Examining Variability in Intra-Hospital Patient Referrals to Specialized Palliative Care: A Comprehensive Analysis of Disciplines and Mortality.

Background: In Austria, specialized palliative care (SPC) access is limited, with unclear referral criteria, making it challenging to identify hospitalized patients requiring SPC and determine referral timing and mortality at the palliative care unit (PCU). Methods: This retrospective cohort study analyzed patients who underwent a palliative care (PC) needs assessment between March 2016 and November 2021 and were subsequently admitted to the PCU of Austria's largest academic hospital. Demographic, clinical, and standardized referral form data were used for analysis, employing descriptive statistics and logistic regression. Results: Out of the 903 assessed patients, 19% were admitted to the PCU, primarily cancer patients (94.7%), with lung (19%) and breast cancer (13%) being most prevalent. Common referral reasons included pain (61%) and nutritional problems (46%). Despite no significant differences in referral times, most patients (78.4%) died in the PCU, with varying outcomes based on cancer type. Referral reasons like pain (OR = 2.3), nutritional problems (OR = 2.4), and end-of-life care (OR = 6.5) were significantly associated with the outcome PCU mortality. Conclusions: This study underscores Austria's SPC access imbalance and emphasizes timely PC integration across disciplines for effective advance care planning and dignified end-of-life experiences in PCUs.

Integrating Palliative Care Into the Management of Genitourinary Malignancies.

Palliative care (PC) plays a critical role in managing the difficulties associated with genitourinary malignancies. Its primary aim is to improve the overall health of patients, provide support to both patients and their caregivers, and help individuals to navigate the complex decisions about treatment and end-of-life care. PC takes a holistic approach to patient care, recognizing that genitourinary malignancies affect multiple aspects of a person's life. By addressing physical, emotional, social, and spiritual needs, PC aims to provide comprehensive support that is consistent with the patient's values and preferences. The goal is to optimize comfort, minimize distress, and enhance the patient's quality of life throughout the course of the illness. PC is not a one-off intervention, but an ongoing source of support. This article aims to provide a thorough overview of the critical elements involved in addressing the challenges posed by genitourinary cancers, emphasizing the importance of palliative interventions. We will highlight the multifaceted aspects of care and explore strategies to optimize the overall well-being of patients throughout the course of treatment for genitourinary malignancies.

Life outcomes after paediatric kidney transplantation: a qualitative, biographical study in long-term survivors.

OBJECTIVE: The objective of this study was to analyse the narrative life stories of children with end-stage kidney disease (ESKD) and their families to determine how health professionals can effectively support these children to achieve better life outcomes. DESIGN: Qualitative narrative biographic study. SETTING: We invited every long-term survivor of paediatric kidney transplants and their families at the Medical University of Vienna between 2008 and 2013 to participate in this study. PARTICIPANTS: Nineteen patients (women: n=8, 42%) and 34 family members (women: n=22, 65%) were interviewed. The patients had a mean age of 7.6 (SD±5.6) years at the time of transplantation and 22.2 (SD±5.4) at the time of interview. MAIN OUTCOMES MEASURES: A qualitative narrative biographical analysis was combined with computational structured topic models using the Latent Dirichlet Allocation. RESULTS: The overarching finding was the desire for normality in daily life in long-term survivors and their families but with different perceptions of what normality looks like and predominance of this aspect evolving. Different strategies were used by patients (focused on their advancement) and caregivers (normality for all family members). Siblings played a major role in supporting survivors' social inclusion. CONCLUSIONS: The strong desire for normality confirms recent findings of the Standardised Outcomes in Nephrology Group initiative, which proposes survival and life participation as core outcomes in children with chronic kidney disease. Our study should be a starting point for an international effort to identify typologies and stratified interventions for children with ESKD and their families, particularly siblings.

Effectiveness of cloth face masks to prevent viral spread: a meta-analysis.

