Peter Eastman

Neuro-oncology and palliative care: a challenging interface.

Patients with high-grade gliomas almost invariably develop disease progression despite recent advances in anticancer therapy. Increasingly, the value of formal palliative care consultation and management has been recognized in both cancer and noncancer medicine. However, there is a paucity of data to definitively guide the provision of palliative care for neuro-oncology patients. This paper aims to review the existing evidence for and describe the interface between palliative care and neuro-oncology, with a particular focus on glioblastoma multiforme (GBM). We also discuss the role of palliative care in nonmalignant neurologic disease where parallels with neuro-oncology might be drawn.

Factors influencing survival after discharge from an Australian palliative care unit to residential aged care facilities: a retrospective audit.

BACKGROUND Increasing demand for palliative care unit (PCU) beds has led to shorter inpatient stays and a requirement to transfer some patients from a PCU to a residential aged care facility (RACF). Concerns have been raised regarding this move with suggestion that patients often die shortly after transfer. Published data investigating this patient group are limited. The aim of the current study was to audit discharges from a PCU to RACFs specifically looking at predictive factors for survival following discharge. METHODS A retrospective audit was undertaken of all discharges from the Barwon Health PCU to RACFs between July 2007 and July 2010. Data on patient demographics, clinical and functional status, admission and discharge details, and survival times were examined. Factors influencing survival were evaluated by Cox proportional-hazards regression analysis. RESULTS Sixty-two discharges from a PCU to an RACF were included in the analysis. The mean age at discharge was 76 and the majority of patients had malignant disease. Mean and median survival times post-transfer were 106 and 42.5 days, respectively, and 16% of subjects survived more than 100 days. From univariate analyses age, PCU length of stay, admission Resource Utilization Groups-Activities of Daily Living (RUG-ADL) score, dependent mobility, having lung cancer or cancer of unknown primary, and living alone or in an RACF pre PCU admission affected survival. Multivariate analyses showed age, PCU length of stay, RUG-ADL score, and living situation prior to PCU admission together were associated with postdischarge survival times. CONCLUSIONS This study is one of the largest investigating this cohort and suggests a number of factors that may predict survival for patients after discharge from a PCU to an RACF.

Who, why and when: stroke care unit patients seen by a palliative care service within a large metropolitan teaching hospital

Objectives To investigate factors associated with referral of patients from an Australian stroke care unit (SCU) to an inpatient palliative care service (PCS). Methods This retrospective observational cohort study included patients who were referred to the PCS after SCU admission between 1 January and 31 December 2008. Variables measured included patient demographics, premorbid functional status, premorbid living situation, stroke type, history of previous stroke and discharge outcomes. Group differences between all SCU patients seen and not seen by the PCS were compared using univariate analyses. Multivariate logistic regression analysis was undertaken to identify factors associated with PCS involvement. Group differences were also compared between deceased stroke patients seen and not seen by the PCS. Results 544 patients were admitted to the SCU during the study period with 62 (11.4%) referred to the PCS. Assistance with end-of-life care was the commonest reason for referral. From univariate analyses, factors significantly associated with PCS involvement included age, gender, premorbid modified Rankin score, living situation prior to stroke and stroke type. Factors predicting PCS involvement for SCU patients from logistic regression were: increasing age, higher premorbid modified Rankin score and haemorrhagic stroke. 87 (16.0%) SCU patients died during their admission, with 49 (56.3%) seen by PCS. Deceased patients seen were significantly older, more disabled premorbidly and lived significantly longer. Conclusions This study indicates there are patient and condition-level factors associated with referral of stroke patients to PCS. It highlights factors that might better stratify hospitalised stroke patients to timely palliative care involvement, and adds an Australian perspective to limited data addressing this patient population.

Inpatient palliative care consultation for patients with glioblastoma in a tertiary hospital

Glioblastoma (GBM) is an uncommon disease with significant mortality and morbidity, but there is a lack of published evidence on palliative care involvement with this population. This audit highlights the heavy symptom burden, extensive allied health involvement and discharge outcomes of GBM inpatients referred to the palliative care service at The Royal Melbourne Hospital. This information can provide an important framework for further research and also supports the role of multidisciplinary palliative care in the care of patients with GBM.

