Anticipatory prescribing in community end-of-life care: systematic review and narrative synthesis of the evidence since 2017.

BACKGROUND: The anticipatory prescribing of injectable medications is recommended practice in controlling distressing symptoms in the last days of life. A 2017 systematic review found practice and guidance was based on inadequate evidence. Since then, there has been considerable additional research, warranting a new review. AIM: To review the evidence published since 2017 concerning anticipatory prescribing of injectable medications for adults at the end-of-life in the community, to inform practice and guidance. DESIGN: Systematic review and narrative synthesis. METHODS: Nine literature databases were searched from May 2017 to March 2022, alongside reference, citation and journal hand-searches. Gough's Weight of Evidence framework was used to appraise included studies. RESULTS: Twenty-eight papers were included in the synthesis. Evidence published since 2017 shows that standardised prescribing of four medications for anticipated symptoms is commonplace in the UK; evidence of practices in other countries is limited. There is limited data on how often medications are administered in the community. Prescriptions are 'accepted' by family caregivers despite inadequate explanations and they generally appreciate having access to medications. Robust evidence of the clinical and cost-effectiveness of anticipatory prescribing remains absent. CONCLUSION: The evidence underpinning anticipatory prescribing practice and policy remains based primarily on healthcare professionals' perceptions that the intervention is reassuring, provides effective, timely symptom relief in the community and prevents crisis hospital admissions. There is still inadequate evidence regarding optimal medications and dose ranges, and the effectiveness of these prescriptions. Patient and family caregiver experiences of anticipatory prescriptions warrant urgent investigation. PROSPERO REGISTRATION: CRD42016052108.

Vitamin D levels in hospice in-patients.

OBJECTIVE: Serum 25-hydroxyvitamin D was obtained alongside routine blood tests in all suitable patients admitted to the St Cuthbert's Hospice Inpatient Unit for a period of 12 months. Supplementation was offered to exclude vitamin D insufficiency or deficiency as a contributor to the complex pain and symptom profile of our patients. METHODS: During admission, and alongside routine blood tests, a serum 25-hydroxyvitamin D test was requested for suitable patients. Supplementation was offered to patients with serum 25-hydroxyvitamin D less than 50 nmol/L. RESULTS: This audit identified that 79.73% of patients assessed had a 25-hydroxyvitamin D level less than 50 nmol/L and were therefore insufficient or deficient in vitamin D. The results of the audit were discussed within the clinical team at the hospice and guidance changed to obtain serum 25-hydroxyvitamin D levels in all suitable patients. A reaudit highlighted that some patients were missed from testing and therefore reminders were sent to the clinical team. CONCLUSIONS: Most patients admitted to St Cuthbert's Hospice had either insufficient or deficient levels of vitamin D. It seems reasonable for all suitable palliative care patients to have their vitamin D level checked and to be started on a suitable dose of vitamin D replacement therapy.

Evaluating Listening Performance for COVID-19 Detection by Clinicians and Machine Learning: Comparative Study.

BACKGROUND: To date, performance comparisons between men and machines have been carried out in many health domains. Yet machine learning (ML) models and human performance comparisons in audio-based respiratory diagnosis remain largely unexplored. OBJECTIVE: The primary objective of this study was to compare human clinicians and an ML model in predicting COVID-19 from respiratory sound recordings. METHODS: In this study, we compared human clinicians and an ML model in predicting COVID-19 from respiratory sound recordings. Prediction performance on 24 audio samples (12 tested positive) made by 36 clinicians with experience in treating COVID-19 or other respiratory illnesses was compared with predictions made by an ML model trained on 1162 samples. Each sample consisted of voice, cough, and breathing sound recordings from 1 subject, and the length of each sample was around 20 seconds. We also investigated whether combining the predictions of the model and human experts could further enhance the performance in terms of both accuracy and confidence. RESULTS: The ML model outperformed the clinicians, yielding a sensitivity of 0.75 and a specificity of 0.83, whereas the best performance achieved by the clinicians was 0.67 in terms of sensitivity and 0.75 in terms of specificity. Integrating the clinicians' and the model's predictions, however, could enhance performance further, achieving a sensitivity of 0.83 and a specificity of 0.92. CONCLUSIONS: Our findings suggest that the clinicians and the ML model could make better clinical decisions via a cooperative approach and achieve higher confidence in audio-based respiratory diagnosis.

