Introduction
The palliative care team consisted of two clinical nurse specialists, a specialized general practitioner (GP), an oncologist, and GP trainees during their hospital internship. Patients were discussed during weekly team meetings. During the pilot study, the transitional care pathway was introduced. Researchers with a background in healthcare provided gave presentations on the early identification of patients with palliative care needs to nurses and physicians at the participating departments. Interactive training on how to initiate end-of-life conversations (in Dutch: STEM-training a) was also offered to nurses and physicians. The goal was to increase knowledge on palliative care among non-specialists |
The pilot study was a mixed-method feasibility studyb. Patients were recruited between February 2018 and July 2018 from the department of pulmonology and gastroenterology in the OLVG teaching hospital in Amsterdam. Patients were screened for eligibility according to Supportive and Palliative Care Indicators Tool (SPICT) criteria. cThese criteria were unplanned hospital admission in the past six months, functional status, and malnutrition. The SPICT cut-off score for inclusion depended on the age of the patient. Patients aged 65–79 years with a score ≥ 2 and patients aged ≥ 80 years with a score ≥ 1 were eligible for inclusion. During the pilot study, eight patients received care according to the care pathway |
Healthcare professionals were interviewed to evaluate the educational program and feasibility of the care pathwayc After the pilot study, the transitional palliative care team integrated parts of the care pathway into their daily practice. The care pathway was followed regardless of the hospital department/specialty from which the consultation was requested |
Methods
Intervention
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2) Systematic palliative assessment, based on the four domains of palliative care [19] and advance care planning after which an individual care plan was formulated. The assessment was conducted by a conversation between a member of the palliative care team and the patient and informal caregiver(s).
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3) Team meetings, to which the patient’s own GP was invited. Individual care plans and the complexity assessments (based on symptom burden, patient needs, and whether the patient’s own GP could provide necessary care) were discussed. These assessments were based on the conversation the member of the palliative care team had with the patient.
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4) The patient’s own GP received a warm handover, which was considered to be a conversation in person or by phone at hospital discharge.
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5) A member of the transmural palliative care team visited the patient at home to follow up on the palliative assessment and adjust plans if needed (Table 2).
Intervention | Components | Conducted by |
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Identification of palliative care needs during hospital admission | • Screening of palliative care needs based on SPICT criteriaa • Consulting the palliative care team | • Ward nurses and department physicians |
Palliative care assessment and advance care planning | • Assessment of needs, preferences, and symptoms on physical, psychological, spiritual, and social level • Discussing treatment wishes, treatment limitations, and the patients’ preferred place of deathb • Formulating an individualized care planb | • Department physician and/or palliative care team |
Multidisciplinary team meeting | • Patients are discussed during weekly meetings of the transitional palliative care team, hospital specialists, and non-medical specialist • The patients’ own GP and community nurse are invited to the meeting (in person or by phone/videoconference)a • The patients’ individual care plan is discusseda • The complexity of the patients’ palliative care situation is assessed using a colour coding system indicating stability and severity of the situationa | • Department physician, patient’s own general practitioner, district nurse, palliative care team |
Discharge | • The patient receives the individual care plana • Informal caregivers receive an information sheet about supporta | • Department physician, ward nurse or palliative care team |
Handover | • The patients’ GP is contacted prior to discharge or during multidisciplinary team meetingb • A summary of the team meeting is sent to the patients’ GP and community nurse within 24 h after dischargeb • The medical handover is sent to the patients’ GP within 24 h after dischargeb | • Department physician, ward nurse or palliative care team |
Home visit and follow-up | • The patient is visited by a member of the transitional palliative care teama • If needed, the patient is discussed during the team meeting, and the individualized care plan and colour code is adjusteda | • Palliative care team |
Data collection
Outcomes
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- Unplanned hospital admissions within six months after consultation (dichotomous). Unplanned hospital admissions was measured by collecting data from the electronic medical record in which hospital admissions are registered as elective or non-elective. Non-elective hospitalizations were registered as an unplanned hospitalization.
