Advanced heart failure patients suffer with breathlessness and peripheral oedema, which are frequently treated with parenteral diuretics despite limited evidence.
To analyse the effectiveness of parenteral diuretics on breathlessness and peripheral oedema in advanced heart failure patients.
We searched Embase, MEDLINE(R), PsycINFO, CINAHL and CENTRAL from their respective inceptions to 2021, and performed handsearching, citation searching and grey literature search; limited to English publications. Selection criteria included parenteral (intravenous/subcutaneous) diuretic administration in advanced heart failure patients (New York Heart Association class III–IV). Two authors independently assessed articles for inclusion; one author extracted data. Data were synthesised through narrative synthesis or meta-analysed as appropriate.
4646 records were screened; 6 trials (384 participants) were included. All were randomised controlled trials (RCTs) comparing intravenous continuous furosemide infusion (CFI) versus intravenous bolus furosemide infusion (BFI). Improvement in breathlessness and peripheral oedema (two studies, n=161, OR 2.80, 95% CI 1.45 to 5.40; I2=0%), and increase in urine output (four studies, n=234, mean difference, MD 344.76, 95% CI 132.87 to 556.64; I2=44%), were statistically significant in favour of CFI. Significantly lower serum potassium was found in BFI compared with CFI (three studies, n=194, MD –0.20, 95% CI –0.38 to –0.01; I2=0%). There was no difference between CFI and BFI on reduction in weight, renal function or length of hospital stay.
CFI appears to improve congestion in advanced heart failure patients in the short term. Available data came from small trials. Larger, prospective RCTs are recommended to address the evidence gap.
Individuals with chronic physical illness are at increased risk of negative psychological sequelae. Immersive virtual reality (VR) is an emerging treatment that might reduce these negative effects and increase quality of life in individuals with chronic physical illness.
To systematically review literature examining the use of immersive VR in adult populations with chronic physical illness to understand: (1) how immersive VR is used to improve psychological well-being of adults with chronic physical illness (2) what effect this immersive VR has on the psychological well-being of adults with chronic physical illness.
Systematic literature review and meta-analysis. Searches of Ovid Medline/PubMed, PsycINFO, Embase, Web of Science and Scopus between July 1993 and March 2023 inclusive.
12 811 texts were identified; 31 met the inclusion criteria. Relaxing and engaging immersive VR interventions were shown to be acceptable and feasible among adults with cancer, dementia, cardiovascular disease, kidney disease and multiple sclerosis. Many of the studies reviewed were feasibility or pilot studies and so the evidence about effectiveness is more limited. The evidence, mostly from studies of people with cancer, suggests that immersive VR can have a positive effects on anticipatory anxiety symptoms and pain.
Environment-based and game-based relaxing immersive VR offer novel interventions, with beneficial effects among people with cancer and, potentially, beneficial effects in those with other long-term physical illness.
Patients and their families face financial hardship during cancer treatment, which may intensify at end of life (EOL) due to increased symptoms and care needs. We undertook a narrative literature review to describe the current understanding of the causes, impacts and factors associated with financial hardship at EOL. We identify gaps in research, policy and clinical practice and propose steps to mitigate financial hardship for patients and caregivers at EOL.
We conducted a Medline search to identify US studies since 2000 that examined EOL financial hardship for patients with cancer and their caregivers.
Twenty-seven adult and four paediatric studies met review criteria. Adults with cancer and their caregivers face significant financial hardship at EOL and in bereavement, especially due to employment changes and informal caregiving time costs. Financial hardship may be higher for younger caregivers and for patients who are uninsured, low income, rural, with high symptom burdens or with certain cancer types. The few paediatric studies showed high financial hardship and employment impact lasting well beyond a child’s death.
There is limited literature examining financial hardship at EOL in the USA, especially in paediatrics. Priorities for future research include longitudinal studies in diverse populations of patients with cancer and informal caregivers using standardised financial hardship measures. Policies to address financial hardship at EOL, especially with hospice care, should include insurance coverage for family caregiving and medical leave policies. There is need for increased financial hardship screening at EOL and in bereavement and a need for financial navigation interventions.
Continuing futile life-sustaining treatment prolongs patients’ suffering and family members’ and medical staff’s psychological distress. Additionally, continuing futile treatment is inefficient in healthcare resource distribution. Although the withdrawal of futile life-sustaining treatment is ideal, the prevalence is variable.
To synthesise nurses’ and physicians’ experiences with continuing futile life-sustaining treatment in the intensive care unit.
