Attitude toward end-of-life care in emergency medicine residents- can a short workshop make a difference?

BACKGROUND: There is a growing demand for palliative care (PC) in Emergency departments (ED) as the number of patients who need end-of-life (EOL) care is increasing. Despite significant variability amongst residency programs, there is a lack of structured core curriculum for PC/EOL care in most emergency medicine (EM) training programs, which often do not meet the needs of EM physicians. In this study, we evaluate the effect of a short EOL care workshop on changing the attitude of Iranian EM residents towards EOL care in ED. METHOD: In this prospective before/after educational study at Tehran University of medical science, we enrolled 40 EM residents using a random sampling method. We obtained demographic and practice background information, and participants underwent a half-day PC training workshop designed by an expert panel. We administered a translated and validated Standard PEAS (physician End of Life Care Attitude Scale) questionnaire before and four weeks after an educational intervention. Baseline and differences in attitude were reported and compared by paired t-test, repeated measure ANOVA, and ANOVA. RESULTS: None of the participants had prior experience of formal PC training. All of the 40 participants completed the follow-up questionnaire. Baseline attitude was not different among demographic groups. The mean (SD) PEAS score before and four weeks after the workshop was 86.9 (5.8) versus 89(6.9), respectively (P = 0.023). Residents with no previous close exposure to a terminal illness in their family members had significantly more attitude change than those with such an experience (P = 0.045). CONCLUSION: A brief educational intervention improved EM residents' attitudes toward EOL care. The optimal design and characteristics of this educational intervention yet remain to be defined by further studies.

Economic Burden of Gynecological Cancers in Iran.

BACKGROUND: Gynecological cancers (GCs) are an important cause of morbidity and mortality among women worldwide. The incidence of cancer is increasing in Iran, and according to statistics, it has become the most important cause of mortality. This study aimed to assess the economic burden of GCs, including cervical, ovarian, and endometrial cancers, in Iran in 2014. METHODS: We used a prevalence-based cost of illness methodology to investigate the annual healthcare cost of GCs and to determine the productivity loss. The productivity loss was estimated, using the human capital approach. We obtained our data from a referral hospital for the year 2014; we also used expert opinion and occupational and statistical data. To estimate direct medical cost, we used bottom-up approach and we estimated the average cost of each procedure, multiplied by the number of patients receiving the procedure. RESULTS: The total cost of GCs in Iran was estimated at $51 million in 2014. The direct costs were $32 million, and indirect costs were $19 million of the total annual cost. The total cost of ovarian cancer was the highest among 3 cancers. CONCLUSIONS: Knowing that the cost of GCs has a significant impact on the burden of disease and imposes an economic burden on the country could force policy makers to allocate their resource in the prevention programs and new approach in patient's management. This could lead to diagnose more GCs in the early stages, reduce mortality, and increase the quality of life.

Evaluation of Care Providers' Attitude toward Perinatal Palliative Care and its Challenges in the Selected Teaching Hospitals of Tehran in 2019.

OBJECTIVES: The present study aims to determine the attitudes of care providers including obstetricians, paediatricians and midwives working in perinatal, obstetric and neonatal intensive care unit (NICU) wards of the selected teaching hospitals in Tehran in 2019. In addition, the challenges of providing palliative care from the perspective of these individuals have been examined. MATERIALS AND METHODS: In this descriptive study, the research population was selected through convenience sampling based on the inclusion criteria. To assess care providers' attitude toward the perinatal palliative care and the challenges of its implementation, in addition to the questionnaire of demographic characteristics, a researcher-made questionnaire was also used. RESULTS: Most of the care providers (90.5%) believed that parents should be involved in decision-making to select the treatment type. Most of the care providers (90%) believed that the lack of prepared infrastructures is one of the major challenges in providing these types of care. CONCLUSION: Care providers have almost positive attitudes toward the various dimensions of providing perinatal palliative care, but it has not been properly implemented yet due to the insufficient knowledge of this type of care, the lack of required infrastructures (appropriate conditions in NICUs to provide this type of care, the sufficient number of staff and experts in this field), as well as the health authorities' neglecting this type of care.

Challenges of paediatric palliative care in the intensive care unit during the COVID-19 pandemic.

