Randomized controlled trial (RCT) of symptom screening with targeted early palliative care (STEP) versus usual care in patients with advanced cancer

Background: To direct limited specialized palliative care resources to patients in greatest need, we developed STEP (Symptom screening with Targeted Early Palliative care). STEP entails symptom screening (ESAS-r) at each oncology clinic visit and triggered alerts (for moderate-high physical and psychological symptoms) to a nurse who calls the patient to offer a palliative care clinic (PCC) visit. We conducted a phase III RCT to assess the impact of STEP versus usual care on quality of life and other patient-reported outcomes (PROs). Methods: Adults with advanced cancer were recruited from medical oncology clinics at the Princess Margaret Cancer Centre, Toronto, Canada. Consenting patients with oncologist-assessed ECOG 0-2 and estimated survival of 6-36 months were enrolled and block randomized (stratified by tumour site and symptom severity) to STEP or usual care. Participants completed measures of quality of life (FACT-G7), depression (PHQ-9), symptom control (ESASr-CS), and satisfaction with care (FAMCARE-P16) at baseline, 2, 4 and 6 months. The primary outcome was FACT-G7 at 6 months, with a planned sample size of 261/arm. Results: From 8/2019 to 3/2020, 69 patients were enrolled: 33 randomized to STEP and 36 to usual care. The trial was then halted permanently due to the COVID-19 pandemic, owing to substantial changes to elements of STEP (shift to virtual symptom screening and palliative care) and usual care (shift to virtual oncology care). Median age was 64 years (range 25-87) and 62% (43/69) were women;study arms were balanced at baseline except gender, with more women randomized to STEP. Within the STEP arm, 20 (61%) participants triggered a nurse's call to offer a PCC visit, of whom 13 attended the clinic at least once. All outcomes tended to be better in the STEP arm compared to usual care, particularly depression and satisfaction with care at 6 months;however, results were not statistically significant (Table). Conclusions: STEP holds promise for improving quality of life and other PROs in patients with advanced cancer and effectively directing early palliative care towards those who need it most. In response to the pandemic, an online version of STEP has been developed and a further trial is in progress.

Palliative care interventions for people who use substances during communicable disease outbreaks: a scoping review

Objectives When resources are strained during communicable disease outbreaks, novel palliative care interventions may be required to optimally support people who use substances with life-limiting illnesses. Therefore, we asked the question, € what is known about communicable disease outbreaks, palliative care and people who use substances?', such as palliative care interventions that can improve the quality of life of patients with life-limiting illnesses. Design We conducted a scoping review that involved comprehensive searches in six bibliographic databases from inception to April 2021 (Medline ALL (Medline and Epub Ahead of Print and In-Process and Other Non-Indexed Citations), Embase Classic+Embase, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trial, PsycInfo all from the OvidSP platform, Scopus from Elsevier) and grey literature searches. We included English and French records about people ≥18 years old with life-limiting illnesses who use substances during communicable disease outbreaks. We identified, summarised and presented the findings about palliative care interventions in figures, tables and narrative descriptions. Results We identified 32 records about palliative care interventions for people who use substances during communicable disease outbreaks. The majority focused on palliative care for people who use substances with AIDS during HIV epidemics (n=27, 84.4%), and approximately half were published in the USA (n=15, 46.9%). Most common substances used were alcohol (n=18, 56.3%), opioids (n=14, 43.8%) and cocaine (n=10, 31.3%). Four groups of palliative care interventions were identified: (1) symptom management (n=20, 62.5%), (2) psychosocial support (n=15, 46.9%), (3) advance care planning (n=8, 25.0%) and (4) healthcare provider training (n=6, 18.8%). Conclusions Beyond studies on HIV epidemics, there is limited knowledge about palliative care interventions for people who use substances during communicable disease outbreaks. Research and guidance are needed about how best to provide palliative care to this population with complex needs including in resource-limited countries. Protocol Buchman DZ, Ding P, Lo S, et al. Palliative care for people who use substances during communicable disease epidemics and pandemics. BMJ Open 2021;11: e053124

SYMPTOM SCREENING WITH TARGETED EARLY PALLIATIVE CARE (STEP) VERSUS USUAL CARE FOR PATIENTS WITH ADVANCED CANCER: A RANDOMIZED CONTROLLED TRIAL

