'How long do you think?' Unresponsive dying patients in a specialist palliative care service: A consecutive cohort study.

BACKGROUND: Predicting length of time to death once the person is unresponsive and deemed to be dying remains uncertain. Knowing approximately how many hours or days dying loved ones have left is crucial for families and clinicians to guide decision-making and plan end-of-life care. AIM: To determine the length of time between becoming unresponsive and death, and whether age, gender, diagnosis or location-of-care predicted length of time to death. DESIGN: Retrospective cohort study. Time from allocation of an Australia-modified Karnofsky Performance Status (AKPS) 10 to death was analysed using descriptive narrative. Interval-censored survival analysis was used to determine the duration of patient's final phase of life, taking into account variation across age, gender, diagnosis and location of death. SETTING/PARTICIPANTS: A total of 786 patients, 18 years of age or over, who received specialist palliative care: as hospice in-patients, in the community and in aged care homes, between January 1st and October 31st, 2022. RESULTS: The time to death after a change to AKPS 10 is 2 days (n = 382; mean = 2.1; median = 1). Having adjusted for age, cancer, gender, the standard deviation of AKPS for the 7-day period prior to death, the likelihood of death within 2 days is 47%, with 84% of patients dying within 4 days. CONCLUSION: This study provides valuable new knowledge to support clinicians' confidence when responding to the 'how long' question and can inform decision-making at end-of-life. Further research using the AKPS could provide greater certainty for answering 'how long' questions across the illness trajectory.

Nurse-led interventions among older adults affected by cancer: An integrative review.

Objective: Aging can introduce significant changes in health, cognition, function, social status, and emotional status among older adults affected by cancer. Little is known about how existing nurse-led interventions address the needs of older adults. The objective was to identify existing nurse-led interventions among older adults to optimize recovery and survivorship needs. Methods: A integrative systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) 2020 Guidelines. Electronic databases (APA PsycINFO, CINAHL, MEDLINE, Scopus, and Google Scholar databases) were searched using key search terms. Articles were assessed for inclusion according to a pre-determined eligibility criterion. Data extraction and quality appraisal were conducted. Findings were integrated into a narrative synthesis. Results: Twenty-one studies were included, and a total of 4253 participants were represented. There were a range of study designs: quantitative (n â€‹= â€‹10), randomised controlled trials (n â€‹= â€‹6), mixed methods studies (n â€‹= â€‹3), qualitative (n â€‹= â€‹1), and a non-randomized controlled study (n â€‹= â€‹1). Most participants had prostate cancer, with some representation in colorectal, lung, head and neck, renal, esophageal, and mixed cancer patient populations. Conclusions: This review shows a lack of evidence on the inclusion of geriatric assessments for older people with cancer within existing nurse-led interventions. Further research is needed to test nurse-led interventions with the inclusion of geriatric assessments and their contribution to the multidisciplinary team across the cancer care continuum for various cancer patient populations.

Context and mechanisms that enable implementation of specialist palliative care Needs Rounds in care homes: results from a qualitative interview study.

BACKGROUND: Improving quality of palliative and end of life care in older people's care homes is essential. Increasing numbers of people die in these settings, yet access to high quality palliative care is not routinely provided. While evidence for models of care are growing, there remains little insight regarding how to translate evidence-based models into practice. Palliative Care Needs Rounds (hereafter Needs Rounds) have a robust evidence base, for providing palliative care in care homes, reducing resident hospitalisations, improving residents' quality of death, and increasing staff confidence in caring for dying residents. This study aimed to identify and describe the context and mechanisms of change that facilitate implementation of Needs Rounds in care homes, and enable other services to reap the benefits of the Needs Rounds approach to care provision. METHODS: Qualitative interviews, embedded within a large randomised control trial, were conducted with a purposive sample of 21 staff from 11 care homes using Needs Rounds. The sample included managers, nurses, and care assistants. Staff participated in individual or dyadic semi-structured interviews. Implementation science frameworks and thematic analysis were used to interpret and analyse the data. RESULTS: Contextual factors affecting implementation included facility preparedness for change, leadership, staff knowledge and skills, and organisational policies. Mechanisms of change that facilitated implementation included staff as facilitators, identifying and triaging residents, strategizing knowledge exchange, and changing clinical approaches to care. Care home staff also identified planning and documentation, and shifts in communication. The outcomes reported by staff suggest reductions in hospitalisations and problematic symptoms for residents, improved staff skills and confidence in caring for residents in their last months, weeks and days of life. CONCLUSIONS: The significance of this paper is in offering care homes detailed insights into service contexts and mechanisms of change that will enable them to reap the benefits of Needs Rounds in their own services. The paper thus will support the implementation of an approach to care that has a robust evidence base, for a population under-served by specialist palliative care. TRIAL REGISTRATION: ACTRN12617000080325 .

Reducing time in acute hospitals: A stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes.

BACKGROUND: Care home residents are frequently transferred to hospital, rather than provided with appropriate and timely specialist care in the care home. AIM: To determine whether a model of care providing specialist palliative care in care homes, called Specialist Palliative Care Needs Rounds, could reduce length of stay in hospital. DESIGN: Stepped-wedge randomised control trial. The primary outcome was length of stay in acute care (over 24-h duration), with secondary outcomes being the number and cost of hospitalisations. Care homes were randomly assigned to cross over from control to intervention using a random number generator; masking was not possible due to the nature of the intervention. Analyses were by intention to treat. The trial was registered with ANZCTR: ACTRN12617000080325. Data were collected between 1 February 2017 and 30 June 2018. SETTING/PARTICIPANTS: 1700 residents in 12 Australian care homes for older people. RESULTS: Specialist Palliative Care Needs Rounds led to reduced length of stay in hospital (unadjusted difference: 0.5 days; adjusted difference: 0.22 days with 95% confidence interval: -0.44, -0.01 and p = 0.038). The intervention also provided a clinically significant reduction in the number of hospitalisations by 23%, from 5.6 to 4.3 per facility-month. A conservative estimate of annual net cost-saving from reduced admissions was A$1,759,011 (US$1.3 m; UK£0.98 m). CONCLUSION: The model of care significantly reduces hospitalisations through provision of outreach by specialist palliative care clinicians. The data offer substantial evidence for Specialist Palliative Care Needs Rounds to reduce hospitalisations in older people approaching end of life, living in care homes.

