Adam Hurlow

Assessment of Fatigue after Blood Transfusion in Palliative Care Patients: A Feasibility Study

BACKGROUND Blood transfusions are often used as a potential treatment for cancer-related fatigue in anaemic palliative care patients. However, evidence of benefit using validated outcomes measures is lacking. AIM The aim of this study was to test the feasibility of using two such tools; the Brief Fatigue Inventory and FACT F-fatigue subscale, to measure change in fatigue following a blood transfusion. METHOD Anemic cancer patients receiving specialist palliative care and undergoing transfusion for fatigue, completed the tools pre- and 3 days post-transfusion. RESULTS Thirty patients with cancer-related fatigue who received a blood transfusion completed the study. Both measures were capable of detecting statistical and clinically significant change in fatigue following transfusion. Furthermore, the measures showed significant differences between patients that did, or did not, report an overall improvement in fatigue. Patients found the measures easy to complete with no preference for one over another. Future clinical trials of blood transfusion for the management of fatigue should incorporate these validated outcome measures.

Obstacles to corneal donation amongst hospice inpatients: a questionnaire survey of multi-disciplinary team member's attitudes, knowledge, practice and experience.

Background: Corneal donation is a sight restoring procedure. Internationally demand exceeds supply. It is a tissue that palliative care patients may be able to donate, yet donation rates from this group are low. Aim: To explore the attitudes, knowledge, practice, and experience of corneal donation from hospice staff with direct clinical contact with patients. Design: Anonymous paper questionnaire with fixed response and free text components. Setting/participants: Questionnaires were delivered to 704 clinical multi-disciplinary team members in 12 hospices within the Yorkshire Palliative Medicine Regional Learning Group, UK. Results: 434 completed questionnaires were received. Most respondents believed that corneal donation is a rewarding opportunity of which patients and families should be aware, but over 90% of respondents rarely or never raised the topic, and only 33% felt that it was part of their role. Key reasons for not engaging in discussions were: concerns about the impact of the discussion on patients and families, a belief held by hospice staff that they lacked essential knowledge, negative experiences of corneal donation, concern about enucleation, a perception that donation is not part of hospice culture, low levels of training and the personal significance of eyes. Conclusions: Despite positive staff attitudes towards corneal donation, many barriers to discussing donation were identified, which may reduce donation rates. This could be improved by local policies encompassing further education, prompts in documentation and availability of leaflets.

What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city

Objective For patients with advanced cancer, several randomised controlled trials have shown that access to palliative care at least 6 months before death can improve symptoms, reduce unplanned hospital admissions, minimise aggressive cancer treatments and enable patients to make choices about their end-of-life care, including exercising the choice to die at home. This study determines in a UK population the duration of palliative care before death and explores influencing factors. Design This retrospective cohort study analysed referrals to three specialist palliative care services; a hospital-based inpatient palliative care team, and two community-based services (hospices). For each patient referred to any of the above services we identified the date of first referral to that team and calculated the median interval between first referral and death. We also calculated how referral time varied by age, sex, diagnosis and type of palliative care service. Participants 4650 patients referred to specialist palliative care services in Leeds UK between April 2012 and March 2014. Results Median age of the sample was 75 years. 3903 (84.0%) patients had a diagnosis of cancer. Age, diagnosis and place of referral were significant predictors of duration of palliative care before death. Age was independently associated (J=2 672 078, z=−392046.14, r=0.01) with duration of palliative care regardless of diagnosis. Patients over 75 years have 29 fewer days of palliative care than patients under 50. Patients with non-cancer diagnoses have 13 fewer days of palliative care than patients with cancer. Additionally, patients referred to hospital palliative care receive 24.5 fewer days palliative care than those referred to community palliative care services. Conclusions The current timing of referral to palliative care may limit the benefits to patients in terms of improvements in end-of-life care, particularly for older patients and patients with conditions other than cancer.