AI and deep learning for processing the huge amount of patient-centric data that assist in clinical decisions

The area of clinical decision support systems (CDSS) is facing a boost in research and development with the increasing amount of data in clinical analysis together with new tools to support patient care. This creates a vibrant and challenging environment for the medical and technical staff. This chapter presents a discussion about the challenges and trends of CDSS considering big data and patient-centered constraints. Two case studies are presented in detail. The first presents the development of a big data and AI classification system for maternal and fetal ambulatory monitoring, composed by different solutions such as the implementation of an Internet of Things sensors and devices network, a fuzzy inference system for emergency alarms, a feature extraction model based on signal processing of the fetal and maternal data, and finally a deep learning classifier with six convolutional layers achieving an F1-score of 0.89 for the case of both maternal and fetal as harmful. The system was designed to support maternal–fetal ambulatory premises in developing countries, where the demand is extremely high and the number of medical specialists is very low. The second case study considered two artificial intelligence approaches to providing efficient prediction of infections for clinical decision support during the COVID-19 pandemic in Brazil. First, LSTM recurrent neural networks were considered with the model achieving R2=0.93 and MAE=40,604.4 in average, while the best, R2=0.9939, was achieved for the time series 3. Second, an open-source framework called H2O AutoML was considered with the "stacked ensemble” approach and presented the best performance followed by XGBoost. Brazil has been one of the most challenging environments during the pandemic and where efficient predictions may be the difference in saving lives. The presentation of such different approaches (ambulatory monitoring and epidemiology data) is important to illustrate the large spectrum of AI tools to support clinical decision-making. © 2022 Elsevier Inc. All rights reserved.

Palliative care teaching in the new internal medicine curriculum: Project ECHO-an innovative approach to postgraduate education.

BACKGROUND: The Internal Medicine Training (IMT) Programme is an evolution of Core Medical Training introduced in 2019. The IMT curriculum places an increased emphasis on palliative care; however, access to palliative care training is variable. Project ECHO (Extension of Community Healthcare Outcomes) develops communities of practice and is a valuable tool for medical education. We report on an evaluation of Project ECHO to deliver palliative medicine training across a geographically large deanery in the North of England. METHODS: The Project ECHO training programme involved multipoint video technology, telementoring, expert talks and case-based discussions over six sessions, and was fully mapped to the palliative care component of the IMT curriculum. We collected data particularly around attendance and self-reported confidence and knowledge. RESULTS: By creating a community of practice, we provided virtual placements and over 9 hours of virtual direct contact with palliative medicine consultants; and in total, 921 individual attendances occurred, with 62% attending all six sessions. The course was associated with an increase in self-reported confidence and high satisfaction. DISCUSSION: Project ECHO is an effective method of delivering teaching to trainees across a large geographical area. Course evaluation shows outstanding results in trainee satisfaction, confidence, knowledge, patient care, clinical skills and reduction in fear when managing death and dying.

COVID-19 communication resources in a major health system: development and dissemination.

OBJECTIVES: Early in the pandemic, institutional leadership recognised the importance of providing staff with practical, clinically based communication resources. This paper describes the process of cultivating and disseminating rapid communication resources across a multisite institution to assist others who may need to rapidly respond to communication challenges in the future. METHODS: In April 2020, the Mayo Healthcare Incident Command System charged the Center for Palliative Medicine with developing and disseminating clinical communication resources within several weeks. The Education Chair for the Center for Palliative Medicine created a COVID-19 communication task force composed of clinician-educators with expertise in serious illness communication from all three academic Mayo Clinic sites. The task force elected to focus on providing accessible, just-in-time online content curated from existing resources and adapted to situational needs. RESULTS: The task force developed one-page resources with example language on 16 topic areas. Topics included exploring patient values, discussing time-limited trials and making recommendations. The COVID-19 communication website was launched on 28 May, 6 weeks after the institutional request. CONCLUSIONS: Key takeaway lessons were the need for: (1) alignment with institutional need and priority, (2) rapid team formation with communication education experts across a variety of institutional geographic settings, (3) quick consensus on topic and content delivery to be practically helpful to clinicians, (4) collaboration with outside groups to use and adapt already available resources when possible and (5) early and iterative involvement with information specialists to help facilitate institutional dissemination.