Introduction To direct scant specialized palliative care (PC) resources to patients in greatest need, we developed the STEP intervention (Symptom screening with Targeted Early Palliative care). STEP entails symptom screening with ESAS-r at each oncology visit and triggered alerts (for moderatehigh symptoms) to a nurse who calls the patient to offer a PC clinic visit. Methods Consenting adults with advanced cancer, ECOG 0-2, attending medical oncology clinics at the Princess Margaret Cancer Centre, were randomized to STEP or usual care. Participants completed quality of life (FACTG7), depression (PHQ-9), symptom control (ESASr-CS), and satisfaction with care (FAMCARE-P16) measures at baseline, 2, 4, and 6 months. The primary outcome was FACT-G7 at 6 months. Results From August 2019 to March 2020, 33 patients were randomized to STEP and 36 to usual care. The trial was subsequently permanently halted due to the COVID-19 pandemic. Groups were balanced at baseline except gender, with more females in the STEP arm (Table 1). In the STEP arm, 20 participants triggered a nurse 's call, of whom 13 had ≥1 PC clinic visit. At 6 months, all outcomes tended to be better in the STEP arm compared to usual care, particularly depression and satisfaction with care;however, results were not statistically significant (Table 2, Figure 1). Conclusions STEP holds promise for improving outcomes in patients with advanced cancer. An online version (eSTEP) is being developed in response to the COVID-19 pandemic.

PATIENTS' EXPERIENCES WITH VIRTUAL OUTPATIENT PALLIATIVE CARE VISITS DURING THE COVID-19 PANDEMIC: A QUALITATIVE STUDY

Introduction Early palliative care, delivered in oncology palliative care clinics (OPCCs) typically involves in-person visits, but virtual care visits were adopted during the COVID-19 pandemic. This study aimed to explore patients' experiences of virtual visits to an OPCC at a tertiary cancer centre in Toronto, Canada during the pandemic. Methods One-on-one telephone interviews were conducted with patients who had a) at least one in-person visit to the OPCC prior to the pandemic, with subsequent virtual follow-up, or b) virtual visits only. Purposive sampling was used to ensure representation based on sex, age, distance from the cancer centre, and mode of virtual visits (telephone vs. video). Interviews were recorded and professionally transcribed;thematic analysis was used. Results Twenty-six patients were interviewed (17 had an in-person visit, 9 virtual only). Patients reported overall satisfaction with virtual care, appreciating that it reduced care disruption during the pandemic. An initial in-person visit was felt to assist with rapport-building with the team. Many participants wished to continue with virtual care beyond the pandemic, especially during periods of relative health stability. At transition points in care, or when advance care planning discussions were anticipated, inperson visits were preferred. Conclusions Virtual visits to the OPCC during the COVID-19 pandemic were feasible and appreciated by patients. The role of virtual care for select scenarios beyond the pandemic should be further explored.

Patients' experiences with virtual outpatient palliative care visits during the COVID-19 pandemic: a qualitative study

Background/aims: Early palliative care, delivered in oncology palliative care clinics (OPCCs) typically involves in-person visits. The COVID-19 pandemic necessitated rapid changes in the delivery of ambulatory care, and the adoption of virtual care where feasible. Aim: To determine the experiences of patients who switched from inperson to virtual visits to an OPCC at a tertiary cancer centre in Toronto, Canada during the COVID-19 pandemic. Methods: One-on-one telephone interviews were conducted with patients who had at least one in-person visit to the OPCC prior to the COVID-19 pandemic, and whose subsequent follow-up was switched to virtual visits. Purposive sampling was used to ensure representation based on sex, age, distance from their home to the cancer centre, and mode of virtual visits (telephone versus video). Interviews were recorded and professionally transcribed;thematic analysis was used. Results: Sixteen patients were interviewed, lasting between 20-60 minutes. Patients reported overall ease with the transition to virtual care, and appreciated that virtual care allowed for continuity of care without disruption during the pandemic. Previous in-person visits to the OPCC were felt to be advantageous in terms of rapport-building with the team, especially for the initial visit;non-verbal communication was highlighted. Many participants expressed a desire to have the option for virtual care beyond the pandemic, especially during periods of relative health stability. Conclusions: Virtual visits to the OPCC during the COVID-19 pandemic were feasible and appreciated by patients. The role of virtual care for select clinical scenarios beyond the pandemic should be further explored.