Is palliative care support associated with better quality end-of-life care indicators for patients with advanced cancer? A retrospective cohort study

Objectives This study aimed to establish the association between timing and provision of palliative care (PC) and quality of end-of-life care indicators in a population of patients dying of cancer. Setting This study uses linked cancer patient data from the National Cancer Registry, the electronic medical record system used in primary care (SystmOne) and the electronic medical record system used within a specialist regional cancer centre. The population resided in a single city in Northern England. Participants Retrospective data from 2479 adult cancer decedents who died between January 2010 and February 2012 were registered with a primary care provider using the SystmOne electronic health record system, and cancer was certified as a cause of death, were included in the study. Results Linkage yielded data on 2479 cancer decedents, with 64.5% who received at least one PC event. Decedents who received PC were significantly more likely to die in a hospice (39.4% vs 14.5%, P<0.005) and less likely to die in hospital (23.3% vs 40.1%, P<0.05), and were more likely to receive an opioid (53% vs 25.2%, P<0.001). PC initiated more than 2 weeks before death was associated with avoiding a hospital death (≥2 weeks, P<0.001), more than 4 weeks before death was associated with avoiding emergency hospital admissions and increased access to an opioid (≥4 weeks, P<0.001), and more than 33 weeks before death was associated with avoiding late chemotherapy (≥33 weeks, no chemotherapy P=0.019, chemotherapy over 4 weeks P=0.007). Conclusion For decedents with advanced cancer, access to PC and longer duration of PC were significantly associated with better end-of-life quality indicators.

Eligibility for corneal donation within the hospice population

Corneal donation is a sight-restoring procedure with graft survival rates of 93% at 1 year. Between 2007 and 2008 the number of corneas grafted rose by 3%, necessitating an increase in the supply of corneas for transplant. Although malignancy is a contraindication to the donation of many organs, corneas are one of a small number of tissues that people with cancer can donate. Many of the 20,000 people who die in UK hospices every year would be eligible to donate their corneas, yet the rate of corneal donation from such units is low. Although 57% of families may be in favour of organ donation, not all hospice inpatients and their families are aware of this possibility. Failure to explore donation could be a source of distress to bereaved families. It is critical to utilize opportunities to secure organs for transplantation. Revised guidance from the General Medical Council, due in January 2010, is expected to require all doctors to discuss organ donation with eligible patients. An understanding of the obstacles to the recruitment of donors is needed to optimize the rates of donation. As part of a study addressing corneal donation in hospices, we sought to quantify the percentage of inpatients who are eligible to donate corneas and the number of patients with whom donation is discussed.

Access to hospital and community palliative care for patients with advanced cancer: A longitudinal population analysis

Background The UK National Health Service is striving to improve access to palliative care for patients with advanced cancer however limited information exists on the level of palliative care support currently provided in the UK. We aimed to establish the duration and intensity of palliative care received by patients with advanced cancer and identify which cancer patients are missing out. Methods Retrospective cancer registry, primary care and secondary care data were obtained and linked for 2474 patients who died of cancer between 2010 and 2012 within a large metropolitan UK city. Associations between the type, duration, and amount of palliative care by demographic characteristics, cancer type, and therapies received were assessed using Chi-squared, Mann-Whitney or Kruskal-Wallis tests. Multinomial multivariate logistic regression was used to assess the odds of receiving community and/or hospital palliative care compared to no palliative care by demographic characteristics, cancer type, and therapies received. Results Overall 64.6% of patients received palliative care. The average palliative care input was two contacts over six weeks. Community palliative care was associated with more palliative care events (p<0.001) for a longer duration (p<0.001). Patients were less likely to receive palliative care if they were: male (p = 0.002), aged 80 years or over (p<0.05), diagnosed with lung cancer (p<0.05), had not received an opioid prescription (p<0.001), or had not received chemotherapy (p<0.001). Patients given radiotherapy were more likely to receive community only palliative care compared to no palliative care (Odds Ratio = 1.49, 95% Confidence Interval = 1.16–1.90). Conclusion Timely supportive care for cancer patients is advocated but these results suggest that older patients and those who do not receive anti-cancer treatment or opioid analgesics miss out. These patients should be targeted for assessment to identify unmet needs which could benefit from palliative care input.