Efficacy of COVID-19 treatments among geriatric patients: a systematic review.

Introduction: A majority of the fatalities due to COVID-19 have been observed in those over the age of 60. There is no approved and universally accepted treatment for geriatric patients. The aim of this review is to assess the current literature on efficacy of COVID-19 treatments in geriatric populations. Methods: A systematic review search was conducted in PubMed, MedRxiv, and JAMA databases with the keywords COVID-19, geriatric, hydroxychloroquine, dexamethasone, budesonide, remdesivir, favipiravir, ritonavir, molnupiravir, tocilizumab, bamlanivimab, baricitinib, sotrovimab, fluvoxamine, convalescent plasma, prone position, or anticoagulation. Articles published from January 2019 to January 2022 with a population greater than or equal to 60 years of age were included. Interventions examined included hydroxychloroquine, remdesivir, favipiravir, dexamethasone, budesonide, tocilizumab, bamlanivimab, baricitinib, sotrovimab, convalescent plasma, prone position, and anticoagulation therapy. Outcome measures included viral load, viral markers, ventilator-free days, or clinical improvement. Results: The search revealed 302 articles, 52 met inclusion criteria. Hydroxychloroquine, dexamethasone, and remdesivir revealed greater side effects or inefficiency in geriatric patients with COVID-19. Favipiravir, bamlanivimab, baricitinib, and supportive therapy showed a decrease in viral load and improvement of clinical symptoms. There is conflicting evidence with tocilizumab, convalescent plasma, and anticoagulant therapy in reducing mortality, ventilator-free days, and clinical improvements. In addition, there was limited evidence and lack of data due to ongoing trials for treatments with sotrovimab and budesonide. Conclusion: No agent is known to be effective for preventing COVID-19 after exposure to the virus. Further research is needed to ensure safety and efficacy of each of the reviewed interventions for older adults.

End of life care in UK care homes - controlled drugs: systematic review and narrative synthesis.

BACKGROUND: Controlled drugs (CDs) such as opioids and midazolam are commonly used in end-of-life care symptom management for care home residents. AIM: To review the published evidence concerning the prescribing, storage, use and disposal of CDs for end-of-life care for care home residents in the UK. DESIGN: Systematic review and narrative synthesis. METHODS: Seven databases (Medline, CINAHL, Embase, PsycINFO, Web of Science, Cochrane Library, and Social Care Online) were searched from January 2000 to January 2021, alongside reference, citation and journal hand searches. Gough's 'Weight of Evidence' framework was used to appraise the relevance of studies to the review questions. RESULTS: The search yielded 1279 titles, from which 125 abstracts and then 42 full-text papers were screened. 14 papers were included in the synthesis. Prescribing is primarily by general practitioners, with administration by nurses. Nurses frequently report feeling inadequately trained in the use of CDs. The storage, monitoring and disposal of end-of-life care CDs in UK care homes has not been researched to date. The attitudes and experiences of residents and family members regarding these medications also remain unknown. CONCLUSION: The current widespread use of CDs for end-of-life care in care homes has a limited evidence base. The lack of research concerning the storing, monitoring and disposing of CDs, alongside the limited evidence concerning resident and family members' perspectives, is a significant knowledge deficit that requires urgent attention. PROSPERO REGISTRATION NUMBER: CRD42020173014.

Community-based anticipatory prescribing during COVID-19: a qualitative study.

