Quality of referrals to specialist palliative care and remote patient triage - a cross-sectional study.

PURPOSE: Choosing the optimal moment for admission to palliative care remains a serious challenge, as it requires a systematic identification of persons with supportive care needs. Despite the screening tools available for referring physicians, revealing the essential information for preliminary admission triage is crucial for an undisturbed qualification process. The study was aimed at analysing the eligibility criteria for specialist palliative care disclosed within provided referrals, expanded when necessary by documentation and/or interview. METHODS: Referral forms with the documentation of 300 patients consecutively referred to the non-profit in-patient ward and home-care team in Poland were analysed in light of prognosis, phase of the disease and supportive needs. RESULTS: Half of the referrals had the sufficient information to make a justified preliminary qualification based solely on the delivered documentation. The majority lacked performance status or expected prognosis. Where some information was revealed, two-thirds were in a progressing phase of the disease, with a within-weeks life prognosis. In 53.7%, no particular reason for admission was given. Social problems were signalled as the only reason for the admission in 7.7%. Twenty-eight percent were labelled as "urgent"; however, 52.4% of them were triaged as "stable" or disqualified. Patients referred to a hospice ward received complete referral forms more often, containing all necessary information. CONCLUSIONS: General physicians need practical tips to facilitate timely referrals and unburden the overloaded specialist palliative care. Dedicated referral forms extended by a checklist of typical patients' concerns should be disseminated for better use of these resources.

Adjustable Compression Wraps (ACW) vs. Compression Bandaging (CB) in the Acute Phase of Breast Cancer-Related Arm Lymphedema Management-A Prospective Randomized Study.

The objective of this study is to compare the effectiveness, comfort and possibilities of the self-application of adjustable compression wraps (ACW) with compression bandaging (CB) in the acute phase of treatment in advanced upper-limb lymphedema. In total, 36 patients who fulfilled the admission criteria were randomly assigned into ACW-Group (18 patients), or CB-Group (18 patients). Treatment in both groups lasted for two weeks. In the first, all patients were educated in applying adjustable compression wraps (ACW-Group) or self-bandaging (CB-Group) and treated by experienced physiotherapists. In the second week, the use of ACW and CB was continued by the patients themselves at home. In both groups, a clinically significant reduction in the affected limb volume was found after the first week (p < 0.001). A further decrease in the affected limb volume within the second week was noted only in the CB-Group (p = 0.02). A parallel trend was found in the percentage reduction in the excess volume after one and two weeks of compression therapy. Within two weeks, both groups achieved a significant improvement in decreasing lymphedema-related symptoms, but women from the ACW-Group reported complications related to carrying out compression more frequently (p = 0.002). ACW can reduce lymphedema and disease-related symptoms, but based on the results it is difficult to recommend this method as an alternative option in the acute phase of CPT among women with advanced arm lymphedema.

Early Detection of Breast Cancer-Related Lymphedema in COVID-19 Pandemic.

Background: This study aimed at presenting a prospective surveillance model of care delivered at home for women qualified for surgery due to breast cancer under the epidemic-related restrictions. Methods and Results: Women (age ≥18 years, diagnosed with breast cancer, no clinical features of upper limbs lymphedema, and a volume difference between the limbs <5%, not using any prophylactic compression products) will be provided with comprehensive education in the field of self-measurements and lymphedema prevention. The outcome measures include limb volume (circumferential measurements with a tape at 4 cm intervals), simplified protocol of three measurement points combined with the symptoms monitoring (according to the physical section of Lymphedema Quality of Life Inventory [LyQLI]). We propose a new calculation method as the RACI (relative arm circumference increase) in accordance with previous research-RAVI (relative arm volume increase) and the new proposal-the RACD (relative arm circumference difference). According to cylinder formula it can be calculated that 5% increase in limb volume results in ∼2% change in RACI. Regular appointments will be planned at 3, 6, 9, and 12 months after the enrollment. Additional urgent appointments will be arranged after the home or phone "red flags" (an increase circumference by ≥2%, positive pitting test, and any new symptoms) detection. We hypothesize that performing only three measurements combined with the typical symptoms monitoring would be accurate for lymphedema diagnosis based on the RAVI of ≥5%. Moreover, RACI/RACD increments combined with positive symptoms would correlate with RAVI. Conclusions: The new proposal of protocol can be the optimal solution in COVID-19 pandemic.