Integrated respiratory and palliative care may improve outcomes in advanced lung disease

The unaddressed palliative care needs of patients with advanced, nonmalignant, lung disease highlight the urgent requirement for new models of care. This study describes a new integrated respiratory and palliative care service and examines outcomes from this service. The Advanced Lung Disease Service (ALDS) is a long-term, multidisciplinary, integrated service. In this single-group cohort study, demographic and prospective outcome data were collected over 4 years, with retrospective evaluation of unscheduled healthcare usage. Of 171 patients included, 97 (56.7%) were male with mean age 75.9 years and 142 (83.0%) had chronic obstructive pulmonary disease. ALDS patients had severely reduced pulmonary function (median (interquartile range (IQR)) forced expiratory volume in 1 s 0.8 (0.6–1.1) L and diffusing capacity of the lung for carbon monoxide 37.5 (29.0–48.0) % pred) and severe breathlessness. All patients received nonpharmacological breathlessness management education and 74 (43.3%) were prescribed morphine for breathlessness (median dose 9 mg·day−1). There was a 52.4% reduction in the mean number of emergency department respiratory presentations in the year after ALDS care commenced (p=0.007). 145 patients (84.8%) discussed and/or completed an advance care plan. 61 patients died, of whom only 15 (24.6%) died in an acute hospital bed. While this was a single-group cohort study, integrated respiratory and palliative care was associated with improved end-of-life care and reduced unscheduled healthcare usage. Integrated respiratory and palliative care is associated with better end-of-life care for patients with advanced lung disease http://ow.ly/mgkn30hlPXV

Palliative Care After Attempted Suicide in the Absence of Premorbid Terminal Disease: A Case Series and Review of the Literature

Palliative care involvement in the management of incomplete suicide in patients without terminal illness is rare. This paper documents two such cases and explores some of the clinical and ethical issues raised.

Underutilisation of Victorian in-patient palliative care consultation services? Results of an exploratory study

The recent Australian Institute of Health and Welfare (AIHW) report on Australian palliative care services highlighted several important issues, including increasing demand for palliative care services and differences in provision across health care settings.1 In response to this report, the peak national organisation, Palliative Care Australia, raised concerns around access, suggesting that the majority of Australians with a need for palliative care services were not currently receiving them.2 The AIHW report addressed many aspects of Australian palliative care service provision; however, limited specific attention was paid to the role of palliative care consultation services (PCCS) for in-patients of acute hospitals. The role of PCCS are worthy of consideration because 51% of all deaths in Australia in 2011-12 occurred in hospital and, of these, more than 60% were not specifically palliative care patients.1There is increasing evidence showing the benefits of PCCS. Improvements have been demonstrated in symptom control, satisfaction with care, patient-clinician communication and end-of-life care.3,4 Important reductions have also been reported in healthcare costs and resource utilisation.5 Attempts have been madetoquantifythepalliativecareneeds ofhospitalin-patients in several international settings. Recent data from the UK, Australia and New Zealand identified between 20% and 36% of in-patients as having palliative care needs.6-8 For the majority of patients, these needs will be met by generalist rather than specialist palliative care services;7 however, the ideal referral rate to PCCS remains unspecified. A recent US report into palliative care utilisation suggested that between 5% and 10% of all hospital admissions should receive a specialist palliative consultation.9 In response to this report, we investigated referral rates from an Australian viewpoint by using the Victorian Admitted Episodes Database (VAED) and the Victorian Integrated Non-Admitted Health (VINAH) dataset to assess PCCS utilisation across Victorian metropolitan public hospital networks. Each network consists of a varying number of separate in-patient facilities and collection and submission of clinical data to these datasets is mandatory for all Victorian health services and Health Department-funded PCCS. No specific paediatric hospitals were included in our analysis and only multiday acute admitted episodes were analysed.Using palliative care consultancy episodes as a numerator and total acute multiday admitted episodes as a denominator we calculated a percentage that approximated PCCS uptake for individual Victorian metropolitan public hospital networks. For 2012-13, across the eight networks with 500 or greater annual palliative care consultancy episodes, this percentage ranged from 2.1% to 18.1%. The 18.1% was from a solely cancer tertiary hospital and, when this was excluded, the range was 2.1%-4.2%. The median of 3.1% is in keeping with US data, suggesting that currently between 2% and 4% of admitted patients receive a palliative care consultation.Many in-patients will never require involvement from specialist palliative care services; however, determining when referral is appropriate can be difficult. Factors influencing this decision include differing goals of care, prognostic uncertainty, variations in clinician recognition of care needs, patient and/or family belief systems, particularly around death and dying, palliative care workforce limitations and concerns around deskilling generalist staff. …