46 Using a quality improvement approach to improve treatment escalation plans and reduce cardiac arrests at a large acute nhs trust

Background Cardiopulmonary resuscitation (CPR) is effective for a minority of patients, with survival to discharge of less than 20%. A recent UK review of in-hospital CPR attempts identified failure to recognise patients at risk of cardiac arrest, discuss treatment escalation plans (TEPs) including CPR, and make do not attempt CPR decisions. Methods In 2014, Leeds Teaching Hospitals NHS Trust (LTHT) established a quality improvement (QI) collaborative to improve the care of patients at risk of clinical deterioration and reduce avoidable deterioration or inappropriate CPR. It consisted of 14 pilot wards across specialty areas, supported by a multi-disciplinary faculty including Palliative Care. Three key drivers for change were identified, including a work-stream focussed on timely TEPs for patients nearing the end of life. Over 12 months, pilot wards developed and tested improvement ideas. In June 2015, a bundle of five key interventions, including a TEP sticker and decision prompts, safety huddles and post-CPR debrief, was tested successfully across the 14 wards. A staggered trust-wide roll out of the bundle started in March 2016. Results Statistical process control charts have shown a sustained and significant 25% reduction in cardiac arrest calls across LTHT, and a 32% reduction at the Saint James’s University Hospital Site. This equates to 87 fewer cardiac arrests annually across the Trust than in 2015. On pilot wards the proportion of patients with a treatment escalation plan and a CPR decision increased by 125% and 72%, respectively. The Trust incidence of cardiac arrests per 1000 admissions at SJUH is now 25% lower than the national average. Conclusion A QI collaborative approach, empowering ward level innovation, with expert faculty support, can improve recognition of patients at risk of cardiac arrest, change behaviours and increase the number of patients with TEPs including CPR decisions; leading to a statistically significant reduction in cardiac arrests.

116 Measuring the impact of end of life care quality improvement (qi) projects

Aim To demonstrate the application of QI methodology to improving end of life care (EOLC), using improvement data (run charts/statistical process control charts (SPC)) to measure the impact of interventions. Background QI methods are applied widely across healthcare. SPC and run charts are employed to demonstrate if interventions can lead to sustained and significant improvements. Identifying variables that suit themselves to measurement by repeated data points is more of a challenge for interpersonal aspects of care (such as palliative and EOLC) than for technical interventions (Conry M, 2012). Methods QI methodology and measures were employed in two QI EOLC initiatives in a large acute NHS trust. The first was a multidisciplinary collaborative to improve the care of patients at risk of clinical deterioration, to reduce avoidable deterioration and/or inappropriate cardiopulmonary resuscitation. The second was an intervention led by the Palliative Care Team to improve the assessment and management of terminal agitation on designated wards. SPC and run charts were created for these initiatives, with baseline data pre-intervention and on-going data collection during the testing, implementation and sustainability phases. Both initiatives were developed following identification of local need; were led by frontline teams and empowered ward level innovation. Results In the first initiative SPC charts demonstrated sustained, significant 25% reductions in cardiac arrest calls across the trust, and on 14 pilot wards a 125% increase in patients with a treatment escalation plan and 75% increase in documented CPR decisions. In the second initiative, run charts demonstrated statistically significant improvements in the rate of assessment, reassessment and evaluation of terminal agitation (p<0.05). Routine review and dissemination of data with the frontline teams in these initiatives enhanced collaborative engagement, motivation and success. Conclusion SPC and run charts can be used to measure the impact of interventions, and contribute to improvements in EOLC.

Older age is associated with less cancer treatment: a longitudinal study of English cancer patients

Background making informed decisions about cancer care provision for older cancer patients can be challenging and complex. Evidence suggests cancer care varies by age, however the relationship between age and care experiences from diagnosis to death for cancer patients within the UK has not previously been examined in detail. Patients and methods retrospective cohort linking cancer registry and secondary care data for 13,499 adult cancer patients who died between January 2005 and December 2011. Cancer therapies (chemotherapy, radiotherapy, surgery), hospital palliative care referrals, hospital admissions and place of death were compared between age groups using multivariable regression models. Trends in cancer care over time, overall and within age groups were also assessed. Results compared with adult patients under 60 years, patients aged 80 years and over were less likely to receive chemotherapy, radiotherapy, a hospital palliative care referral; or be admitted to hospital but were more likely to die in a care home. Overall, the percentage of patients receiving chemotherapy, surgery, hospital palliative care referrals and hospital admissions have increased while deaths in hospital have decreased. Deaths at home have increased for patients aged 80 years and over. Conclusion older patients are less likely to receive cancer therapies or hospital palliative care before death. Further research is needed to identify the extent to which these results reflect unmet need.