Katherine Clark

Improving national hospice/palliative care service symptom outcomes systematically through point-of-care data collection, structured feedback and benchmarking

PurposeEvery health care sector including hospice/palliative care needs to systematically improve services using patient-defined outcomes. Data from the national Australian Palliative Care Outcomes Collaboration aims to define whether hospice/palliative care patients’ outcomes and the consistency of these outcomes have improved in the last 3xa0years.MethodsData were analysed by clinical phase (stable, unstable, deteriorating, terminal). Patient-level data included the Symptom Assessment Scale and the Palliative Care Problem Severity Score. Nationally collected point-of-care data were anchored for the period July–December 2008 and subsequently compared to this baseline in six 6-month reporting cycles for all services that submitted data in every time period (nu2009=u200930) using individual longitudinal multi-level random coefficient models.ResultsData were analysed for 19,747 patients (46xa0% female; 85xa0% cancer; 27,928 episodes of care; 65,463 phases). There were significant improvements across all domains (symptom control, family care, psychological and spiritual care) except pain. Simultaneously, the interquartile ranges decreased, jointly indicating that better and more consistent patient outcomes were being achieved.ConclusionThese are the first national hospice/palliative care symptom control performance data to demonstrate improvements in clinical outcomes at a service level as a result of routine data collection and systematic feedback.

Reducing gastric secretions—a role for histamine 2 antagonists or proton pump inhibitors in malignant bowel obstruction?

Goals of workInoperable bowel obstructions are not uncommon in advanced cancer and are associated with a very poor prognosis. Symptom control includes reducing the frequency of vomiting by prescription of antisecretory medications. The most commonly used agents for this are either hyoscine butylbromide or octreotide. Either histamine 2 antagonists or proton pump inhibitors are sometimes recommended as adjuvants to reduce gastric secretions. The aim of this study was to examine the effects of histamine 2 antagonists and proton pump inhibitors and to objectively compare the effects of one agent over another.Materials and methodsPreviously, electronic databases were searched for trials that compared ranitidine versus proton pump inhibitors in their effect on volume of gastric aspirates.ResultsSeven trials were included in a meta-analysis. Pooled outcomes suggest that both proton pump inhibitors and ranitidine reduce gastric volumes, but the most superior agent is ranitidine, which reduces the volume of gastric secretions by an average of 0.22xa0ml.kg−1; 95% confidence interval 0.04 to 0.41.ConclusionsBased on well-conducted studies, objective evidence exists that confirms ranitidine will decrease the volume of gastric aspirates. This forms a sound basis from which to develop further research aimed at improving the care of people with malignant bowel obstructions.

A pragmatic, phase III, multisite, double-blind, placebo-controlled, parallel-Arm, dose increment randomised trial of regular, low-dose extended-release morphine for chronic breathlessness: Breathlessness, Exertion and Morphine Sulfate (BEAMS) study protocol

Introduction Chronic breathlessness is highly prevalent and distressing to patients and families. No medication is registered for its symptomatic reduction. The strongest evidence is for regular, low-dose, extended- release (ER) oral morphine. A recent large phase III study suggests the subgroup most likely to benefit have chronic obstructive pulmonary disease (COPD) and modified Medical Research Council breathlessness scores of 3 or 4. This protocol is for an adequately powered, parallel-arm, placebo-controlled, multisite, factorial, block-randomised study evaluating regular ER morphine for chronic breathlessness in people with COPD. Methods and analysis The primary question is what effect regular ER morphine has on worst breathlessness, measured daily on a 0–10 numerical rating scale. Uniquely, the coprimary outcome will use a FitBit to measure habitual physical activity. Secondary questions include safety and, whether upward titration after initial benefit delivers greater net symptom reduction. Substudies include longitudinal driving simulation, sleep, caregiver, health economic and pharmacogenetic studies. Seventeen centres will recruit 171 participants from respiratory and palliative care. The study has five phases including three randomisation phases to increasing doses of ER morphine. All participants will receive placebo or active laxatives as appropriate. Appropriate statistical analysis of primary and secondary outcomes will be used. Ethics and dissemination Ethics approval has been obtained. Results of the study will be submitted for publication in peer-reviewed journals, findings presented at relevant conferences and potentially used to inform registration of ER morphine for chronic breathlessness. Trial registration number NCT02720822; Pre-results.