OBJECTIVES: To understand healthcare professionals' experiences of delivering anticipatory prescribing (AP) during the first wave of the UK COVID-19 pandemic. METHODS: Semistructured qualitative interviews were conducted with a purposive sample of 16 healthcare professionals involved in community palliative care. Data were analysed inductively using thematic analysis. RESULTS: Some of practitioners' fears about the pandemic's impact on delivering AP had not been realised during the first wave. Among patients with COVID-19 for whom community end-of-life care was deemed appropriate, deaths were perceived to be relatively easy to palliate with standard medications. These deaths were typically too rapid for AP to be appropriate or feasible. For non-COVID deaths, providing timely AP was more challenging: although community nurses and some palliative specialists continued to visit patients regularly, general practitioners did many fewer visits, moving abruptly to mainly remote consultations. This left some community nurses feeling undersupported, and prompted some palliative specialists to increase their direct involvement in AP. Several other changes were widely welcomed: collaboration to maintain drug supplies, adoption of online meetings and paperless practice, enhanced specialist helplines and a new policy allowing reuse of medication in care homes. The inclusion of more non-injectable options in AP protocols allowed clinicians to offer selected patients more choice, but few had yet done this in practice. No participants reported changing their prepandemic practice regarding administration of AP by lay caregivers. CONCLUSIONS: Accomplishing AP during a pandemic was challenging, requiring healthcare professionals to make rapid changes to their systems and practices. Some changes may produce lasting improvements.

COVID-19 deaths in care homes: primary care management study.

OBJECTIVES: COVID-19 presented a new risk to the care home sector. Primary care adapted their approach to the management of COVID-19 in care homes as the pandemic evolved. Our aim was to evaluate the clinical presentation, management, care planning and clinical decision-making, and after death care of care home residents who died due to COVID-19 in Aneurin Bevan University Health Board in Southeast Wales. METHOD: Clinical records of 136 in care homes were reviewed by a General Practitioner reviewer using a standardised template. These were then reviewed by a multidisciplinary panel to identify themes. RESULTS: Most individuals presented with 'typical' COVID-19 symptoms (cough, fever); however, >50 presented with atypical symptoms. 90% had a record of Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision, but only 46% had documented advance care planning (ACP), and only 37% had a clearly documented treatment escalation plan. CONCLUSION: Care home residents are at risk of sudden clinical deterioration and death. This evaluation demonstrates that although DNACPR is in place for most individuals, holistic planning for end of life (including ACP and clinical care plans covering management of deterioration and escalation of care) is only present for a minority.

Opioid safety recommendations in adult palliative medicine: a North American Delphi expert consensus.

OBJECTIVES: Despite the escalating public health emergency related to opioid-related deaths in Canada and the USA, opioids are essential for palliative care (PC) symptom management.Opioid safety is the prevention, identification and management of opioid-related harms. The Delphi technique was used to develop expert consensus recommendations about how to promote opioid safety in adults receiving PC in Canada and the USA. METHODS: Through a Delphi process comprised of two rounds, USA and Canadian panellists in PC, addiction and pain medicine developed expert consensus recommendations. Elected Canadian Society of Palliative Care Physicians (CSPCP) board members then rated how important it is for PC physicians to be aware of each consensus recommendation.They also identified high-priority research areas from the topics that did not achieve consensus in Round 2. RESULTS: The panellists (Round 1, n=23; Round 2, n=22) developed a total of 130 recommendations from the two rounds about the following six opioid-safety related domains: (1) General principles; (2) Measures for healthcare institution and PC training and clinical programmes; (3) Patient and caregiver assessments; (4) Prescribing practices; (5) Monitoring; and (6) Patients and caregiver education. Fifty-nine topics did not achieve consensus and were deemed potential areas of research. From these results, CSPCP identified 43 high-priority recommendations and 8 high-priority research areas. CONCLUSIONS: Urgent guidance about opioid safety is needed to address the opioid crisis. These consensus recommendations can promote safer opioid use, while recognising the importance of these medications for PC symptom management.

Do not attempt cardiopulmonary resuscitation (DNACPR) decisions for older medical inpatients: a cohort study.