Medical referral criteria for palliative care in adults: a scoping review.

Palliative care (PC) is focused on the relief of serious suffering due to severe illness. The Polish health care reimbursement system limits the access to PC to a so-called "basket" of recipients with life­limiting incurable diseases (mainly cancer), not responding to disease­modifying therapy. This scoping literature review was aimed to define the criteria of medical referral for PC in the context of the interpretation of the terms life­limiting illness and disease­modifying therapy, which may aid in increasing the number of appropriate referrals and patients receiving optimal treatment. The PubMed and Google Scholar databases (2011-2021) were searched using the following terms: referral, eligibility, admission as well as life-limiting, end­stage and palliative care. Of 790 rertrieved articles, 103 studies met the inclu-sion criteria. Two groups of referral criteria were found: disease-or prognosis-based and needs­based. The first group was focused on a survival prognosis of 6 to 12months, while the second encompassed the presence of severe, complex, or persistent symptoms or health problems not responding to optimal treatment. Numerous examples of disease­modifying treatments for specific advanced diseases were found. The discriminants characterizing life­limiting diseases in individual cases should preferably be used in clusters to accurately screen for PC eligibility. Equally important as limited survival prognosis is the presence of severe, complex, and persistent symptoms or problems occurring despite optimal treatment and general care. Based on the reviewed literature, the national reimbursement program should be urgently extended to cover more patients who are eligible and could benefit from specialist PC. Additionally, the importance of general PC should be universally acknowledged.

Psychometric validation and cross-cultural adaptation of the Integrated Palliative care Outcome Scale in Polish (IPOS-Pol).

OBJECTIVE: The study aimed to assess the reliability and validity of the IPOS-Pol for patient self-reporting. METHOD: Patients (>18 years of age) with advanced cancer admitted to three palliative care centers (inpatient units and home-based) were recruited to a multicenter, cross-sectional, observational, prospective study. Participants provided responses to the IPOS-Pol Patient version and the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - Core 15 - Palliative Care (EORTC QLQ-C15-PAL) Polish version at baseline (T1) and four to seven days later (T2). We assessed test-retest reliability, internal consistency, and construct validity of the tool. RESULTS: One hundred and eighty patients were included. Test-retest reliability demonstrated no statistically significant differences in the average outcomes of the IPOS-Pol between T1 and T2 (27.2 ± 9.2 vs. 26.5 ± 8.7; p > 0.05). The intra-class correlation coefficient between T1 and T2 was r = 0.83 (p < 0.0001), the intra-class correlation coefficient for test-retest reliability of the IPOS-Pol items ranged from 0.63 to 0.84 (p < 0.0001), and the Cronbach's α coefficient for internal consistency was 0.773. The correlation coefficient between the IPOS-Pol and EORTC QLQ-C15-PAL total score was 0.79 (p < 0.001). SIGNIFICANCE OF RESULTS: The patient version of the Polish adaptation of IPOS is a valid and reliable outcome measure for assessing symptoms and concerns of individuals receiving palliative care, as well as the quality of care provided.

Multicomponent Compression Bandaging Combined with Diuretic Therapy of Anasarca Secondary to Palliative Chemotherapy: A Case Report.

Background: Although decongestive physiotherapy combined with diuretics may be efficient in limb edemas, no such therapy has been described in the context of anasarca. Case Description: A bedbound 62-year-old man with stage IV pancreatic cancer, presenting with progressing severe dyspnea at rest and anasarca, was admitted to the free-standing hospice 3 weeks after receiving nab-paclitaxel with gemcitabine. Two weeks before admission, oral loop and potassium-sparing diuretics were started for bilateral lower limb edema, which progressed to anasarca even though the drug dose was increased. Hypotension hindered further dose escalation of diuretics. Supportive multicomponent bandage compression on both legs with concurrent intravenous furosemide in hypersaline infusion was implemented with good clinical toleration. Afterward, the loop diuretic dose was increased, and supplemented with dexamethasone. A spectacular edema decrease and marked dyspnea improvement with 19 kg body weight reduction were observed within 7 days. Furosemide was switched to oral route and the patient was discharged needing only occasional assistance in daily living. Conclusion: Compression bandaging with diuretic therapy may be considered even in advanced generalized edemas; however, further studies are needed to determine the adequate therapeutic regime.