Relation carer–patient and teleconsultation

In France, teleconsultation and, more broadly, telemedicine have been encouraged for several years to respond to health issues. However, these practices have experienced difficulties in their development, mainly because caregivers are concerned that the carer-patient relationship might be altered. The COVID-19 health crisis led caregivers to experiment with these tools abruptly, in order to maintain the continuity of healthcare. Caregivers from the diabetes department of the University Hospital of Besançon (France) and patients who benefited from teleconsultation share the lessons learned from this experience, which most of them experienced positively, without altering the care relationship. This forced experimentation allowed the advantages and the limits of this practice to be revealed. It seems that in diabetology–endocrinology, teleconsultation provides an interesting opportunity, not to replace the physical consultation, but to offer a complementary solution, facilitating the follow-up of those patients who want it. Nevertheless, integrating quality teleconsultation into healthcare practices in the long-term requires certain conditions in terms of equipment, organization, coordination, training, and vigilance regarding the digital divide.

Nationwide strategies employed to provide and integrate palliative care to patients with covid-19

Background: Little is known on what palliative care (PC) has been provided to patients with COVID-19. Aims: To understand what PC was provided nationwide to patients with COVID-19 and strategies implemented to overcome barriers during the pandemic. Methods: Semi-structured interviews were conducted with physicians across Canada about their experiences providing PC to patients with COVID-19. Thematic analysis was used to describe and interpret overarching themes. Results: Twelve specialized PC (SPC) and 11 primary PC (PPC) were interviewed. Interim analysis of 16 coded interviews demonstrated SPC and PPC physicians used traditional strategies (such as opioids, oxygen and serious illness conversations) to manage symptoms, support end of life, and engage patients and families in goals of care conversations (GOC). Neither SPC nor PPC indicated strong adoption of GOC and symptom management tools circulated early in the pandemic. Both SPC and PPC indicated a shift to virtual communication due to restrictive visitor policies, highlighting the need for distanced support and planned communication. Care coordination for PC patients was challenged by a lack of community resources, family infected with COVID-19, prolonged hospital stays, and increased number of PC patients discharged to rehabilitation services. New PC structures included;GOC teams that functioned in the emergency department and medicine floors, integrated clinical rounding by non-PC clinicians with PC teams, and hospital-based PC outreach to long term care. Strategies to improve PC implementation included: virtual technologies, team collaboration, patient and family engagement tools, and symptom management and GOC conversations tools. Conclusions: While PC management approaches to support patients with COVID-19 were mostly unchanged, new structures and strategies were developed to ensure patients and their families were provided with support.

Barriers and facilitators to specialized palliative care integration for patients with COVID-19

Background: Specialized palliative care (SPC) teams are well placed to support patients with advanced COVID-19 in Canada, but evidence indicates integration so far has been variable. Aim: To understand barriers and facilitators of SPC integration in the management of patients with COVID-19. Methods: Semi-structured interviews were conducted with physicians across Canada about their experiences providing care to patients with COVID-19. Thematic analysis was used to describe and interpret overarching themes. Results: Twenty-three physicians (12 SPC, 5 intensivists, 6 general internists) were interviewed. Interim analysis of 16 coded interviews demonstrated that facilitators/barriers to providing COVID-19 care fell into 5 main categories: patient-related, provider-related, Disease-specific, SPC service, and leadership factors. Patient-related items included age, comorbidities, goals, speed of decline and clustering of patients. Non- SPC provider-related factors included experience providing palliative care and working with the SPC team, time, and motivation. Uncertainty around COVID-19 progression, management and infection control practices were identified disease-specific barriers. SPC service factors included stigma related to palliative care, the accessibility, availability, and readiness of SPC services to meet the perceived needs of patients with COVID-19. Leadership facilitators included institutional mandated or supported integration, and SPC? presence at COVID-19 planning tables. Ways to improve integration included educational initiatives, relationship building, formal integrated structures and presence at institutional COVID-19 planning tables. Conclusion: Preliminary analysis highlights the need for high-level support for formal SPC integrated structures, a SPC role in pandemic planning, and the need for ongoing educational and relationship building initiatives to overcome barriers of SPC integration in COVID-19 care.