BACKGROUND: The effectiveness of cloth face masks to prevent viral spread has not yet been conclusively established. In this meta-analysis, we evaluate their effectiveness in comparison to standard medical/surgical and N95-typed masks against viral spread. METHODS: We identified literature through a systematic search in three databases and meta-analytically synthesized relevant studies by means of random-effects as well as multilevel modelling. RESULTS: Twelve studies comprising k = 28 effect sizes (N = 338) were included. Medical/surgical and N95-typed masks outperformed cloth masks, yielding a large effect (g = 1.40). This effect remained robust when data were grouped according to comparisons with medical/surgical masks (g = 1.25) and N95-typed masks (g = 1.29). However, effects were differentiated according to mask fit, indicating reversals of signs when cloth mask effects were compared with ill-fitting medical/surgical and N95-typed masks (gs = -12.50 and - 10.90, respectively). CONCLUSIONS: Cloth face masks were found to have significantly poorer filtering performance than medical/surgical masks and N95 masks, but only if non-cloth masks were properly fitted. Our results illustrate the necessity of using well-fitting medical/surgical or N95-typed masks to prevent viral spread, although some allowance should be made in circumstances where higher compliance with cloth mask mandates are expected.

On dying alone in prison and the social responsibility of medicine: a pilot interview study of physicians caring for terminally ill incarcerated patients in Austria and the United States.

BACKGROUND: This group of physicians is difficult to reach and small in number. While studies of palliative care and end-of-life (EOL) issues in prison have increased, especially in the United States and since the coronavirus disease 2019 (COVID-19) pandemic, they are still limited due to the constraints of carrying out research in carceral contexts. At present, there is very little knowledge of the experiences of physicians providing EOL care in prisons. The aim of this pilot study was to examine the experiences of doctors caring for terminally ill patients inside prisons. METHODS: Three expert qualitative interviews were conducted in March and April 2021 with physicians working in carceral institutions in New York State and Austria. The interviews were audio-recorded and transcribed verbatim. Braun and Clarke's thematic analysis was used to examine the data. RESULTS: The following five themes were found: (I) a lack of training and support; (II) interrupted relationships; (III) limitations on visits and saying one's goodbyes; (IV) security as a main concern; and (V) the possibility of release. CONCLUSIONS: The study reveals the difficulties physicians face when caring for dying incarcerated patients. Provider-patient relationships are hardly continuous. The findings represent a starting point for further research. Support from the medical and palliative care community is needed for adequate provision of EOL care within prisons, improved post-release conditions, and help for physicians working in existing structures.

The impact of COVID-19 and socioeconomic status on psychological distress in cancer patients

Objective: We aimed to investigate the impact of the COVID-19 pandemic on psychological symptom burden against the socioeconomic background of cancer patients using data from routine assessments before and during the pandemic Method: In this cross-sectional study, standardised assessment instruments were applied in N = 1,329 patients to screen for symptoms of anxiety, depression, post-traumatic stress, and fatigue from 2018 to 2022. Two MANOVAs with post-hoc tests were computed. First, only time was included as predictor to examine the isolated impact of the pandemic. Second, income level and education level were included as further predictors to additionally test the predictive power of socioeconomic factors Results: In the final model, only income had a significant impact on all aspects of psychological symptom burden, with patients with low income being highly burdened (partial η² = .01, p = .023). The highest mean difference was found for depressive symptoms (MD = 0.13, CI = [0.07; 0.19], p < .001). The pandemic had no further influence on psychological distress Conclusions: Although the pandemic is a major stressor in many respects, poverty may be the more important risk factor for psychological symptom burden in cancer outpatients, outweighing the impact of the pandemic. (AU)

Routine laboratory parameters to support decision on parenteral nutrition in palliative care.

Introduction: Parenteral nutrition (PN) is widely used in palliative care (PC), but there is limited evidence to support its use at the end of life (EOL). This aim of this was to investigate the relationship between routine laboratory parameters and survival in patients receiving PN, and to develop a decision tree model to support clinicians decide whether to start or forgo PN. Methods: The laboratory parameters of 113 patients with advanced diseases who were admitted to a specialized palliative care unit (PCU) were analyzed at two points in time: T0 = before PN, T1 = two weeks after initiation of PN. Univariate Mann-Whitney U-tests and multivariate linear regression models, as well as a decision tree analysis were computed; all in relation to survival time. Results: The final regression model was significant with p = 0.001 (adjusted R2 = 0.15) and included two predictors for survival time after PN initiation: the CRP/albumin ratio and urea at T1 (ps = 0.019). Decision tree analysis revealed three important predictors for classification of survival time after PN initiation: CRP, urea, and LDH (all at T0). Discussion: The decision tree model may help to identify patients likely to benefit from PN, thus supporting the clinical decision whether or not to start PN.

The impact of COVID-19 and socioeconomic status on psychological distress in cancer patients.