Palliative Performance Scale: cross cultural adaptation and psychometric validation for Polish hospice setting.

BACKGROUND: Measuring functional status in palliative care may help clinicians to assess a patient's prognosis, recommend adequate therapy, avoid futile or aggressive medical care, consider hospice referral, and evaluate provided rehabilitation outcomes. An optimized, widely used, and validated tool is preferable. The Palliative Performance Scale Version 2 (PPSv2) is currently one of the most commonly used performance scales in palliative settings. The aim of this study is the psychometric validation process of a Polish translation of this tool (PPSv2-Polish). METHODS: Two hundred patients admitted to a free-standing hospice were evaluated twice, on the first and third day, for test-retest reliability. In the first evaluation, two different care providers independently evaluated the same patient to establish inter-rater reliability values. PPSv2-Polish was evaluated simultaneously with the Karnofsky Performance Score (KPS), Eastern Cooperative Oncology Group (ECOG) Performance Status (ECOG PS), and Barthel Activities of Daily Living (ADL) Index, to determine its construct validity. RESULTS: A high level of full agreement between test and retest was seen (63%), and a good intra-class correlation coefficient of 0.85 (P < 0.0001) was achieved. Excellent agreement between raters was observed when using PPSv2-Polish (Cohen's kappa 0.91; P < 0.0001). Satisfactory correlations with the KPS and good correlations with ECOG PS and Barthel ADL were noticed. Persons who had shorter prognoses and were predominantly bedridden also had lower scores measured by the PPSv2-Polish, KPS and Barthel ADL. A strong correlation of 0.77 between PPSv2-Polish scores and survival time was noted (P < 0.0001). Moderate survival correlations were seen between KPS, ECOG PS, and Barthel ADL of 0.41; - 0.62; and 0.58, respectively (P < 0.0001). CONCLUSION: PPSv2-Polish is a valid and reliable tool measuring performance status in a hospice population and can be used in daily clinical practice in palliative care and research.

Lay Caregivers Education in Multicomponent Compression Bandaging in Obese Patients with Lower Limb Edema: A Case-Control Pilot Study.

Background: A report on the usefulness of the instruction of lay carers in multilayer short-stretch compression bandaging within the initial intensive phase physical treatment of mixed-etiology chronic lower limb edema. Methods and Results: In a group of adult obese patients (including 24 females) with venous insufficiency and chronic bilateral lower limb edema, and without a history of physical therapy, 20 (ambulatory managed) were bandaged once daily (four layers, short stretch with cotton tube, and foam padding underneath) for 3 weeks (Monday-Friday) by skilled physiotherapists, and in 20 cases (education group, EG), the patients' lay carers were educated by these physiotherapists according to the same regime during one session. The outcome measures included limb volume (the method of circumference measurement with a tape at 4 cm intervals) after 1, 3, and 6 months, the time to reach the maintenance phase, the frequency of complementary bandaging during this phase, and the sense of self-efficacy (General Self-Efficacy scale, GSEs). No significant differences were noted between the two groups in the baseline measurements of age, body mass, and limb volume. The carers were able to apply compression bandages in all cases during the observation period. The time to reach the maintenance phase was longer in EG (6 vs. 1 weeks; p < 0.001). A similar median reduction in edema volume was observed at the end of the bandaging period, which continued for 3 and 6 months. It was only in EG that further improvement between 1 and 3 months was observed (p = 0.008). All participants represented an equally high optimistic sense of personal competence (GSEs). Conclusions: The instruction of lay carers in bandaging may provide a simple clinically effective solution for lower limb edema management, thus lowering its costs.

Polypharmacy and medication errors on admission to palliative care.

