Journal of pain and symptom management
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J Pain Symptom Manage · Jul 2009
ReviewQuality indicators for palliative care: a systematic review.
Research has demonstrated a greater understanding of the needs of terminally ill patients and their families, but it also has been found that the palliative care is not optimal. Because of a lack of quality indicators in palliative care, the quality of the care is often not assessed. The aim of this systematic review was to give an overview of published quality indicators for palliative care in all patient groups and settings, to determine whether these quality indicators cover all domains of palliative care, to describe the different types of quality indicators, and to determine the methodological characteristics of the quality indicators. ⋯ The methodological characteristics of the quality indicators varied considerably. We conclude that a substantial number of quality indicators for palliative care are available, but most have not been described in detail. More detailed methodological specifications are needed to accurately monitor the quality of palliative care.
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J Pain Symptom Manage · Jul 2009
Randomized Controlled Trial Multicenter Study Comparative StudyAtropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care.
Death rattle is a frequent symptom (25%-50%) in the terminal stage of life, but there is neither standardized treatment nor prospective investigation performed on the effectiveness of anticholinergic drugs. The aim of the present study was to investigate the effectiveness of three different anticholinergic drugs in the treatment of death rattle in the terminal stage of life. Terminal patients who developed death rattle were randomly assigned 0.5mg atropine, 20mg hyoscine butylbromide, or 0.25mg scopolamine. ⋯ Further, effectiveness improved over time without significant differences among the treatment groups (effectiveness at 24 hours was 76%, 60%, and 68%, respectively). In an analysis on the three groups together, treatment was more effective when started at a lower initial rattle intensity; median survival after start of therapy was 23.9 hours. These data suggest that there are no significant differences in effectiveness or survival time among atropine, hyoscine butylbromide, and scopolamine in the treatment of death rattle.
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Although palliative care is rarely profitable by itself, palliative care in hospitals is associated with significant reductions in per diem costs and total costs, and can generate substantial savings to the health system by "cost avoidance." Palliative care alongside usual care in recent randomized outpatient trials has maintained or improved the quality of care while generating substantial cost savings. The data are mixed about the impact of palliative care consultation on inpatient length of stay and are related to local patterns of care, consultation, and assumption of control of the course of care. In collecting and presenting the data to administrators and others, we have found that the simplest approach is the most effective-for example, presenting a few clinical outcomes alongside cost-saving data.
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J Pain Symptom Manage · Jul 2009
Using the Palliative Performance Scale to provide meaningful survival estimates.
Although there is a growing body of knowledge on survival prediction in populations with advanced cancer receiving palliative care using the Palliative Performance Scale (PPS), this literature has focused on disease, gender, and care location, and less is known about how to apply such knowledge to be clinically meaningful. To address this issue, we evaluated a database comprising 13 years of initial PPS scores on 6066 patients, which were recorded on their first assessment by the Victoria Hospice palliative care team in the home or palliative care unit setting. ⋯ We also evaluated the concept of Kaplan-Meier survival curve "nose-tail" refinement, and observed that this approach requires more research. More work is needed to better identify those who live "longer than expected" or die "sooner than expected" to provide clinical utility in discussion with patients and families.
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J Pain Symptom Manage · Jul 2009
ReviewMeasuring outcomes in palliative care: limitations of QALYs and the road to PalYs.
Tools for measuring outcomes in health and social care have become key parts of the processes of evaluation and setting priorities. Measures of output that can be used in all settings and specialties have the advantage that they facilitate comparisons and choices between and within patient groups. However, the most commonly used composite measure of outcomes, the quality-adjusted life year (QALY) appears not to work well in complex interventions, such as palliative care, leading to the paradox that there is evidence that people would give priority to interventions and services that would be shown not to be cost-effective, using QALYs as an outcome measure. This article explores the possible reasons for this paradox, and looks at alternative approaches that may provide better tools for setting priorities within palliative care and for comparison of palliative and other care services.