Identifying the consequences of restrictive visitor policies on palliative care providers, their patients and caregivers

Background: Restrictive institution visitor policies were implemented to minimize infection risks during the COVID-19 pandemic. Little data exists on the relationship between these policies and the provision of palliative care(PC). Aim: To describe the experiences and reflections of PC physicians on the effects of restrictive visitor policies. Methods: Semi-structured interviews were conducted with physicians about their experience providing PC in institutions with restrictive visitor policies. Thematic analysis was used to describe and interpret overarching themes. Results: Twelve specialized PC and 11 primary PC were interviewed. Interim analysis of 16 coded interviews demonstrates 4 main thematic categories including patient, caregiver, provider, and system effects. Patient-related items included isolation, dying alone, lack of caregiver advocacy and forced care decisions to allow for visitor presence. Caregiver factors included the inability to support or provide care to patients, poor communication with care teams, poor illness understanding, the need to make distanced care decisions, and challenges in identifying visitors. Provider factors included increased time and effort on communication, lack of caregiver input on patient status, increased complaints, the need to be a caregiver surrogate, visitor advocate or gatekeeper. System effects included the increased interest to be provided care in the community and the lack of interest in palliative care units. These factors were often exacerbated by several issues including the lack of clear evidence on their validity, and inconsistent enforcement or interpretation of policies at the unit, which led to patient and caregiver anger and distrust, and provider frustration. Conclusion: Preliminary analysis highlights substantial negative consequences of restrictive visitor policies at the patient, caregiver, provider and system levels which were exacerbated by their lack of evidence and inconsistent enforcement.

Health care providers' experiences with establishing goals of care for patients with covid-19

Background: Exploring patients' goals of care (GOC) is integral to palliative care practice. COVID-19 may present new challenges to establishing GOC. Aim: To describe the experiences and reflections of physicians regarding exploring GOC for patients with COVID-19. Methods: Semi-structured interviews were conducted with physicians about their experience assessing GOC for patients with COVID-19. Thematic analysis was used to describe and interpret over-arching themes. Results: Twenty-three physicians (12 Palliative Care, 5 Internal Medicine, and 6 Critical Care) were interviewed. Interim analysis of 16 coded interviews revealed 4 thematic categories of factors influencing establishment of GOC: resource availability, COVID-19 factors, patients' baseline health, and unusual communication challenges between health care providers and substitute decision makers (SDMs) or patients. Resourcerelated factors included impact of ICU/ventilator availability and personal protective equipment (PPE) shortages on GOC discussions. COVID-19 factors affecting GOC conversations included physician uncertainty of the course of illness;lack of definitive, evidence-based treatment;patient and family preconceived ideas about COVID-19;and risk of rapid decline. Factors associated with patients' baseline health included comorbid disease and ability to treat comorbid disease in parallel with COVID-19. Unusual communication challenges impacting GOC discussions included a high level of SDM involvement for GOC conversations, visitor policies potentially limiting SDMs' illness understanding, and virtual discussions or discussions taking place under layers of PPE creating barriers to effective communication between physicians, patients, and SDMs. Conclusion: Preliminary analysis highlights the unique challenges faced by both health care providers and patients/SDMs to facilitate and participate in GOC conversations in the context of the COVID-19 pandemic.

Reflections and experiences of physicians working during the COVID-19 pandemic: A qualitative study

Background: The need to recognize and attend to physician health and wellness has recently been emphasized, due to high levels of documented distress and burnout. The global pandemic has imposed even greater stressors and novel work demands on clinicians. Aim: To understand the experiences of physicians providing care during a global pandemic. Methods: Semi-structured interviews were conducted with physicians across Canada about their experiences providing care to patients during the COVID-19 pandemic. Thematic analysis methodology was used to describe overarching themes. Results: Twenty-three physicians (12 specialized palliative care, 5 intensivists, 6 general internists) were interviewed. Interim analysis of 16 coded interviews revealed 8 main categories: confusion and uncertainty;exhaustion and burnout;trauma;ethical considerations;isolation;professional re-evaluation;altruism;and cohesion. Confusion and uncertainty related mainly to the novel virus, leadership, and institutional preparedness. Exhaustion and burnout encompassed workload, personal protective equipment, family life, and complexity. The trauma theme included visitor policies, family surrogates, and patient management. Ethical considerations included job demands vs personal and family safety. Isolation was largely related to infection control measures. Professional re-evaluation items included job satisfaction due to changed patient encounters or novel structuring. Altruism items included unique personal contribution to pandemic response and societal needs. Cohesion items included supporting each other and team building. Conclusion: Preliminary analysis revealed trauma and distress, but also altruism and cohesion. These findings may inform interventions for physician health and wellness, as well as indicating ways to integrate meaning and purpose into negative experiences to promote resilience.