Lessons from the Literature

2020; Volume 21, No 2, February

Lessons from the Literature

Under My Microscope

Dr. Tania Pastrana. Used with permission.

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Association between the Implementation of Hospital-Based Palliative Care and Use of Intensive Care during Terminal Hospitalizations

M Hua, Y Lu, Z Ma. Jama Netw Open 2020; 3(1): e1918675. DOI: 10.1001/jamanetworkopen.2019.18675

I found this paper when looking for one at the edges of palliative care; it was written by a group of medical doctors from Canada and the U.S. representing different specialties — anesthesiology, epidemiology, geriatrics and palliative medicine, critical care. It is well known that many patients at the end of life prefer to die at home or, at least, not isolated in the intensive care setting, which is considered a negative indicator for the quality of end-of-life care. The goal of intensive care is to discharge patients with recovered functions, to the greatest extent possible. Neither patients and families, nor health professionals, nor the health care system, want patients dying in the intensive care unit.

The researchers looked at the use of intensive care at the end of life for hospitalized patients, when palliative care services are implemented.

For this cohort study, 51 hospitals with and without palliative care programs were included and the records of 73,370 adults who died during hospitalization were analyzed. Of these, 51.3% were inpatients in hospitals with palliative care services and 48.7% were not.

An analysis of the data suggest that the implementation of palliative care at a hospital was associated with a 10% reduction in intensive care unit use and, consequently, better ratings of quality of life, quality of death, and quality of end-of-life care.

A deeper investigation of the individual cases as well as of provided services and circumstances would be useful to further understand the relationship between palliative care and intensive care for “the better care of the dying,” which is everyone’s wish.

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Importance: The use of intensive care at the end of life continues to be common. Although the provision of palliative care has been advocated as a way to mitigate the use of high-intensity care, it is unknown whether implementation of hospital-based palliative care services is associated with reduced use of intensive care at the end of life.

Objective:To determine whether implementation of hospital-based palliative care services is associated with decreased intensive care unit (ICU) use during terminal hospitalizations.

Design, setting, and participants: This cohort study included 51 hospitals in New York State that either did or did not implement a palliative care program between 2008 and 2014. Hospitals that consistently had a palliative care program during the study period were excluded. Participants were adult patients who died during hospitalization. Data analysis was performed between January 2018 and July 2019.

Exposure:Implementation of a palliative care program.

Main outcomes and measures: The primary outcome was ICU use. A difference-in-differences analysis was performed using multilevel regression to assess the association between implementing a palliative care program and ICU use during terminal hospitalizations while adjusting for patient and hospital characteristics and time trends.

Results: During the study period, 73 370 patients (mean [SD] age, 76.5 [14.1] years; 38 467 [52.4%] women) died during hospitalization, of whom 37 628 (51.3%) received care in hospitals that implemented palliative care services and 35 742 (48.7%) received care in a hospital without palliative care implementation. Patients who received care in hospitals after implementation of palliative care services were less likely to receive intensive care than patients admitted to the same hospitals before implementation (49.3% vs 52.8%; difference 3.5%; 95% CI, 2.5%-4.5%; P < .001). Compared with hospitals that never had a palliative care program, the implementation of palliative care was associated with a 10% reduction in ICU use during terminal hospitalizations (adjusted relative risk, 0.90; 95% CI, 0.85-0.95; P < .001).

Conclusions and relevance: The implementation of hospital-based palliative care services in New York State was associated with a modest reduction in ICU use during terminal hospitalizations.

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Media Watch: Grief & Bereavement

Different forms of grief have gained increasing attention; initiatives within the hospice and palliative care communities address what is widely seen as a public health issue. The articles below are selected from Barry R. Ashpole’s weekly report, Media Watch.

Grief, Bereavement, and Coping with Loss

PDQ Supportive & Palliative Care Editorial Board | Online – 15 November 2019 – This summary first defines the constructs of grief, mourning, and bereavement. It then distinguishes the grief reactions of anticipatory grief, prolonged complicated grief, normal or common grief, and models of normal grief, and complicated or prolonged grief. Psychosocial and pharmacologic treatments are explained. The important developmental issues of children and grief are presented, and a section on cross-cultural responses to grief and mourning concludes the summary. The information combines theoretical and empirical reviews of the general literature on grief, bereavement, and mourning. Evidence and practice issues as they relate to adults are discussed. The evidence and application to practice related to children may differ significantly.

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Can a Single Question about Family Members’ Sense of Security during Palliative Care Predict Their Well-Being during Bereavement? A longitudinal study during ongoing care and one year after the patient’s death

BMC Palliative Care | Online – 25 July 2019 – The findings of this study reveal possibilities to identify family members at risk of negative adjustment to bereavement in clinical practice and may help to develop interventions to support family members during ongoing palliative care (PC). Family members were asked, “How often have you felt secure?” during the period of palliative care. Sixteen variables were positively related to family members’ sense of security. The five variables with the highest importance were selected into the model (in decreasing importance): 1) Family members’ mastery; 2) Nervousness and stress; 3) Self-efficacy; 4) Patient having gynecological cancer; and 5) Family members’ perceived quality of life. The family members’ sense of security during ongoing PC predicted 10 variables indicating their well-being one year after the patient’s death, e.g., psychological well-being, complicated grief symptoms, and health-related quality of life. DOI: 10.1186/s12904-019-0446-1

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Matching Response to Need: What makes social networks fit for providing bereavement support?

Plos One | Online – 7 March 2019 – The research literature emphasizes the many negative consequences of bereavement, with increases in physical and psychological morbidity and mortality, and the disruption of social relationships being primary determinants of both health and mortality. This puts the impact of bereavement squarely into a public health perspective that pursues health equity. The authors argue for adopting and strengthening a compassionate communities approach, not only for end-of-life care for dying people but also along the continuum of bereavement support. To support this approach, more research is needed into practice models that connect health and social services with local neighbourhoods and cultural life. Settings such as workplaces, schools, social and sporting clubs, and faith communities all have potential in making these connections. DOI: a10.1371/journal.pone.0213367

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  1. (Special issue) Critical Explorations of Marginalized Grief. Illness, Crisis, and Loss, 2020; 27(1).
  2. (Special issue) Bereavement Care. Nursing in Critical Journal, 2020; 24(4): 183-245.
  3. Bereavement and Persistent Grief: Mental health considerations. Depression & Anxiety, 2020; 37(1): 1-98.
  4. (Editorial) American Journal of Bioethics: 50th Anniversary of On Death & Dying by Elisabeth Kübler-Ross
  5. Crossroads of Grief Project: Grieving or Bereaved Children Literature Review

Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.

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