BACKGROUND: The integration of paediatric palliative care into the Iranian health system is essential. AIMS: The aim of this study was to identify the challenges of palliative care in the paediatric intensive care unit during COVID-19 through the experiences of healthcare providers. METHODS: A qualitative study with content analysis approach was conducted. Fifteen physicians and nurses were selected by purposeful sampling. The semi-structured, in-depth interviews were applied in the data collection. FINDINGS: Ten main categories were extracted from data analysis, including 'caring in COVID-19', 'communication and family centre care', 'breaking bad news', palliative care training', 'pain and symptom management', 'support of the child, family and clinical team', 'physical environment', 'guidelines', 'specialised staff' and 'home based palliative care'. CONCLUSION: Palliative care in the PICU faces several challenges, especially during COVID-19, but the clinical team are making every attempt to improve the comprehensive care of children and their families. Telehealth is important in COVID-19, and education is also a key component to improve palliative care in the PICU in Iran.

Health Care Providers' Experiences of the Non-Pharmacological Pain and Anxiety Management and Its Barriers in the Pediatric Intensive Care Units.

OBJECTIVES: Children in the intensive care unit experience a high level of pain and anxiety. This study aimed to reveal the health care providers experience of non-pharmacological pain and anxiety management and its barriers in the pediatric intensive care unit. METHODS: This qualitative-descriptive study was conducted with thirteen nurses and five physicians in the pediatric intensive care unit in Iran. Individual, in-depth and semi-structured interviews were conducted, which were analyzed by conventional content analysis. RESULTS: Five main categories were identified from data analysis: 1) The importance of parents' presence, 2) Disturbance in the presence of parents and communication during the COVID-19 pandemic, 3) Choosing non-pharmacological approaches according to the child's interests and conditions, 4) Building trust in the child through non-pharmacological interventions 5) Barriers to non-pharmacological pain and anxiety management in the pediatric intensive care unit. CONCLUSION: Health care providers implement some non-pharmacological methods to manage pain and anxiety in the pediatric intensive care unit. Facilitating the open presence of parents, using innovative methods to communicate with children, and training and psychological support for nurses and parents, especially during the COVID-19 pandemic are recommended.

The Impact of COVID-19 on Cancer Care in the Post Pandemic World: Five Major Lessons Learnt from Challenges and Countermeasures of Major Asian Cancer Centres.

OBJECTIVE: The COVID-19 pandemic has dramatically affected healthcare services around Asia. The Asian National Cancer Centres Alliance and the Asia-Pacific Organisation for Cancer Prevention collaborated to assess the mid- and long- term impact of COVID-19 to cancer care in Asia. METHODS: The two entities organised a combined symposium and post-meeting interactions among representatives of major cancer centres from seventeen Asian countries to outlining major challenges and countermeasures. RESULTS: Participating stakeholders distilled five big questions. 1) "Will there be an explosion of late-stage cancers after the pandemic?" To address and recover from perceived delayed prevention, screening, treatment and care challenges, collaboration of key stakeholders in the region and alignment in cancer care management, policy intervention and cancer registry initiatives would be of essential value. 2) "Operations and Finance" The pandemic has resulted in significant material and financial casualties. Flagged acute challenges (shortages of supplies, imposition of lockdown) as well as longer-standing reduction of financial revenue, manpower, international collaboration, and training should also be addressed. 3) "Will telemedicine and technological innovations revolutionize cancer care?" Deploying and implementing telemedicine such as teleconsultation and virtual tumour boards were considered invaluable. These innovations could become a new regular practice, leading to expansion of tele-collaboration through collaboration of institutions in the region. 4) "Will virtual conferences continue after the pandemic?" Virtual conferences during the pandemic have opened new doors for knowledge sharing, especially for representatives of low- and middle-income countries in the region, while saving time and costs of travel. 5) "How do we prepare for the next pandemic or international emergency?" Roadmaps for action to improve access to appropriate patient care and research were identified and scrutinised. CONCLUSION: Through addressing these five big questions, focused collaboration among members and with international organisations such as City Cancer Challenge will allow enhanced preparedness for future international emergencies.
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Frequency of Polypharmacy in Advanced Cancer Patients Consulted with the Palliative Service of Imam Khomeini Hospital (Tehran), Iran, 2017