Objective: We aimed to investigate the impact of the COVID-19 pandemic on psychological symptom burden against the socioeconomic background of cancer patients using data from routine assessments before and during the pandemic. Method: In this cross-sectional study, standardised assessment instruments were applied in N = 1,329 patients to screen for symptoms of anxiety, depression, post-traumatic stress, and fatigue from 2018 to 2022. Two MANOVAs with post-hoc tests were computed. First, only time was included as predictor to examine the isolated impact of the pandemic. Second, income level and education level were included as further predictors to additionally test the predictive power of socioeconomic factors. Results: In the final model, only income had a significant impact on all aspects of psychological symptom burden, with patients with low income being highly burdened (partial η² = .01, p = .023). The highest mean difference was found for depressive symptoms (MD = 0.13, CI = [0.07; 0.19], p < .001). The pandemic had no further influence on psychological distress. Conclusions: Although the pandemic is a major stressor in many respects, poverty may be the more important risk factor for psychological symptom burden in cancer outpatients, outweighing the impact of the pandemic.

Palliative care in severe mental illnesses.

In this editorial, we highlight the interaction between patients who are diagnosed with severe mental illness and their treatment within palliative care, a clinical area of specialized focus which has a multitude of complex impacts on affected patients, their (chosen) family members and caregivers, as well as the healthcare professionals who are caring for them.

Statements of Austrian hospices and palliative care units after the implementation of the law on assisted suicide : A qualitative study of web-based publications.

BACKGROUND: Since January 2022, assisted suicide (AS) in Austria is legal under certain conditions. One of these conditions is informative consultations with two physicians, one of whom must be qualified in palliative medicine. Patients who are thinking about AS can approach palliative care institutions. This study aims to assess the availability and nature of Austrian palliative care institutions' web-based statements about AS. METHODS: In this qualitative study, the websites of all Austrian palliative care units (n = 43) and all Austrian inpatient hospices (n = 14) were searched for possible statements on AS once in February 2022 and once in August 2022 using the three search terms "suicide", "assisted", and "euthanasia". The findings were subsequently evaluated using thematic analysis and NVivo software. RESULTS: Statements or texts that included positions on AS were found on the websites of 11 institutions (19%). The results covered three main themes 1) demarcation: denial of involvement and judgment about AS, 2) duty: handling of requests and describing the target group of care recipients, and 3) explanation: experience, values, concerns, and demands. CONCLUSION: The results of this study indicate that people in Austria who wish to have AS and who may use the internet as their first source of information largely find no relevant information. There is no online statement of a palliative care or hospice institution that endorses AS. Positions on AS are mostly lacking, while reluctant attitudes of Christian institutions are predominant.

The potential of medical comics to teach palliative care skills: a cross-sectional study of 668 medical students.

BACKGROUND: Palliative care (PC) skills are important when caring for patients with advanced illness in a broad range of settings. Students need to be trained in communication and empathy, both representing essential PC skills. Therefore, creative approaches could promote the understanding of relevant PC skills. METHODS: In an online lecture about graphic medicine, different medical comics (MC) were used to introduce the field of graphic medicine and to illustrate relevant skills in PC. After the lecture, an online survey was conducted. The survey consisted of each respondent`s sociodemographic profile and a questionnaire on multiple aspects related to the field of MC. Spearman correlation coefficients and Cohen's effect sizes were used for statistical analysis. RESULTS: The survey respondents comprised 668 students, 337 female, 326 male and 5 diverse. The results showed that the students had never (27.2%) or had very rarely (31.9%) been involved in with the field of MC. The largest number would rate their interest as somewhat or very interested (58.8%). When considering the use of MC to understand different perspectives, the students mainly rated them as useful (54.6%) or very useful (23.4%). Women had a more positive attitude towards MC than men (P<0.001). Students who placed more importance on PC skills were more likely to recommend the use of MC in general medical education (r=0.11, P=0.005). The majority of the students (58.8%) moderately or strongly agreed on the use of MC as a teaching method in PC. CONCLUSIONS: After a single lecture on graphic medicine, the students were positive about using MC for teaching PC skills. Since the lecture was short and the majority of the medical students stated that they had not been previously exposed to the field of MC, this study demonstrates that it is promising to further use and evaluate a set of visual and narrative illustrations as a teaching method in PC.

'It needs experience and courage': Awareness towards end of life communication practices in oncologists: A mixed methods study.