OBJECTIVES: A decision not to attempt cardiopulmonary resuscitation in the event of cardiorespiratory arrest requires a discussion between the doctor and the patient and/or their relatives. We aimed to determine how many older patients admitted to acute medical wards had a pre-existing 'do not attempt cardiopulmonary resuscitation' (DNACPR) decision, how many had one recorded on the ward and how many of those who died had a DNACPR decision in place. METHODS: A prospective cohort study, using data from medical records, of 481 consecutive patients aged ≥65 years admitted to the six acute medical wards of the John Radcliffe Hospital, Oxford. RESULTS: 105/481 (22%) had a DNACPR decision at ward admission, 30 of which had been made in the emergency unit. A further 45 decisions were recorded on the ward, mostly after discussion with relatives. Of the 37 patients who died, 36 had a DNACPR decision. For the 20 deceased patients whose DNACPR decision was recorded during their admission, the median time from documentation to death was 4 days with 7/20 (35%) recorded the day before death. CONCLUSIONS: Older patients with multimorbidity need the opportunity to discuss the role of CPR earlier in their care and preferably before acute hospital admission.

Comorbidity-adjusted NEWS predicts mortality in suspected patients with COVID-19 from nursing homes: Multicentre retrospective cohort study.

AIMS: To assess the prognostic accuracy of comorbidity-adjusted National Early Warning Score in suspected Coronavirus disease 2019 patients transferred from nursing homes by the Emergency Department. DESIGN: Multicentre retrospective cohort study. METHODS: Patients transferred by high-priority ambulances from nursing homes to Emergency Departments with suspected severe acute respiratory syndrome coronavirus 2 infection, from March 12 to July 31 2020, were considered. Included variables were: clinical covariates (respiratory rate, oxygen saturation, systolic blood pressure, heart rate, temperature, level of consciousness and supplemental oxygen use), the presence of comorbidities and confirmatory analytical diagnosis of severe acute respiratory syndrome coronavirus 2 infection. The primary outcome was a 2-day mortality rate. The discriminatory capability of the National Early Warning Score was assessed by the area under the receiver operating characteristic curve in two different cohorts, the validation and the revalidation, which were randomly selected from the main cohort. RESULTS: A total of 337 nursing homes, 10 advanced life support units, 51 basic life support units and 8 hospitals in Spain entailing 1,324 patients (median age 87 years) was involved in this study. Two-day mortality was 11.5% (152 cases), with a positivity rate of severe acute respiratory syndrome coronavirus 2 of 51.2%, 77.7% of hospitalization from whom 1% was of intensive care unit admission. The National Early Warning Score results for the revalidation cohort presented an AUC of 0.771, and of 0.885, 0.778 and 0.730 for the low-, medium- and high-level groups of comorbidities. CONCLUSION: The comorbidity-adjusted National Early Warning Score provides a good short-term prognostic criterion, information that can help in the decision-making process to guide the best strategy for each older adult, under the current pandemic. IMPACT: What problem did the study address? Under the current coronavirus disease 2019 pandemic, targeting older adults at high risk of deterioration in nursing homes remains challenging. What were the main findings? Comorbidity-adjusted National Early Warning Score helps to forecast the risk of clinical deterioration more accurately. Where and on whom will the research have impact? A high NEWS, with a low level of comorbidity is associated with optimal predictive performance, making these older adults likely to benefit from continued follow up and potentially hospital referral under the current coronavirus disease 2019 pandemic.

Prediction of the Rehabilitation Duration and Risk Management for Mild-Moderate COVID-19.

OBJECTIVES: More than 80% of coronavirus disease 2019 (COVID-19) cases are mild or moderate. In this study, a risk model was developed for predicting rehabilitation duration (the time from hospital admission to discharge) of the mild-moderate COVID-19 cases and was used to conduct refined risk management for different risk populations. METHODS: A total of 90 consecutive patients with mild-moderate COVID-19 were enrolled. Large-scale datasets were extracted from clinical practices. Through the multivariable linear regression analysis, the model was based on significant risk factors and was developed for predicting the rehabilitation duration of mild-moderate cases of COVID-19. To assess the local epidemic situation, risk management was conducted by weighing the risk of populations at different risk. RESULTS: Ten risk factors from 44 high-dimensional clinical datasets were significantly correlated to rehabilitation duration (P < 0.05). Among these factors, 5 risk predictors were incorporated into a risk model. Individual rehabilitation durations were effectively calculated. Weighing the local epidemic situation, threshold probability was classified for low risk, intermediate risk, and high risk. Using this classification, risk management was based on a treatment flowchart tailored for clinical decision-making. CONCLUSIONS: The proposed novel model is a useful tool for individualized risk management of mild-moderate COVID-19 cases, and it may readily facilitate dynamic clinical decision-making for different risk populations.