INTRODUCTION: Many patients at the end of their life are treated with multiple medications while some of the drugs may no longer be beneficial and should be reduced. OBJECTIVES: The aim of the study was to assess polypharmacy, overprescribing, and the incidence of presumable pharmacological errors at referral to palliative care. PATIENTS AND METHODS: Current treatment in consecutive patients was analyzed based on the clinical judgment of a palliative care specialist on the first appointment. The number of drugs/tablets with pharmacotherapy inappropriateness was counted, analyzed, and a new therapy was proposed. RESULTS: A total of 337 patients were admitted. The median number of drugs / tablets used at referral was 7 / 9 per day. In patients with short life prognosis, the corresponding numbers were higher (8 / 10). Polypharmacy was found in 265 patients (78.6%) and at least 1 drug inappropriateness occurred in 238 patients (70.6%). The most frequent error type was lack of necessary concomitant drug. Patients who were bed­bound (Palliative Performance Scale ≤40 points), with the shortest life expectancy (Gold Standards Framework, D), who died within 2 weeks or were discharged from the hospital and admitted to hospice had more often 1 or more potentially inappropriate medication. The risk of inappropriateness increased with the number of drugs / tablets prescribed by 13.3% / 7.4% per drug / tablet. The median number of drugs / tablets decreased on palliative consultation by 1.0 / 2.0 (P = 0.01 / P <0.001, respectively). Subgroups with a higher number of errors had a larger drug reduction. CONCLUSIONS: Polypharmacy and increased risk of drug inappropriateness particularly affect elderly patients referred by hospitals, with poor prognosis, low performance, admitted to in­patient hospice. Therapy reduction may diminish the risk of therapeutic inappropriateness but requires further education within nonspecialist palliative care.

Do Compression Sleeves Reduce the Incidence of Arm Lymphedema and Improve Quality of Life? Two-Year Results from a Prospective Randomized Trial in Breast Cancer Survivors.

BACKGROUND: In a previous randomized controlled trial it has been demonstrated that arm compression sleeves worn immediately after breast cancer surgery, including axillary lymph node removal in addition to physical therapy are able to reduce the occurrence of early postoperative swelling and of arm lymphedema up to 1 year and to improve quality of life. The aim of the present investigation was to check the further development of the arm swelling in patients using compression sleeves or not, and to compare the quality of life in women treated due to breast cancer 2 years after surgery. MATERIALS AND METHODS: Twenty from originally 23 patients who still wore their compression sleeves (15 mmHg) and 21 from 22 patients who had been randomized into the control group without compression could be seen after one more year. Arm volume measurements were performed and quality of life (QLQ-C30 and QLQ-BR23 questionnaires) was assessed. RESULTS: Three from 20 patients in the compression group (CG) and 6 from 21 without compression showed arm lymphedema, defined by an increase of the arm volume exceeding 10% compared with the preoperative values. Significant improvement of several quality of life parameters were found in the CG. CONCLUSION: Light compression sleeves worn for 2 years are not only able to reduce the incidence of early postoperative edema and of lymphedema, but also lead to a significant improvement of important quality-of-life parameters like physical functioning, fatigue, pain, arm and breast symptoms, and future perspectives.

Edema of Advanced Cancer: Prevalence, Etiology, and Conservative Management-A Single Hospice Cross-Sectional Study.

CONTEXT: Edema of advanced cancer, seldom recognized in the literature, significantly impairs patient quality of life. OBJECTIVES: The purpose was to assess edema frequency, etiology, and impact on common symptoms and present its conservative management. METHODS: A prospective analysis of 784 patients admitted to a hospice was performed, of whom 119 were diagnosed with edema. For 18 patients with short life prognosis, an individually tailored physiotherapy (limb elevation, bandaging, manual lymphatic drainage, and Kinesio Taping) or subcutaneous needle drainage was administered. Forty-six patients with longer prognosis were treated by standardized limb bandaging (5-7 days) and re-evaluated, 28 of them with venous congestion resistant to enteral diuretics received supplementary furosemide infusion. RESULTS: Among those admitted with edema (96.6% with advanced cancer), 81.5% had bilateral and 10.9% generalized edema, 10.9% had lymphorrhea, 5.9% skin ulcerations, and in 27.7% edema was the main problem. The high mean comorbidity C3-index score (2.97) was observed. The main precipitating factors of the edema were chronic immobilization (79.8%) medications (58.8%), and congestive heart failure (28.6%). Before admission, 47.9% had received diuretics for edema and only 4.2% had physiotherapy. Among those re-evaluated (46 patients [84 limbs]), the mean reduction of limb volume (1.18L; 16.6%; P < 0.001) was accompanied by a decrease of edema symptoms/signs intensity and ESAS-Core by median 1 point (P < 0.002). CONCLUSION: Limb edema of advanced cancer occasionally treated by physical therapy concerns patients with numerous comorbidities and precipitating factors. It can be managed sufficiently with decongestive or supportive physiotherapy, depending on patients' life prognosis, symptom burden, edema stage, and progression.