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- Death at place of preference (dichotomous Yes/No), which was defined by the preferred place of death that was registered in the electronic medical record by a member of the palliative care team after their conversation with the patient. The actual place of death that was registered in the electronic medical record.
Independent variables
Statistical analysis
Results
Patients and consultations
Total N = 711 | Pre-implementation N = 212 | During/short-term after implementation N = 248 | Long-term after implementation N = 251 | P-value | |
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Male, N (%) | 358 (50.4) | 109 (51.4) | 125 (50.4) | 124 (49.4) | 0.89a |
Age, mean (SD) | 71.6 (12.6) | 70.5 (13.4) | 72.0 (12.3) | 72.0 (12.1) | 0.67b |
Diagnosis, N (%) | |||||
Non-malignant diseases | 204 (28.7) | 44 (20.8) | 81 (32.7) | 79 (31.5) | 0.008a |
WHO/ECOG performance status, N (%) | N = 654 | N = 199 | N = 216 | N = 240 | 0.05a |
2: Ambulatory and capable of self-care but unable to carry out any work | 140 (21.4) | 43 (21.6) | 47 (21.8) | 50 (21.0) | |
3: Capable of only limited self-care: confined to bed/chair more than 50% of waking hours | 261 (39.9) | 79 (39.7) | 76 (35.2) | 106 (44.2) | |
4: Completely disabled | 172 (26.3) | 44 (22.1) | 62 (28.7) | 66 (27.5) | |
Prognosis, N (%) | N = 693 | N = 210 | N = 236 | N = 248 | 0.09a |
Days to weeks | 181 (26.1) | 47 (22.4) | 66 (28) | 68 (27.4) | |
< 3 months | 212 (30.5) | 65 (31.0) | 62 (26.3) | 85 (34.3) | |
< 6 months and < 1 year | 158 (22.8) | 50 (23.8) | 64 (27.1) | 44 (17.7) | |
> 1 year | 20 (2.9) | 7 (3.3)) | 6 (2.5) | 7 (2.8) | |
Difficult to make an estimation | 123 (17.7) | 41 (19.5) | 38 (16.1) | 44 (17.7) | |
Admission department, N (%) | N = 583 | N = 156 | N = 212 | N = 215 | < 0.001a |
Pulmonology/cardiology | 215 (36.9) | 47 (30.1) | 78 (37.0) | 90 (41.7) | |
Internal medicine (both malignant and non-malignant internal diseases) | 182 (31.2) | 68 (43.6) | 32 (15.2) | 82 (38.0) | |
Otherd | 186 (31.9) | 41 (26.3) | 101 (47.9) | 43 (20.0) | |
Reason for consultation | N = 684 | N = 201 | N = 234 | N = 245 | < 0.001a |
Advance care planning and/or guidance in the upcoming process | 331 (43.4) | 103 (51.2) | 100 (42.6) | 128 (51.6) | |
Advice on symptoms, medication | 129 (18.9) | 35 (17.4) | 34 (14.5) | 60 (24.2) | |
Guidance in after care and support system | 107 (15.6) | 36 (17.9) | 30 (12.8) | 41 (16.5) | |
Guidance/advice in the dying phase | 117 (17.1) | 27 (13.4) | 71 (30.2) | 19 (7.7) | |
Preferred place of death discussed, N (%) | 321 (45.1) | 115 (54.2) | 60 (24.2) | 146 (58.2) | 0.02a |
Home | 160 (49.8) | 64 (55.7) | 34 (56.7) | 62 (42.5) | |
Hospital | 21 (6.5) | 6 (5.2) | 8 (13.3) | 7 (4.8) | |
Care facility (care home / hospice) | 94 (29.3) | 29 (25.2) | 17 (28.3) | 48 (32.9) | |
No clear place mentioned | 46 (14.3) | 16 (13.9) | 1 (1.7) | 29 (19.9) | |
Time until death after consultation (days), Median [IQR] N = 557 | 18.46 [4.62 – 65.77] | 26.5 [8.1 – 92.0] | 12.3 [3.5 – 47.3] | 18.5 [4.6 – 61.2] | 0.004c |