Uptake of clinical trials in a palliative care setting: A retrospective cohort study

There has been growth in the number of clinical trials conducted in the palliative care setting. However, issues exist regarding patient acceptance and vulnerability as well as the appropriateness of conducting trials in the dying patient. This study aimed to investigate the uptake of palliative care clinical trials at the Royal Melbourne Hospital, evaluate patient demographics for those enrolled onto study and assess the proportion of patients who died within 28 days of enrolling on a palliative care clinical trial.

Is opioid-induced hyperalgesia a genuine issue for palliative care patients and clinicans?

197 Background: Opioid-Induced Hyperalgesia (OIH) has been described as a paradoxical response whereby opioid administration induces an increase in pain sensitivity rather than an analgesic effect. It is proposed this results from increased pro-nociceptive sensitivity following changes in central and peripheral neural pathways. While there is basic science and pre-clinical evidence supporting OIH, debate remains about its clinical relevance or even existence. The existence or otherwise of OIH has relevance for palliative care as many patients are prescribed opioids and the standard management of unstable pain in palliative care may worsen symptoms in OIH. Therefore recognition of the concept would seem important for palliative care clinicians. METHODS An electronic survey of Australian and New Zealand palliative care clinicians was undertaken addressing awareness of OIH as well as approaches to recognising and managing it. The survey which contained single response, multiple-choice and open-ended questions was distributed through the Australian New Zealand Society of Palliative Medicine. Mixed-methods analysis was performed. RESULTS One hundred and twenty-three surveys were returned (response rate = 31%). The majority of respondents identified as palliative care specialists. More than 75% of respondents reported observing OIH in their clinical practice, often with malignant disease and with morphine, oxycodone and fentanyl identified as the commonest causal agents. The three features felt to be most suggestive of OIH were; escalating pain despite increasing opioids, demonstrable hyperalgesia or allodynia and a more diffuse pain distribution away from pre-existing pain sites. Most clinicians utilized more than one approach when OIH was encountered. The commonest of these were opioid reduction, opioid rotation and optimization of adjuvant analgesia. CONCLUSIONS Our survey found a higher rate of reported observation of OIH amongst clinicians than might have been anticipated given debate about the existence of OIH in humans outside of a research environment. These results suggest that many palliative care clinicians perceive OIH to be a genuine issue for their patients.

Palliative Care and Stroke

There have been significant advances in the prevention and management of stroke over the last few decades. Despite these important developments, stroke, both in the acute and chronic phases, remains a major cause of morbidity and mortality. The value of integrating palliative care principles and practices into stroke care management is being increasingly recognized across a range of domains including symptom management, assistance with complex decision-making, discharge planning, and end-of-life care. This chapter will explore the logistics, benefits, complexities, and challenges associated with the evolving relationship between stroke and palliative care services. P. Eastman (*) Department of Palliative Care, Barwon Health, North Geelong, VIC, Australia Department of Palliative and Supportive Care, Royal Melbourne Hospital/Melbourne Health, Parkville, VIC, Australia e-mail: eastman@gmp.usyd.edu.au B. Le Department of Palliative and Supportive Care, Royal Melbourne Hospital/Melbourne Health, Parkville, VIC, Australia e-mail: Brian.Le@mh.org.au # Springer International Publishing AG 2018 R. D. MacLeod, L. Block (eds.), Textbook of Palliative Care, https://doi.org/10.1007/978-3-319-31738-0_59-1 1