Background: Polypharmacy is defined as the concurrent use of more than four or five medications by an individual. The prevalence of this condition has increased due to the ageing population and the related illnesses. Use of multiple medications would increase the risk of side-effects, drug interactions, and medical costs. The present study aimed to determine the frequency of polypharmacy in the advanced cancer patients. Methods: In this cross-sectional study, 92 patients with advanced cancer were selected through convenience sampling from the inpatients and outpatients who referred to the Palliative Care Unit of Imam Khomeini Hospital (Tehran) in 2017. An examining physician completed a researcher-made checklist for all the subjects based on the patients' biography and medical records. Statistical analysis was performed by using SPSS software (version 19.0) through descriptive and analytical tests at the significance level of p<0.05. Results: The participants' mean age was 55.5±16.2 years. A minimum of one comorbid disease was seen in 81.5% of the patients (n=75), the most prevalent of which were psychiatric disorders. Eighty-eight percent of the patients (n=81) were on at least 5 or more medications. Opioids and antacids were the most common medications used by these patients. Conclusion: The frequency of polypharmacy and average number of consumed medications were high in patients with advanced cancer. Studying the effectiveness of these medications can highly help the physicians stop or continue prescribing such medications, and guide the focus of attention towards the drugs that can improve the patients' quality of life in the final days.

Long-Lasting Orthostatic Hypotension and Constipation After Celiac Plexus Block; A Case Report.

This case report presents a 55 years old man, presented with abdominal pain and diagnosed with a metastatic pancreatic tumor, who developed long lasting orthostatic hypotension and constipation following a celiac plexus block.

Pediatric Palliative Care in Iran: Applying Regionalization of Health Care Systems

Background: Establishing palliative care services is a priority in the health system of Iran. Considering the necessity of integrating these services into the health system, this study aimed to explore the stakeholders' perceptions about the provision of a conceptual framework for palliative care services for children with cancer according to the health system in of Iran. Methods: The present qualitative study was conducted through in-depth semi-structured interviews held with 29 participants including palliative care specialists, policy-makers, health care providers, the parents of children with cancer selected through purposive sampling, between August 2016 and February 2017. Interviews continued until saturation of data. All interviews were recorded, transcribed and analyzed using MAXQDA10 software. Results: The codes extracted from interviews produced the main theme " classes of palliative care services" with the two main categories "comprehensive care" including, strengthening family shelter, maintaining the child in a familiar environment, achieving stability and "establishing social justice" including, easy access to services, financial relief and quality care. Conclusion: Presenting a framework based on level of palliative care services, the findings of this study paves the way for integrating these services into Iranian health system.

Palliative Nursing for Cancer Patients as an Abstract Concept: A Hermeneutic Study.

BACKGROUND: Understanding the outcomes of palliative care (PC) that is provided to patients with cancer is necessary. PURPOSE: The aim of this study was to explore the lived experiences of Iranian nurses with regard to PC outcomes in cancer patients. METHODS: This hermeneutic study interviewed 14 nurses to understand their lived experiences with regard to PC outcomes in cancer patients. A seven-stage process of data analysis was employed. RESULTS: One constitutive pattern "palliative nursing for cancer patients is an abstractive concept" and the two associated themes of "providing excellent PC" and "PC as an alarm" were identified. Providing excellent PC had two subthemes: being a unique nurse and experiencing the humanistic approach to caring. PC as an alarm also had two subthemes: caring-related concerns and challenging issues caused by caring. CONCLUSIONS: The findings provide a deeper understanding of the nursing experience with regard to PC outcomes in cancer patients.

Cost-Effectiveness of Different Cervical Screening Strategies in Islamic Republic of Iran: A Middle-Income Country with a Low Incidence Rate of Cervical Cancer.

OBJECTIVE: Invasive cervical cancer (ICC) is the fourth most common cancer among women worldwide. Cervical screening programs have reduced the incidence and mortality rates of ICC. We studied the cost-effectiveness of different cervical screening strategies in the Islamic Republic of Iran, a Muslim country with a low incidence rate of ICC. METHODS: We constructed an 11-state Markov model, in which the parameters included regression and progression probabilities, test characteristics, costs, and utilities; these were extracted from primary data and the literature. Our strategies included Pap smear screening and human papillomavirus (HPV) DNA testing plus Pap smear triaging with different starting ages and screening intervals. Model outcomes included lifetime costs, life years gained, quality-adjusted life years (QALY), and incremental cost-effectiveness ratios (ICERs). One-way sensitivity analysis was performed to examine the stability of the results. RESULTS: We found that the prevented mortalities for the 11 strategies compared with no screening varied from 26% to 64%. The most cost-effective strategy was HPV screening, starting at age 35 years and repeated every 10 years. The ICER of this strategy was $8,875 per QALY compared with no screening. We found that screening at 5-year intervals was also cost-effective based on GDP per capita in Iran. CONCLUSION: We recommend organized cervical screening with HPV DNA testing for women in Iran, beginning at age 35 and repeated every 10 or 5 years. The results of this study could be generalized to other countries with low incidence rates of cervical cancer.

