Transition Points for the Routine Integration of Palliative Care in Patients With Advanced Cancer

Collins, Anna; Sundararajan, Vijaya; Burchell, Jodie; Millar, Jeremy; McLachlan, Sue Anne; Krishnasamy, Meinir; Le, Brian; Mileshkin, Linda; Hudson, Peter; Philip, Jennifer

doi:10.1016/j.jpainsymman.2018.03.022

Cited by 39 publications

(52 citation statements)

References 33 publications

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“…We advocate that benchmarks for palliative care engagement at standardised time‐points should be added to the patient‐reported outcome set. We propose that the standardised time for palliative care referral should be at first multiday admission with mPCa , as a minimum requirement, and should occur earlier if particular needs are identified. This time‐point would be readily identifiable, and, based upon these data, represents a time of high health service use and poor prognosis.…”

Section: Discussionmentioning

confidence: 99%

The trajectory of patients who die from metastatic prostate cancer: a population‐based study

et al. 2018

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ObjectivesTo describe health service use, symptom and survival characteristics in metastatic prostate cancer (mPCa) in order to outline usual care practices and identify future opportunities to improve the quality of care in this patient group. Patients and MethodsThis population cohort study, conducted in Victoria, Australia, used 10 years (2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009)(2010) of linked hospital discharge, emergency visit, and death registration data, to track patients from their first inpatient admission with mPCa until death. Descriptive statistics on inpatient health service use, symptoms, procedures, survival, and place of death are presented. ResultsIn all, 4436 patients survived a median (interquartile range [IQR]) of 4 (1, 12) months from their first multiday admission with mPCa. They had a median (IQR) of 3 (1, 9) admissions, 1 (0, 2) emergency department presentation, and 35 (18, 63) days admitted to hospital. Lower urinary tract symptoms were common (50%), and 21% underwent lower urinary tract procedures, whilst 48% had blood product transfusions. In the last month of life, 3685 (83%) had at least one indicator of aggressive end-of-life care, including 48% with more than one acute hospital admission, and 55% staying ≥14 days. Hospital-based palliative care was accessed by 2657 (60%), occurring a median (IQR) of 30 (11, 74) days before death. In all, 23% died in the community, whilst 77% died in hospital, of whom 55% died in an acute hospital bed. ConclusionHalf of all decedents first admitted for a multiday stay with mPCa survived <4 months thereafter. They had a marked symptom burden, underwent multiple procedures and had multiple admissions. In all, 40% of patients did not receive any hospital-based palliative care. Several opportunities exist to improve the timely transition to palliative care services with mPCa. These data form a benchmark against which future improvements to palliative care integration may be measured.

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Section: Discussionmentioning

confidence: 99%

The trajectory of patients who die from metastatic prostate cancer: a population‐based study

et al. 2018

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“…We have defined such transitions that are evidencebased, disease-specific, and anchored in episodes of engagement with health services, with increasing engagement heralding change in illness course. 2 These are times of key change in the illness. For example, a hospital admission for a patient with prostate cancer with metastatic disease heralds subsequent poor prognosis and higher health service utilisation.…”

Section: When Should Palliative Care Be Introduced?mentioning

confidence: 99%

“…For example, a hospital admission for a patient with prostate cancer with metastatic disease heralds subsequent poor prognosis and higher health service utilisation. 2 This admission therefore acts as a transition point and may prompt the clinician to consider additional domains to care, including, for example, referral to specialist palliative care. So defined, the illness transition is grounded in care systems and health service data can be used to raise an automated prompt to clinicians.…”

Section: When Should Palliative Care Be Introduced?mentioning

confidence: 99%

“…In Victoria, Australia, just 59% of patients with cancer access hospital-based palliative care, and this occurs 27 days (median) before death. 2 For 61% of those who die in hospital, first access to palliative care occurs in this final admission which concludes with their death. 2 For patients with non-malignant disease, access is both less and later.…”

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confidence: 99%

“…2 For 61% of those who die in hospital, first access to palliative care occurs in this final admission which concludes with their death. 2 For patients with non-malignant disease, access is both less and later. In a UK cohort of 42,758 decedents, access to palliative care for those with cancer was significantly longer than for those with non-malignant disease (53 vs. 27 days).…”

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Defining ‘transition points’ in the illness course as standardised times to integrate palliative care

Philip¹,

Collins

2019

Progress in Palliative Care

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Despite emerging evidence of the benefits of palliative care, and the apparent match of this form of care with patient preferences in the setting of advanced disease, there remains marked variability and many gaps in access to palliative care. A series of barriers to accessing services include appropriate timing of introduction of palliative care, who requires these services and how they should be delivered. In this editorial, we raise the concept of evidence-based illness transitions as a solution to some of these barriers. Drawing on literature detailing integration of palliative care, these transitions are described as standardised points reached in an illness course, objectively identified and which herald a time of greater needfor care, for symptom relief. These transition points may be based in health service use milestones. By linking a clinician prompt to a transition point, a 'flag' can be raised for the clinician to consider tasks of palliative care or indeed a palliative care referral. In this way, through identification and use of illness transitions, integration of high quality end of life care can become standardised across populations and benchmarks for care can be established.

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Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

Grant,

McCarthy,

Kearney

et al. 2024

Support Care Cancer

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Purpose Health service use is most intensive in the final year of a person’s life, with 80% of this expenditure occurring in hospital. Close involvement of primary care services has been promoted to enhance quality end-of-life care that is appropriate to the needs of patients. However, the relationship between primary care involvement and patients’ use of hospital care is not well described. This study aims to examine primary care use in the last year of life for cancer patients and its relationship to hospital usage. Methods Retrospective cohort study in Victoria, Australia, using linked routine care data from primary care, hospital and death certificates. Patients were included who died related to cancer between 2008 and 2017. Results A total of 758 patients were included, of whom 88% (n = 667) visited primary care during the last 6 months (median 9.1 consultations). In the last month of life, 45% of patients were prescribed opioids, and 3% had imaging requested. Patients who received home visits (13%) or anticipatory medications (15%) had less than half the median bed days in the last 3 months (4 vs 9 days, p < 0.001, 5 vs 10 days, p = 0.001) and 1 month of life (0 vs 2 days, p = 0.002, 0 vs 3 days, p < 0.001), and reduced emergency department presentations (32% vs 46%, p = 0.006, 31% vs 47% p < 0.001) in the final month. Conclusion This study identifies two important primary care processes—home visits and anticipatory medication—associated with reduced hospital usage and intervention at the end of life.

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Transition Points for the Routine Integration of Palliative Care in Patients With Advanced Cancer

Cited by 39 publications

References 33 publications

The trajectory of patients who die from metastatic prostate cancer: a population‐based study

The trajectory of patients who die from metastatic prostate cancer: a population‐based study

Defining ‘transition points’ in the illness course as standardised times to integrate palliative care

Primary care usage at the end of life: a retrospective cohort study of cancer patients using linked primary and hospital care data

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