OBJECTIVE: End of life communication (EOLC) is generally regarded as a challenging aspect of the medical profession, with high influences of culture, the physician's experience and awareness. The aim of the current study was to assess the awareness of Austrian oncologists towards EOLC practices in their daily clinical routine and to identify limiting and supporting factors of these conversations. METHODS: Overall, 45 oncologists participated in the assessment in this cross-sectional, mixed-method design using semi-structured interviews and questionnaire. RESULTS: Themes that occurred during the interviews included the initiation of EOLC, EOLC in practice, strategies for EOLC, limiting and supporting factors and consequences of EOLC. There were several variations in the EOLC approach, that is, the use of time frames, timing, initiation and the amount of details given to the patient. CONCLUSION: Oncologists agreed that EOLC is important in their daily clinical routine and for their patients. Nevertheless, there seems to be an underlying variation in approaches chosen by Austrian oncologists. This variation might be reduced by asking patients about their information preferences in advance and by routine implementation of communication guidelines, nomograms and prognostic calculators to reduce uncertainty.

Challenges in Palliative Care Nursing at a University Hospital: A Qualitative Interview Study.

We examined the perception of palliative care nurses regarding challenges, coping strategies, resources, and needs when working in a university hospital in Austria. A qualitative descriptive design was applied, using semistructured interviews with 8 female and 2 male nurses. All interviews were recorded as digital audio and transcribed verbatim. We used thematic analysis and MAXQDA. In our analysis, 6 themes emerged: Four themes related to challenges: ( a ) lack of a supporting structural framework, ( b ) conflict in interdisciplinary work, ( c ) conflict with caregivers, and ( d ) dealing with death in a highly specialized university environment. One theme related to ( e ) individual solutions and coping strategies, and 1 theme comprised ( f ) needs and suggestions for improvements. Taking care of the family of a dying person, handling threatening situation, and working with inexperienced physicians were among the most important challenges reported by nurses. A supportive team, professional counseling, and training related to communication skills and to culturally specific needs of families are perceived to be necessary to provide high-quality palliative care. Addressing the needs of nurses can substantially improve their working condition and has an impact not only on the nurses themselves but also on the quality of patient care.

Evaluation of diagnostic and treatment approaches to acute dyspnea in a palliative care setting among medical doctors with different educational levels.

BACKGROUND: Dyspnea is common in patients with advanced cancer. Diagnostic procedures in patients with dyspnea are mandatory but often time-consuming and hamper rapid treatment of the underlying refractory symptoms. Opioids are the first-line drugs for the treatment of refractory dyspnea in palliative care patients with advanced lung cancer. METHODS: To evaluate the knowledge levels of medical doctors with different educational levels on the diagnosis of and treatment options for dyspnea in patients with advanced lung cancer in a palliative care setting, a case report and survey were distributed to physicians at the University Hospital Krems, describing acute dyspnea in a 64-year-old stage IV lung cancer patient. A total of 18 diagnostic and 22 therapeutic options were included in the survey. The physicians were asked to suggest and rank in order of preference their diagnosis and treatment options. Statistical analyses of the data were performed, including comparison of the responses of the senior doctors and the physicians in training. RESULTS: A total of 106 surveys were completed. The respondents were 82 senior physicians and 24 physicians in training (response rates of 86% and 80%, respectively). Regarding diagnostic investigations, inspection and reading the patient's chart were the most important diagnostic tools chosen by the respondents. The choices of performing blood gas analysis (p = 0.01) and measurement of oxygen saturation (p = 0.048) revealed a significant difference between the groups, both investigations performed more frequently by the physicians in training. As for non-pharmacological treatment options, providing psychological support was one of the most relevant options selected. A significant difference was seen in choosing the option of improving a patient's position in relation to level of training (65.9% senior physicians vs. 30.4% physicians in training, p = 0.04). Regarding pharmacological treatment options, oxygen application was the most chosen approach. The second most frequent drug chosen was a ß-2 agonist. Only 9.8% of the senior physicians and 8.7% of the physicians in training suggested oral opioids as a treatment option, whereas intravenous opioids were suggested by 43.9% of the senior physicians and 21.7% of the physicians in training (p = 0.089). For subcutaneous application of opioids, the percentage of usage was significantly higher for the physicians in training than for the senior physicians (78.3% vs. 48.8%, p = 0.017, respectively). CONCLUSION: The gold standard treatment for treating refractory dyspnea in patients with advanced lung cancer is opioids. Nevertheless, this pharmacological treatment option was not ranked as the most important. Discussing hypothetical cases of patients with advanced lung cancer and refractory dyspnea with experienced doctors as well as doctors at the beginning of their training may help improve symptom control for these patients.