussions throughout the course of the illness.

Outcomes Associated with End-of-Life Discussions (DRAFT)

2018 ◽  
Author(s):  
Masanori Mori
Keyword(s):  
Quality Of Life ◽  
End Of Life ◽  
Cancer Patients ◽  
Advanced Cancer ◽  
Advance Care Planning ◽  
Care Planning ◽  
Advanced Cancer Patients ◽  
Advance Care ◽  
Aggressive Care

Physicians and advanced cancer patients are often reluctant to talk about death. They frequently avoid end-of-life discussions (EOLds), although such conversations are essential to initiate advance care planning. In this prospective, a longitudinal multisite cohort study of advanced cancer patients and their informal caregivers, the authors suggested cascading benefits of EOLds between patients and their physicians. In total, 123 of 332 (37.0%) patients reported having EOLds with their physicians at baseline. EOLds were not associated with higher rates of emotional distress or psychiatric disorders. Instead, after propensity-score weighted adjustment, EOLds were associated with less aggressive medical care near death and earlier hospice referrals. Aggressive care was associated with worse patient quality of life and worse bereavement adjustment. These findings may help destigmatize EOLds and assist physicians and patients in initiating such conversations and engaging in advance care planning.

scholarly journals Designing a Mission statement Mobile app for palliative care: an innovation project utilizing design-thinking methodology

2020 ◽  
Vol 19 (1) ◽  
Author(s):  
Rakhshan Kamran ◽  
Arianna Dal Cin
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Mobile Application ◽  
Design Thinking ◽  
Mission Statement ◽  
Care Delivery ◽  
Mobile App ◽  
Care Planning ◽  
Individual Values ◽  
Advance Care

Abstract Background Eliciting individual values and preferences of patients is essential to delivering high quality palliative care and ensuring patient-centered advance care planning. Despite advance care planning conserving healthcare costs by up to 36%, reducing psychological distress of patients and caregivers, and ensuring palliative care delivery in line with patient wishes, less than 33% of adults engage in it. We aimed to develop a mobile application intervention to address the challenges related to advance care planning and improve the delivery of palliative care. Methods Design-thinking methodology was used to develop a mobile application, in response to issues prominently identified in current palliative care literature. Results Issues surrounding communication of patient values from both the patient and provider side is identified as a main issue in palliative care. We designed a mobile application intervention prototype to address this. Conclusions Our “Mission Statement” mobile application will allow patients to create a mission statement identifying what they want their care team to know about them, as well as space to identify important values and preferences. Patients will be able to evolve their mission statement and values and preferences over the course of their palliative care journey through the application. Design-thinking methodology is an effective tool to drive healthcare innovation and bridge the gap between research findings and implementation.

scholarly journals Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients

2003 ◽  
Vol 18 (7) ◽  
pp. 1345-1352 ◽  
Author(s):  
S. D. Weisbord ◽  
S. S. Carmody ◽  
F. J. Bruns ◽  
A. J. Rotondi ◽  
L. M. Cohen ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
Advance Care Planning ◽  
Symptom Burden ◽  
Care Planning ◽  
Potential Value ◽  
Advance Care

scholarly journals Palliative care in day-hospital for advanced cancer patients: a study protocol for a multicentre randomized controlled trial

2021 ◽  
Vol 20 (1) ◽  
Author(s):  
Laura Thery ◽  
Amélie Anota ◽  
Lorraine Waechter ◽  
Celine Laouisset ◽  
Timothee Marchal ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Palliative Care ◽  
Advanced Cancer ◽  
End Of Life Care ◽  
Care Planning ◽  
Life Care ◽  
Day Hospital ◽  
Advanced Cancer Patients ◽  
Advance Care