Place of death, N (%) | N = 484 | N = 118 | N = 161 | N = 202 | 0.06a |
Home | 135 (27.9) | 30 (25.4) | 44 (27.3) | 60 (29.7) | |
Hospital | 250 (51.7) | 65 (55.1) | 93 (57.8) | 90 (44.6) | |
Care facility (care home / hospice) | 99 (20.5) | 7 (5.9) | 4 (2.5) | 8 (4.0) | |
Death at place of preference | N = 208 121 (58.2) | N = 61 25 (41,0) | N = 44 26 (59,1) | N = 103 70 (68.0) | 0.003a |
Hospital (re)admission within six months after consultation | N = 522 121 (23.2) | N = 171 41 (24.0) | N = 175 43 (24.6) | N = 175 37 (21.1) | 0.46a |
Consult with multidisciplinair team meeting, N (%) | 547 (76.9) | 163 (76.5) | 181 (73.0) | 203 (81.5) | 0.12a |
At least one of the patients’ own primary care professional attended the multidisciplinair team meeting, N (%) | 271 (49.5) | 80 (49.1) | 129 (71.3) | 62 (30.5) | < 0.001a |
Patient’s own GP attended the multidisciplinary team meeting, N (%) | 151 (23.7) | 63 (38.7) | 56 (30.9) | 32 (15.8) | < 0.001a |
Warm handover to GP (by member of palliative care team or ward physician), N (%) | 259 (36.5) | 81 (34.6) | 95 (38.9) | 95 (34.7) | 0.002a |
Home visit, N (%) | 15 (2.9) | 1 (0.6) | 7 (4.0) | 7 (4.0) | 0.14a |
Key elements of the care pathway
Unplanned hospital admission after consultation
Univariable logistic regression analysis | Multivariable logistic regression analysis | |||||
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OR | 95% CI | P-value | OR | 95% CI | P-value | |
During/shortly after implementationa | 1.09 | 0.67–1.79 | 0.73 | 1.23 | 0.67–2.26 | 0.51 |
Long term after implementationa | 0.86 | 0.52–1.43 | 0.56 | 0.79 | 0.44 – 1.41 | 0.42 |
Malignant disease | 1.63 | 0.94 – 2.83 | 0.08 | |||
Admission department: Internal medicineb | 2.26 | 1.27 – 4.02 | 0.006 | |||
Admission department: Otherb | 0.85 | 0.43 – 1.69 | 0.65 | |||
Reason for consultation: Advice on symptom management/medicationc | 0.87 | 0.47 – 1.61 | 0.65 | |||
Reason for consultation: guidance in after care and support systemc | 0.75 | 0.42 – 1.35 | 0.34 | |||
Reason for consultation: Guidance/advice in the dying phasec | 0.12 | 0.03 – 0.38 | < 0.001 |
Mortality and death at place of preference
Univariable logistic regression analysis | Multivariable logistic regression analysis | |||||
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OR | 95% CI | P-value | OR | 95% CI | P-value | |
During/shortly after implementationa | 2.22 | 2.12 | 0.84 – 5.35 | 2.12 | 0.84 – 5.35 | 0.11 |
Long term after implementationa | 2.17 | 3.14 | 1.49 – 6.62 | 3.14 | 1.49 – 6.62 | 0.003 |
Admission department: Internal medicineb | 0.85 | 0.46 – 1.91 | 0.85 | |||
Admission department: Otherb | 0.88 | 0.39 – 1.99 | 0.76 | |||
Reason for consultation: Advice on symptom management/medicationc | 1.33 | 0.52 – 3.40 | 0.56 | |||
Reason for consultation: guidance in after care and support systemd | 1.63 | 0.74 – 3.57 | 0.23 | |||
Reason for consultation: Guidance/advice in the dying phased | 0.79 | 0.27 – 2.32 | 0.67 | |||
Preferred place of death: hospitald | 3.38 | 1.09 – 10.54 | 0.04 | |||
Preferred place of death: care facilityd | 2.80 | 0.29 – 26.96 | 0.37 |