Diuretics Combined With Compression in Resistant Limb Edema of Advanced Disease-A Case Series Report.

INTRODUCTION: The extremity edema of advanced disease is a common, multifactorial feature, which impairs patients' activities and quality of life. The most frequently chosen management is based on combined decongestive physiotherapy or pharmacotherapy (with diuretics or steroids). Subcutaneous lymphatic drainage in refractory edema may decrease the swelling, prevent spontaneous lymphorrhea, but also increase the risk of infection. Safe and effective conservative management in diuretics-resistant edemas is lacking. The objective of this prospective, observational study was to assess the effectiveness and tolerability of combined physiotherapeutic and diuretic therapy in edemas refractory to parenteral diuretics. METHODS: A group of 19 patients with advanced disease and severe bilateral leg edema resistant to parenteral diuretic therapy were treated for three days with a combination of multilayer short-stretch compression bandaging and furosemide in hypersaline intravenous infusion. RESULTS: A clinically meaningful decrease in mean limb volume (of 1.52 L; 20.6%; P < 0.0001)-strongly correlating with patients' weight loss (ρ = 0.71; P = 0.0001), with a lowering of the intensity of complaints-was achieved. The treatment was well tolerated, without decreasing the performance status in any patient. Stable levels of blood pressure, laboratory kidney profile (potassium, sodium, creatinine clearance), and serum albumin were observed. Maintenance of the achieved results with a good compliance was seen during an informal follow-up at the hospice. CONCLUSION: The combination of compression therapy with hypersaline diuretics could be considered as a valuable option for refractory cases of limb edema in advanced disease.

Physical Activity With and Without Arm Sleeves: Compliance and Quality of Life After Breast Cancer Surgery-A Randomized Controlled Trial.

BACKGROUND: After breast cancer surgery patients are at higher risk of lymphedema development and decreasing physical activity (PA), as well as decreasing health-related quality of life (HRQOL). The aim of the study was to compare the level of PA and HRQOL in women after breast cancer surgery using light arm compression with women not using compression 1 year after oncological treatment. METHODS AND RESULTS: Forty-five women were preoperatively randomly assigned to a compression group (CG, n = 23) or to no compression group (NCG, n = 22). Arm volumes were measured before surgery and 12 months thereafter. The CG received circular-knit sleeves in compression class 1 for daily wearing in the postoperative period up to 1 year. Both groups underwent a standardized physical exercise program. PA with the short version of International Physical Activity Questionnaire (IPAQ), compliance, and HRQOL by EORTC QLQ-C30 and QLQ-BR23 questionnaires was assessed in both groups 1 year after surgery. After 1 year observation the CG showed significantly lower mean affected arm volume compared to NCG. The total PA (calculated as the sum of vigorous moderate exercises and walking) was markedly higher within the CG, with no difference in particular IPAQ items. There were no correlations between reported PA items and observed arm/edema volume or body mass index changes. The QLQ-BR23 revealed only better sexual functioning (p = 0.014) and greater upset by hair loss in NCG (p = 0.01). CONCLUSIONS: The available data indicate that wearing compression sleeves neither interfere with the level of PA nor decrease quality of life 1 year after breast cancer surgery.

Preventing Early Postoperative Arm Swelling and Lymphedema Manifestation by Compression Sleeves After Axillary Lymph Node Interventions in Breast Cancer Patients: A Randomized Controlled Trial.