Abstract Background Team-based and timely integrated palliative care is a gold standard of care in oncology, but issues concerning its optimal organization remain. Palliative Care in Day-Hospital (PCDH) could be one of the most efficient service model of palliative care to deliver interdisciplinary and multidimensional care addressing the complex supportive care needs of patients with advanced cancer. We hypothesize that, compared to conventional outpatient palliative care, PCDH allows the clinical benefits of palliative care to be enhanced. Methods/design This study is a multicentre parallel group trial with stratified randomization. Patient management in PCDH will be compared to conventional outpatient palliative care. The inclusion criteria are advanced cancer patients referred to a palliative care team with an estimated life expectancy of more than 2 months and less than 1 year. The primary endpoint is health-related quality of life with deterioration-free survival based on the EORTC QLQ-C30 questionnaire. The secondary objectives are the following: increase in patient satisfaction with care using the EORTC PATSAT-C33 and OUT-PATSAT7 questionnaires, better understanding of the prognosis using the PTPQ questionnaire and advance care planning; decrease in the need for supportive care among relatives using the SCNS-P&C-F questionnaire, and reduction in end-of-life care aggressiveness. Patients will complete one to five questionnaires on a tablet before each monthly visit over 6 months and will be followed for 1 year. A qualitative study will take place, aiming to understand the specificity of palliative care management in PCDH. Cost-effectiveness, cost-utility and, an additional economic evaluation based on capability approach will be conducted from a societal point of view. Discussion The first strength of this study is that it combines the main relevant outcomes assessing integrated palliative care; patient quality of life and satisfaction; discussion of the prognosis and advance care planning, family well-being and end-of-life care aggressiveness. The second strength of the study is that it is a mixed-method study associating a qualitative analysis of the specificity of PCDH organization, with a medical-economic study to analyse the cost of care. Trial registration Name of the registry: IDRCB 2019-A03116–51 Trial registration number:NCT04604873 Date of registration: October 27, 2020 URL of trial registry record

scholarly journals Advance care planning in patients with advanced cancer: A 6-country, cluster-randomised clinical trial

PLoS Medicine ◽  
2020 ◽  
Vol 17 (11) ◽  
pp. e1003422
Author(s):  
Ida J. Korfage ◽  
Giulia Carreras ◽  
Caroline M. Arnfeldt Christensen ◽  
Pascalle Billekens ◽  
Louise Bramley ◽  
...  
Keyword(s):  
Quality Of Life ◽  
Decision Making ◽  
Palliative Care ◽  
Advanced Cancer ◽  
Care Planning ◽  
Shared Decision ◽  
Specialist Palliative Care ◽  
Cluster Randomised ◽  
Advance Care

Background Advance care planning (ACP) supports individuals to define, discuss, and record goals and preferences for future medical treatment and care. Despite being internationally recommended, randomised clinical trials of ACP in patients with advanced cancer are scarce. Methods and findings To test the implementation of ACP in patients with advanced cancer, we conducted a cluster-randomised trial in 23 hospitals across Belgium, Denmark, Italy, Netherlands, Slovenia, and United Kingdom in 2015–2018. Patients with advanced lung (stage III/IV) or colorectal (stage IV) cancer, WHO performance status 0–3, and at least 3 months life expectancy were eligible. The ACTION Respecting Choices ACP intervention as offered to patients in the intervention arm included scripted ACP conversations between patients, family members, and certified facilitators; standardised leaflets; and standardised advance directives. Control patients received care as usual. Main outcome measures were quality of life (operationalised as European Organisation for Research and Treatment of Cancer [EORTC] emotional functioning) and symptoms. Secondary outcomes were coping, patient satisfaction, shared decision-making, patient involvement in decision-making, inclusion of advance directives (ADs) in hospital files, and use of hospital care. In all, 1,117 patients were included (442 intervention; 675 control), and 809 (72%) completed the 12-week questionnaire. Patients’ age ranged from 18 to 91 years, with a mean of 66; 39% were female. The mean number of ACP conversations per patient was 1.3. Fidelity was 86%. Sixteen percent of patients found ACP conversations distressing. Mean change in patients’ quality of life did not differ between intervention and control groups (T-score −1.8 versus −0.8, p = 0.59), nor did changes in symptoms, coping, patient satisfaction, and shared decision-making. Specialist palliative care (37% versus 27%, p = 0.002) and AD inclusion in hospital files (10% versus 3%, p < 0.001) were more likely in the intervention group. A key limitation of the study is that recruitment rates were lower in intervention than in control hospitals. Conclusions Our results show that quality of life effects were not different between patients who had ACP conversations and those who received usual care. The increased use of specialist palliative care and AD inclusion in hospital files of intervention patients is meaningful and requires further study. Our findings suggest that alternative approaches to support patient-centred end-of-life care in this population are needed. Trial registration ISRCTN registry ISRCTN63110516.