COVID-19 emergency and palliative medicine: an intervention model'.

OBJECTIVES: The aim of this work is to describe the multidisciplinary model of intervention applied and the characteristics of some COVID-19 patients assisted by the hospital palliative care unit (UCP-H) of an Italian hospital in Lombardy, the Italian region most affected by the COVID-19 pandemic. METHODS: A retrospective study was conducted on patients admitted to the A. Manzoni Hospital (Lecco, Lombardy Region, Italy) and referred to the UCP-H between 11 March 2020 and 18 April 2020, the period of maximum spread of COVID-19 in this area. Data were collected on the type of hospitalisation, triage process, modality of palliative care and psychological support provided. RESULTS: 146 COVID-10 patients were referred to the UCP-H. Of these, 120 died during the observation time (82%) while 15 (10.2%) improved and were discharged from the UCP-H care. 93 had less favourable characteristics (rapid deterioration of respiratory function, old age, multiple comorbidities) and an intensive clinical approach was considered contraindicated, while 48 patients had more favourable presentations. Mean follow-up was 4.8 days. A mean of 4.3 assessments per patient were performed. As to respiratory support, 94 patients were treated with oxygen only (at different volumes) and 45 with Continuous Positive Airway Pressure (CPAP). CONCLUSION: The ongoing pandemic highlighted the need for dedicated palliative care teams and units for dying patients. This work highlights how palliative medicine specialist can make a fundamental contribution thanks to their ability and work experience in an organised multiprofessional context.

Ethical issues related to the COVID-19 pandemic in patients with cancer: experience and organisations in a French comprehensive cancer centre.

BACKGROUND: The COVID-19 pandemic has aggressively reached the most vulnerable, not only the elderly but also patients with chronic conditions such as cancer. In this study, we present the outlines of ethical thinking and the measures implemented to try to respect our basic values of care, in the specific environment of an oncology hospital. METHODS: Our ethics committee created an ethical watch system based on 24/7 shifts to assist practitioners in their daily decisions. We discuss the challenges faced by patients with cancer during the pandemic, such as access to critical care and ethical dilemmas in the context of resource scarcity, as well as the issue of isolation of patients. We also debate the restrictions in access to oncology care in a health context strongly 'prioritised' against COVID-19. RESULTS: In all areas of an ethical dilemma, either for sorting out access to critical care or for the dramatic consequences of prolonged isolation of patients, our common thread was our attempt to protect, whenever possible, the principles of deontological ethics by strictly resisting utilitarian pressure. Respecting democratic health decision-making processes is a cornerstone of ethically relevant decisions, including in the context of a sanitary crisis. CONCLUSION: The role of an ethics committee related to real-life situations includes not only a reflexive perspective in respect of fundamental principles, but also the help to enlighten and resolve ethical dilemmas in complex clinical situations. This ethical watch team assists physicians in decision-making, promoting the supportive and palliative dimension of care with a holistic approach.

Virtual visits in palliative care: about time or against the grain?

While the additional value from adding the option of virtual visits is not in question, numerous issues are raised around how to decide between face-to-face and virtual visits in individual cases and how best to set up such provision within an organisation. With only limited palliative care-specific literature and no time to set up and evaluate pilots, we had to get on and set up a prototype 'virtual visits' model, retro-fitting guidance and a supporting ethical framework. We looked at the issues spanning clinical, ethical and logistics domains; identifying areas of benefit as well as drawbacks, some specific to the rushed implementation because of COVID-19's infective risks and the 'rules' of lockdown, but many are generic areas to help guide longer term service design. Unsurprisingly, it appears clear that a 'one-size-fits-all' mentality is a poor fit for the individualised needs of the heterogeneous palliative care population. Virtual visits have great potential even if they are not a panacea.