This meta-synthesis was conducted following the thematic synthesis. The Preferred Reporting Items for Systematic Review and Meta-Analyses and Enhancing transparency in reporting the synthesis of qualitative research statement were used in reporting the synthesis of qualitative research statements.
A systematic search was conducted following the inclusion and exclusion criteria in APA PsycINFO, CINAHL Plus, EMBASE, MEDLINE, PubMed and Web of Science in May 2023. Two reviewers independently screened and extracted the data. The extracted data were analysed using thematic analysis of qualitative research.
A total of 16 studies were finally included, and 141 quotes were extracted and analysed. The main findings were categorised into four themes: (1) contextual and cultural diversity, (2) perceptions of futile treatment, (3) professional roles and responsibilities, and (4) emotional distress.
The study highlights the influence of culture, religion and family members, as well as perceptions of futile treatment among clinicians, on continuing futile life-sustaining treatment. Also, nurses’ awareness of their roles and responsibilities in ensuring patients’ comfort at end of life was revealed. This study informs future research to explore the experiences of futile life-sustaining treatment across various contexts.
The use of virtual reality (VR) is increasing in palliative care. However, despite increasing interest in VR, there is little evidence of how this technology can be implemented into practice.
This paper aims to: (1) explore the feasibility of implementing VR therapy, for patients and caregivers, in a hospital specialist inpatient palliative care unit and a hospice, and (2) to identify questions for organisations, to support VR adoption in palliative care.
The Samsung Gear VR system was used in a hospital specialist palliative inpatient unit and a hospice. Patients and caregivers received VR distraction therapy and provided feedback of their experience. Staff completed a feedback questionnaire to explore their opinion of the usefulness of VR in palliative care. A public engagement event was conducted, to identify questions to support implementation of VR in palliative care settings.
Fifteen individuals (12 (80%) patients and 3 (20%) caregivers) participated. All had a positive experience. No adverse effects were reported. Ten items were identified for organisations to consider ahead of adoption of VR in palliative care. These were questions about: the purpose of VR; intended population; supporting evidence; session duration; equipment choice; infection control issues; content choice; setting of VR; person(s) responsible for delivery and the maintenance plan.
It is feasible to use VR therapy in palliative care; however, further evidence about its efficacy and effectiveness is needed. Palliative care practitioners considering VR use should carefully consider several factors, to ensure that this technology can be used safely and effectively in clinical practice.
Burnout, which is a state of prolonged physical and psychological exhaustion, seems to be a prevalent and serious problem among healthcare workers. Our aim was to investigate the prevalence of burnout symptoms among members of Danish Society of Palliative Medicine (DSPaM).
All 160 physician members of DSPaM were invited to a questionnaire survey. The Copenhagen Burnout Inventory (CBI) was used to evaluate and differentiate between personal, work-related and client-related burnout.
76 members responded (47,5%). 51% regularly received supervision. Scores on personal burnout demonstrated that 25% had no symptoms and 55% had symptoms that required attention; however, no respondents needed immediate intervention. Regarding work-related burnout: 40% had no symptoms, 20% had symptoms that needed attention and 3% needed immediate help. Regarding client-related burnout: 65% had no symptoms, 32% had symptoms that needed attention and none needed immediate intervention.
This survey demonstrated a relatively low rate of burnout symptoms among members of the DSPaM. In particular, the client-related burnout score was low, while higher scores were observed in personal and work-related burnout. Despite the relatively low overall levels of burnout, it is notable that about half of the physicians reported personal burnout, which needs to be addressed.
The Dietetic Assessment and Intervention in Lung Cancer (DAIL) study was an observational cohort study. It triaged the need for dietetic input in patients with lung cancer, using questionnaires with 137 responses. This substudy tested if machine learning could predict need to see a dietitian (NTSD) using 5 or 10 measures.
76 cases from DAIL were included (Royal Surrey NHS Foundation Trust; RSH: 56, Frimley Park Hospital; FPH 20). Univariate analysis was used to find the strongest correlates with NTSD and ‘critical need to see a dietitian’ CNTSD. Those with a Spearman correlation above ±0.4 were selected to train a support vector machine (SVM) to predict NTSD and CNTSD. The 10 and 5 best correlates were evaluated.
18 and 13 measures had a correlation above ±0.4 for NTSD and CNTSD, respectively, producing SVMs with 3% and 7% misclassification error. 10 measures yielded errors of 7% (NTSD) and 9% (CNTSD). 5 measures yielded between 7% and 11% errors. SVM trained on the RSH data and tested on the FPH data resulted in errors of 20%.