Assessment of a Hospital Palliative Care Unit (HPCU) for Cancer Patients; A Conceptual Framework.

INTRODUCTION: The first hospital palliative care unit (HPCU) in Iran (FARS-HPCU) has been established in 2008 in the Cancer Institute, which is the largest referral cancer center in the country. We attempted to assess the performance of the HPCU based on a comprehensive conceptual framework. The main aim of this study was to develop a conceptual framework for assessment of the HPCU performances through designing a value chain in line with the goals and the main processes (core and support). MATERIALS AND METHODS: We collected data from a variety of sources, including international guidelines, international best practices, and expert opinions in the country and compared them with national policies and priorities. We also took into consideration the trend of the HPCU development in the Cancer Institute of Iran. Through benchmarking the gap area with the performance standards, some recommendations for better outcome are proposed. RESULTS: The framework for performance assessment consisted of 154 process indicators (PIs), based on which the main stakeholders of the HPCU (including staff, patients, and families) offered their scoring. The outcome revealed the state of the processes as well as the gaps. CONCLUSION: Despite a significant improvement in many processes and indicators, more development in the comprehensive and integrative aspects of FARS-HPCU performance is required. Consideration of all supportive and palliative requirements of the patients through interdisciplinary and collaborative approaches is recommended.

End-of-life care ethical decision-making: Shiite scholars' views.

Recent advances in life-sustaining treatments and technologies, have given rise to newly-emerged, critical and sometimes, controversial questions regarding different aspects of end-of-life decision-making and care. Since religious values are among the most influential factors in these decisions, the present study aimed to examine the Islamic scholars' views on end-of-life care. A structured interview based on six main questions on ethical decision-making in end-of-life care was conducted with eight Shiite experts in Islamic studies, and was analyzed through deductive content analysis. Analysis revealed certain points in Islamic views on the definition of death and the persons making decisions about end-of-life care. According to the participants, in addition to conventional criteria ('urf) such as absence of heartbeat and respiration, the irreversible cessation of human voluntary acts (as a sign that the soul has control over the body and the faculty of thinking) are considered to be the criteria in establishing death. The participants also recognized physicians as the main authorities in verifying signs of death. Furthermore, it was emphasized that life preservation and continuation of care must be sensible, and the patient can request not to have death-prolonging procedures started or continued. In the view of participants, patient's autonomy cannot be the sole basis for all measures, but Islamic ethical and jurisprudential principles should be relied upon to make correct and sensible decisions whether to continue or stop terminal patients' care. Final decisions should be made by a team of experts, and physicians must be at the center of such a team. Finally, we suggest that a guideline in keeping with Islamic norms on human life and death, purpose of life, God's will, boundaries of man's authority, and the physician's ethical duties and obligations should be developed.

Human relationships in palliative care of cancer patient: lived experiences of Iranian nurses.

BACKGROUND: cancer patients require palliative care. AIM: the purpose of this study was to explore the experiences of nurses, who provide palliative care for cancer patients, within the context of Iranian culture. METHODS: we conducted a hermeneutic phenomenological study. Semi structured in-depth interviews with 10 nurses were audio taped and transcribed. The transcriptions were then analyzed by Van Manen's method. RESULTS: one of the most important themes that emerged was "human relationships", which also contained the subthemes of "comprehensive acceptance" and "psychological support". CONCLUSIONS: the results provide deep understanding of human relationships in palliative care of cancer patients in Iran.

Iranian nurses' perceptions of palliative care for patients with cancer pain.

AIM: The purpose of this study was to identify Iranian nurses' perceptions of palliative care for patients with cancer pain. METHODS: The study took a qualitative approach. Semi-structured interviews were held with 15 nurses with Bachelor's degrees working in three teaching hospitals in Iran. Transcripts of the interviews underwent content analysis, and categories were extracted from the material. FINDINGS: The findings came under two main categories: management of physical pain and psychological empowerment. Management of physical pain had two subcategories: the importance of communication, and pain palliation using drugs. Psychological empowerment also had two subcategories: supportive behaviour and distress reduction. CONCLUSION: The sample felt that palliative care for patients with cancer pain must include psychological empowerment, support, and communication as well as physical pain relief.

Ethical issues in the end of life care for cancer patients in iran.