CONTEXT: Breast cancer-related lymphedema (LE) remains one of the major long-term complications after surgery. Many reports showed the effectiveness of compression in breast cancer-related LE treatment, but randomized controlled trials evaluating compression garments for postoperative prevention are lacking. OBJECTIVES: The aim of the study was to evaluate the potential role of light arm compression sleeves for reducing the incidence of early postoperative swelling and of breast cancer-related arm LE. METHODS: A total of 45 women were pre-operatively randomly assigned to a group with compression of circular-knit sleeves in compression class I (15-21 mm Hg) for daily wearing (compression group [CG]; n = 23) or to a control group without compression (no CG, n = 22). Both groups underwent a standardized physical exercise program. Arm volumes were measured before surgery and one, three, six, nine, and 12 months thereafter. RESULTS: At one month, postoperative swelling was reduced only in CG. After 12 months, the average change of excess volumes (edema) reached -67.6 mL in the CG vs. +114.5 mL in the no CG (P < 0.001). Significantly less edema was seen in the CG after three, six, nine, and 12 months. No significant difference between groups in health-related quality of life (measured by EORTC QLQ-C30) was observed. CONCLUSION: Fifteen to 21 mm Hg compression sleeves in combination with physical activity may be a safe and efficient option to prevent postsurgical arm swelling and development of LE.

Complex Decongestive Lymphatic Therapy With or Without Vodder II Manual Lymph Drainage in More Severe Chronic Postmastectomy Upper Limb Lymphedema: A Randomized Noninferiority Prospective Study.

CONTEXT: Complex decongestive lymphatic therapy (CDT) has been the method of choice in conservative management of lymphedema. Although effective, it is time consuming and manual lymph drainage (MLD) usually requires skilled therapists. OBJECTIVES: The purpose of this study was to compare the reduction in edema volume in more advanced (≥20% limb volume difference) postmastectomy arm lymphedema achieved by compression bandaging (CB) and physical exercises vs. the same management augmented by an additional 30 minutes of MLD (Vodder II method). METHODS: Sixty postmastectomy women were randomly assigned to either the CB group or the CDT group. Of those, 51 women (26 within the CB group) completed 26 weeks of therapy (two weeks of the intensive phase and six months of the maintenance phase). RESULTS: A decrease of limb volume (15.6% in the CB group and 13.8% in the CDT group), edema volume (47.2% and 47.4%, respectively), and limb-related volume change (14.7% and 12.5%) during the intensive phase were observed. This improvement remained constant in both groups after six months of maintenance therapy. The health-related quality of life (measured by the Lymphedema Questionnaire) similarly showed improvement in both groups, with a high level of treatment satisfaction. CONCLUSION: These results indicate that parallel (immediate and delayed) results may be obtained by CDT without the use of Vodder MLD and CB may be an essential part of lymphedema management.

Five-year assessment of maintenance combined physical therapy in postmastectomy lymphedema.

BACKGROUND: Combined physical therapy (CPT) is the treatment of choice for patients with lymphedema. Intensive stage CPT (I-CPT) results in a substantial reduction of the size of lymphedema, while the second stage CPT (M-CPT) maintains the achieved result for many years. AIM: The article analyses the outcome M-CPT for 5 years in patients with lymphedema after mastectomy. METHODS: Forty patients had regularly been attending follow-up appointments every six months for five years (Group A). Out of the group of patients who had not been reporting for follow-up, twenty women accepted an invitation for assessment (Group B); none of them complied with the prescribed compression therapy. All patients were submitted to I-CPT and patients from group A completed M-CPT comprising compression garments and an individual program of physical exercises. RESULTS: During five-year M-CPT, the difference in limb volumes (Vo), relative size of edema (Vor) reduction achieved after I-CPT was maintained in Group A, while in Group B a considerable increase of Vo by 14% was noted. Ultimately lymphedema in these patients was more pronounced than before their physical therapy had commenced. For 40 women using compression sleeves the mean Suitability Score System was 8.3 points on maximum 11-point scale, for 15 patients wearing additional compression gloves, the mean score was 4.3 points on maximum 5 points. CONCLUSIONS: The reduction of lymphedema achieved during I-CPT can be retained during M-CPT when the patient systematically attends follow-up examinations, applies compression therapy, and follows the therapy instructions. Non-compliance is followed by a worsening of lymphedema.