Improved Quality of Death and Dying in Care Homes: A Palliative Care Stepped Wedge Randomized Control Trial in Australia.

OBJECTIVES: Mortality in care homes is high, but care of dying residents is often suboptimal, and many services do not have easy access to specialist palliative care. This study examined the impact of providing specialist palliative care on residents' quality of death and dying. DESIGN: Using a stepped wedge randomized control trial, care homes were randomly assigned to crossover from control to intervention using a random number generator. Analysis used a generalized linear and latent mixed model. The trial was registered with ANZCTR: ACTRN12617000080325. SETTING: Twelve Australian care homes in Canberra, Australia. PARTICIPANTS: A total of 1700 non-respite residents were reviewed from the 12 participating care homes. Of these residents, 537 died and 471 had complete data for analysis. The trial ran between February 2017 and June 2018. INTERVENTION: Palliative Care Needs Rounds (hereafter Needs Rounds) are monthly hour-long staff-only triage meetings to discuss residents at risk of dying without a plan in place. They are chaired by a specialist palliative care clinician and attended by care home staff. A checklist is followed to guide discussions and outcomes, focused on anticipatory planning. MEASUREMENTS: This article reports secondary outcomes of staff perceptions of residents' quality of death and dying, care home staff confidence, and completion of advance care planning documentation. We assessed (1) quality of death and dying, and (2) staff capability of adopting a palliative approach, completion of advance care plans, and medical power of attorney. RESULTS: Needs Rounds are associated with staff perceptions that residents had a better quality of death and dying (P < .01; 95% confidence interval [CI] = 1.83-12.21), particularly in the 10 facilities that complied with the intervention protocol (P < .01; 95% CI = 6.37-13.32). Staff self-reported perceptions of capability increased (P < .01; 95% CI = 2.73-6.72). CONCLUSION: The data offer evidence for monthly triage meetings to transform the lives, deaths, and care of older people residing in care homes. J Am Geriatr Soc 68:305-312, 2020.

Quantifying physical activity and the associated barriers for women with ovarian cancer.

OBJECTIVE: The purpose of this study was to quantify physical activity levels and determine the barriers to physical activity for women with ovarian cancer. MATERIALS AND METHODS: Women with ovarian cancer from 3 oncology clinics enrolled in the cross-sectional study. Physical activity and barriers to physical activity were measured using the International Physical Activity Questionnaire and Perceived Physical Activity Barriers scale, respectively. Demographic, medical, and anthropometric data were obtained from medical records. RESULTS: Ninety-five women (response rate, 41%), with a mean (SD) age of 61 (10.6) years, a body mass index of 26.5 (6.8) kg/m², and 36.6 (28.2) months since diagnosis, participated in the study. The majority of the participants had stage III (32%) or IV (32%) ovarian cancer, were undergoing chemotherapy (41%), and had a history of chemotherapy (93%). The majority of the participants reduced their physical activity after diagnosis, with 19% meeting recommended physical activity guidelines. The participants undergoing treatment reported lower moderate-vigorous physical activity compared with those not undergoing active treatment (mean [SD], 42 [57] vs 104 [119] min/wk; P < 0.001) and less total physical activity barriers (mean [SD], 49 vs 47; P > 0.4). The greatest barriers to physical activity included fatigue (37.8%), exercise not in routine (34.7%), lack of self-discipline (32.6%), and procrastination (27.4%). CONCLUSIONS: Women with ovarian cancer have low levels of physical activity. There are disease-specific general barriers to physical activity participation. The majority of the participants reduced their physical activity after diagnosis, with these patients reporting a higher number of total barriers. Behavioral strategies are required to increase physical activity adherence in this population to ensure that recommended guidelines are met to achieve the emerging known benefits of exercise oncology.

Advance care planning in the oncology settings.

BACKGROUND: Self-determination and patient choice of end-of-life care are emphasised in palliative care. Advance care planning (ACP) is an approach to enabling patients' choices. The use of ACP has not been extensively studied in our current context. Little is known about oncology care nurses' views and the barriers they face in the implementation of ACP. OBJECTIVE: The aims of this study were to assess the uptake of ACP by health professionals and explore nurses' perceived barriers for implementing ACP. METHODS: This study employed a pre- and post-implementation audit design using the Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System (PACES) and Getting Research into Practice (GRIP) programs. An education programme on ACP was provided between pre-and post-implementation audits. Nurses and medical professionals (pre-audit, n = 32; post-audit, n = 30) working in oncology departments were invited to complete a questionnaire based on the audit criteria. A convenience sample of 25 nurses participated in the focus group interview. Interview data were analysed by content analysis. RESULTS: The post-audit results were lower than the pre-audit results with a range of decreased compliance from 1% for criterion 5 to 14% for criterion 6. Lack of time to implement ACP was the most frequently raised barrier by oncology nurses. CONCLUSIONS: The study findings were disappointing, but this first audit is significant to provide insights for future dissemination and implementation of ACP interventions. An ongoing mandatory professional development programme in ACP for healthcare staff is promising to promote the uptake of ACP in healthcare settings.