Measure Scan and Synthesis of Palliative and End-of-Life Process Quality Measures for Advanced Cancer

2020 ◽  
pp. OP.20.00240
Author(s):  
Claire E. O’Hanlon ◽  
Charlotta Lindvall ◽  
Karl A. Lorenz ◽  
Karleen F. Giannitrapani ◽  
Melissa Garrido ◽  
...  
Keyword(s):  
Palliative Care ◽  
End Of Life ◽  
Advanced Cancer ◽  
End Of Life Care ◽  
Quality Measures ◽  
Process Quality ◽  
Care Planning ◽  
Life Care ◽  
Advance Care

PURPOSE: Monitoring and improving the quality of palliative and end-of-life cancer care remain pressing needs in the United States. Among existing measures that assess the quality of palliative and end-of-life care, many operationalize similar concepts. We identified existing palliative care process measures and synthesized these measures to aid stakeholder prioritization that will facilitate health system implementation in patients with advanced cancer. METHODS: We reviewed MEDLINE/PubMed-indexed articles for process quality measures related to palliative and end-of-life care for patients with advanced cancer, supplemented by expert input. Measures were inductively grouped into “measure concepts” and higher-level groups. RESULTS: Literature review identified 226 unique measures from 23 measure sources, which we grouped into 64 measure concepts within 12 groups. Groups were advance care planning (11 measure concepts), pain (7), dyspnea (9), palliative care–specific issues (6), other specific symptoms (17), comprehensive assessment (2), symptom assessment (1), hospice/palliative care referral (1), spiritual care (2), mental health (5), information provision (2), and culturally appropriate care (1). CONCLUSION: Measure concepts covered the spectrum of care from acute symptom management to advance care planning and psychosocial needs, with variability in the number of measure concepts per group. This taxonomy of process quality measure concepts can be used by health systems seeking stakeholder input to prioritize targets for improving palliative and end-of-life care quality in patients with advanced cancer.

Gute Lebens- und Sterbensqualität – Versorgung und Versorgungslücken von Palliative Care in der Schweiz

2017 ◽  
Vol 74 (1) ◽  
pp. 805-811 ◽  
Author(s):  
Tanja Krones ◽  
Settimio Monteverde
Keyword(s):  
Palliative Care ◽  
Advance Care Planning ◽  
Palliative Care Team ◽  
Care Team ◽  
Care Planning ◽  
Quality Of Death ◽  
Advance Care

Zusammenfassung. Der medizinische Fortschritt erforderte eine grundlegenden Neubesinnung über das Verhältnis von Medizin und Tod. Paradigmatisch vollzogen wurde diese erstmals durch das Wirken der Krankenschwester, Sozialarbeiterin und Ärztin Cicely Saunders, die das Zulassen und das Gestalten des letzten Lebensabschnitts als genuinen Auftrag der Medizin verstand, klinisch konsequent umsetzte und erforschte. Durch die WHO-Definition der Palliative Care wurde die globale, kultur- und systemübergreifende Bedeutung des Themas ins Bewusstsein gerufen. Bald schon konnte die Forschung die Wirksamkeit von Palliative Care auf die Lebensqualität unheilbar kranker und sterbender Menschen belegen. Aber auch Faktoren wie die Belastung pflegender Angehöriger oder der wirksame Einsatz von Gesundheitsressourcen können durch Palliative Care positiv beeinflusst werden. Auch in der Schweiz hat sich Palliative Care in den Versorgungsstrukturen des Gesundheitswesens gut etabliert, was dem Zusammenwirken verschiedener Akteure aus der Ebene der Gesundheitspolitik, der Patientenversorgung und der privaten Initiative zu verdanken ist. Trotzdem belegt die Schweiz in der Quality of Death Studie des „Economist“ weltweit keinen der vorderen Plätze, wofür gemäss Studie gerade auch Finanzierungslücken in der Palliative Care verantwortlich gemacht werden. Dieser Beitrag zeigt, wie schwierig es ist, Palliative Care als Teil einer flächendeckenden Gesundheitsversorgung zu verstehen und umzusetzen. Auch die mit Palliative Care verbundene finanzielle Belastung für Einzelne und Haushalte ist dabei nicht ausser Acht zu lassen. Aufbauend auf bisherigen Bemühungen sind weitere Schritte in Richtung flächendeckender Implementierung nötig, die dem Motto „The palliative care team follows the patient“ („engl. „Das Palliative Care Team folgt dem Patienten“) folgen und problematische implizite Steuerungseffekte aufgrund bestehender Finanzierungslücken aufdecken. Als Möglichkeit einer solchen integrierten, patientenzentrierten Palliative Care Versorgung wird das Konzept des Advance Care Planning ausgeführt.

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