J Palliat Care
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We report on the case of an elderly patient in a palliative care unit who fell and sustained a hip fracture. Hip fractures are potentially terminal events for elderly patients with other life-limiting conditions. The case highlights the need for more evidence to determine the best approach to care for hip fractures in patients who are in the final weeks or months of life.
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Continuity of care is important for palliative patients in their end of life. In the Netherlands, after-hours primary care for palliative patients is either provided by large-scale general practitioner (GP) cooperatives or GPs choose to give palliative care by themselves while they are not on duty. ⋯ The large majority of Dutch GPs is personally available for telephone consultation and/or willing to provide palliative care for their own patients outside office hours. For the future, it is important to maintain the willingness of GPs to remain personally available for their palliative patients.
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Earlier goals of care (GOC) discussions in patients with advanced cancer are associated with less aggressive end-of-life care including decreased use of medical technologies. Unfortunately, conversations often occur late in the disease trajectory when patients are acutely unwell. Here, we evaluate practitioner perspectives of patient, family, physician, and external barriers to early GOC discussions in the ambulatory oncology setting. ⋯ Oncologists ranked patient- and family-related factors as the most important barriers to GOC discussions, while clinicians' self-identified difficulty estimating prognosis and uncertainty regarding treatment benefits were also considered important. Further work is required to assess patient preferences and perceptions and develop targeted interventions.
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Patients who are frequently admitted to Medicine inpatient services comprise a distinct subset of readmitted patients about whom not much is known. ⋯ These findings point to distinct groups of patients who are frequently hospitalized, and therefore would benefit from tailored management strategies: Those with progression of end-stage disease comprised one-third of the group and targeting that subset with palliative care referrals could help decrease readmission rates. Those with recurrent exacerbations of a chronic medical condition could be managed through telemanagement programs. Those with exacerbations of chronic pain could be addressed through collaboration with pain management specialists. Individualized care management plans may be useful for all, especially the latter two groups. Based on differences between survivors and deceased patients, an age-adjusted CCI score of 4 or 5 could be valuable sensitive or specific cutoffs, respectively, for predicting those who would benefit most from palliative care consultation regarding end-of-life goals and management.
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Goals of care (GoC) conversations optimally begin early in the course of cancer care, yet most happen near the end of life. We sought to describe oncologist-reported facilitators of and barriers to GoC conversations with patients who have advanced cancer. ⋯ GoC conversations may be facilitated by enabling oncologists to conduct these conversations despite difficult circumstances and emotional reactions by activating patients and family via increased health literacy and by advancing palliative-informed practice environments.