Clinician-reported changes in octreotide prescribing for malignant bowel obstruction as a result of an adequately powered phase III study: A transnational, online survey:

Background: Translating research evidence into clinical practice often has a long lag time. Aim: To determine the impact of a phase III randomised controlled trial on palliative care clinicians’ self-reported practice change. Design: Online survey about use of octreotide in managing inoperable malignant bowel obstruction due to cancer or its treatments distributed in November 2016, 2u2009years after the first publication of the study in a peer-reviewed journal. Demographic, self-reported practice and the reasons underpinning this were collected. Responses were aggregated to ‘practice modified’ or ‘practice not modified’. A multinomial regression model explored predictors of practice change. Setting: Members of the Australian New Zealand Society of Palliative Medicine. Results: Response rate was 20.8% (106/509): 55.6% were aged >50u2009years, 56.5% were female and 77% had previously prescribed octreotide for this clinical indication. Out of 106 respondents, 52 (49.1%) indicated modified practice (60.9% of those who had previously prescribed octreotide in this setting). In those who reported practice change, most frequently octreotide was now used when other therapies failed; for not changing practice, ‘more confirmatory evidence was needed’ was most often cited. In the regression model, older age (clinician ageu2009=u200950–59u2009years; relative risku2009=u20090.147; 95% confidence intervalu2009=u20090.024–0.918; pu2009=u20090.04) and having practices with lower proportions of people treated with octreotide (0%–20%; relative risku2009=u20090.039; 95% confidence intervalu2009=u20090.002–0.768; pu2009=u20090.033) predicted greater self-reported practice change. Conclusion: Clinician-reported change in practice in the survey is seen in the majority of respondents. This suggests that there is a cohort of ‘early adopters’ within palliative care practice as new evidence becomes available.

Knowledge of, and participation in, advance care planning: A cross-sectional study of acute and critical care nurses perceptions

BACKGROUNDnNurses have a core role in facilitating discussions and enacting decisions about end-of-life issues for patients in hospitals. Nurses own knowledge and attitudes may influence whether they engage in meaningful end-of-life conversations with patients.nnnAIMSnTo determine in a sample of nurses working in acute and critical care hospital wards: 1) their knowledge of advance care planning, including the authority of substitute decision-makers and legal validity of advance directives; 2) their own participation in advance care planning decision-making practices; and 3) associations between nurses socio-demographic characteristics; clinical expertise; and knowledge and behaviour in relation to advance care planning practices.nnnDESIGNnQuestionnaire-based, cross-sectional study.nnnSETTING AND PARTICIPANTSnThe study was conducted with 181 registered and enrolled nurses employed in acute and critical care wards of three metropolitan hospitals in Australia.nnnRESULTSnNurses were least knowledgeable about items relating to the authority of medical (56%) and financial (42%) substitute decision-makers. Few nurses had prepared advance directives (10%) or appointed medical (23%) or financial (27%) decision-makers, when compared to discussing end-of-life wishes (53%) or organ donation (75%). Overall, 15% of nurses had not engaged in any advance care planning practices. Nurses who had cared for 11-30 dying patients in the last six months were more likely to have an increased knowledge score. Older nurses were more likely to participate in a greater number of advance care planning practices and an increase in shifts worked per week led to a significant decrease in nurses participation.nnnCONCLUSIONnNurses have a key role in providing advice and engaging dying patients and their families in advance care planning practices. Nurses own knowledge and rates of participation are low. Further education and support is needed to ensure that nurses have an accurate knowledge of advance care planning practices, including how, when and with whom wishes should be discussed and can be enacted.