BACKGROUND: In the recent years, advances in medical technologies for end stage cancer patients' care have affected the end-of-life decision-making in clinical practice and exposed oncologists to serious ethical dilemmas. But little is known about oncologists' viewpoints in our country regarding their ethical problems in this mention. We aimed to clarify the ethical dilemmas which Iranian oncologists may face in our health care setting and to determine factors influencing decision-making process. METHODS: In this qualitative study, a phenomenological approach was used. We interviewed 8 cancer specialists in teaching hospitals in Iran and used content analysis to identify codes and categorize themes in the data. RESULTS: DURING THE PROCESS OF ANALYSIS, THREE MAIN THEMES EMERGED ABOUT ETHICAL DILEMMAS IN END OF LIFE CARE FOR ADVANCED CANCER PATIENTS: illness factors, socio-cultural context and patient-physician relationship. Cancer specialists identified ethical problems on several main issues, the most important of which were telling the truth in Iranian cultural context, uncertainty in end stage definition, multidisciplinary team working and cost consideration in Iranian health care system. CONCLUSION: Health care and insurance system in Iran face to end of life care challenges; therefore, health care providers and policy makers need to allocate appropriate resources and programs to improve quality of care in terminal stages. Appropriate physicians' communication skills training, multidisciplinary team working and supplementary insurance services that provide essential health care can improve the quality of care of patients with end stages of cancer. The findings of this study can help us to provide ethical policies for decision-making in end-of-life care.

Perception of Iranian nurses regarding ethics-based palliative care in cancer patients.

Palliative care is still a topic under discussion in the Iranian healthcare system, and cancer patients require palliative care. Moreover, nursing ethics has an important role in caring for these patients. The purpose of this study was to identify the perception of Iranian nurses regarding ethics-based palliative care in cancer patients. This study was done with a qualitative approach and by using content analysis. In this study, 14 nurses were selected through purposive sampling, and a face-to-face semi structured interview was conducted with each of them. After data collection, all interviews were transcribed and reviewed, and categories were extracted. At first, similarities in meaning were reviewed and based on centralization arranged in sub-categories. Then, relevant sub-categories were arranged in a category after a second review. In general, original categories in the ethics-based palliative care in cancer patients encompass the following: "human dignity", "professional truthfulness" and "altruism". Human dignity has 3 sub-categories consisting of 'respecting patients', 'paying attention to patient values' and 'empathizing'. Professional truthfulness has 2 sub-categories consisting of 'truthful speech' and 'truthful action'. Lastly, altruism has 3 sub-categories consisting of 'complete and multi-dimensional patient acceptance', 'supportive behavior' and 'responsibility'. Content analysis of ethics-based palliative care in cancer patients revealed the required conditions for this type of care based on the perception of nurses. The results of this study suggest that in nurses' point of view, human dignity, professional truthfulness and altruism all have important roles in ethics-based palliative care in cancer. The findings of this study will give nurses a greater knowledge about ethics-based palliative care in cancer patients, leading to a better understanding of the ethical needs of these patients, and may ultimately help improve the nursing practice.

How to break bad news: physicians' and nurses' attitudes.

OBJECTIVE: Bad news disclosure is one of the most complex tasks of physicians. Recent evidences indicate that patients' and physicians' attitude toward breaking bad news has been changed since few years ago. The evidence of breaking bad news is different across cultures. The aim of this study is to evaluate the attitude of medical staff toward breaking bad news to provide a clinical guideline in Iran. METHODS: A descriptive study was conducted during 2008-2009 on a sample of 100 medical staff (50 physicians and 50 nurses) at Cancer Institute of Imam Khomeini hospital. The subjects' demographic characteristics and their attitudes toward the manner of revealing the diagnosis were registered in a questionnaire. RESULTS: The majority of the physicians (86%, n=43) and nurses (74%, n=37), mostly the older and more experienced, tended to reveal the diagnosis to patients. Only a few physicians (8%, n=4) had been trained how to disclose bad news, which discloused diagnosis more than non trained ones. Physicians and nurses preferred to inform the patients about the diagnosis when either the patients were alone or in the presence of their spouse respectively. Only a few physicians (14%) and nurses (24%) agreed to explain life expectancy to patients. CONCLUSION: Compared to past, physicians and nurses are more willing to share cancer diagnosis with patients. However, lack of adequate communication skills in caregivers, and their concerns about managing patients' emotional reactions reduce their tendency to disclose bad news to the patients. Therefore, training physicians and nurses to expose bad news to the patients seems to be necessary.