Machine learning can predict NTSD producing misclassification errors <10%. With further work, this methodology allows integrated early referral to a dietitian independently of a healthcare professional.
Limited descriptive data are available on continuous and deep sedation maintained until death (CDSUD) at the patient’s request in palliative care units. This study aimed to describe such practices in the context of refractory suffering or after a request to stop life-sustaining treatment, evaluating the duration and dosage of sedative treatments used.
This retrospective observational study included consecutively hospitalised patients in a palliative care unit from January 2020 to December 2021. Data on patient profiles, reasons for the sedation request, duration of sedation and doses of sedatives were collected.
Among 42 patients who underwent CDSUD, 79% occurred due to refractory suffering. In cases of sedation following a request to stop life support, high-dose corticosteroid therapy was the most commonly involved life-sustaining treatment. Midazolam was always the first-line sedative treatment. Chlorpromazine was added in 79% of cases, and propofol in 40%, to achieve a deep level of sedation. The mean maximum doses of midazolam, chlorpromazine and propofol were 7.6 mg/hour (±1.9), 3.3 mg/hour (±0.9) and 1.7 mg/kg/hour, respectively. The average duration of sedation was 37 hours.
This study provides new descriptive elements on CDSUD. Notably, it highlights the use of second-line sedative molecules, such as propofol.
The Surprise Question (SQ) is a prognostic screening tool used to identify patients with limited life expectancy. We assessed the SQ’s performance predicting 1-year mortality among patients in ambulatory heart failure (HF) clinics. We determined that the SQ’s performance changes according to sex and other demographic (age) and clinical characteristics, mainly left ventricular ejection fraction (LVEF) and the New York Heart Association (NYHA) functional classifications.
We conducted a prospective cohort study in two HF clinics. To assess the performance of the SQ in predicting 1-year mortality, we calculated the sensitivity, specificity, positive and negative likelihood ratios, and the positive and negative predictive values. To illustrate if the results of the SQ changes the probability that a patient dies within 1 year, we created Fagan’s nomograms. We report the results from the overall sample and for subgroups according to sex, age, LVEF and NYHA functional class.
We observed that the SQ showed a sensitivity of 85% identifying ambulatory patients with HF who are in the last year of life. We determined that the SQ’s performance predicting 1-year mortality was similar among women and men. The SQ performed better for patients aged under 70 years, for patients with reduced or mildly reduced ejection fraction, and for patients NYHA class III/IV.
We consider the tool an easy and fast first step to identify patients with HF who might benefit from an advance care planning discussion or a referral to palliative care due to limited life expectancy.
Providing high-quality safe palliative care requires high-quality clinically driven research. Little is known about how to optimise clinical research capacity in this field.
To understand interest and capacity to conduct clinical research in palliative medicine and identify key facilitators and barriers, by surveying palliative medicine consultants and academic trainees.
National online survey exploring experience in conducting research, including facilitators and barriers. Sent to all current UK palliative medicine consultants, and previous/current academic trainees. Descriptive statistics are reported with framework analysis of free text responses.
195 surveys were submitted including 15 respondents with Integrated Academic Training (IAT) experience. 78% (n=140/180) of consultants were interested in conducting research. Despite this enthusiasm, 83% had no allocated time within their job plan. 88% of those who undertook IAT would recommend IAT, but 60% reported difficulty transitioning from academic trainee to research active consultant.
Barriers to research included; insufficient research culture and integration, with small teams working in a mixture of National Health Service (NHS) and non-NHS settings, leading to isolated, silo working. Even those who had undertaken IAT, felt a ‘cliff edge’ in opportunities after completing IAT. Filling service gaps was routinely prioritised over research activity.
Palliative medicine consultants, including those who have completed academic training want to conduct research but overwhelming barriers limit activity. A palliative care-specific strategy that permeates different palliative care settings, promotes interspecialty collaboration and improves the current infrastructure for palliative care research to maximise gains from IAT and embed a research culture are suggested.
To determine adherence to Department of Health and Social Care target of fast-track pathway discharge for end-of-life care within 48 hours.
Multicentre audit in England using retrospective analysis of patient records for fast-track pathway tools submitted between 1 March 2019 and 31 March 2019.
Most patients (72%) were not discharged within the 48-hour target. There was significant variability in success between hospital sites. Delays in discharge were most frequently considered to be secondary to delays in sourcing packages of care and 24-hour care facility placements. Involvement of specialist discharge nurses in paperwork submission improved rates by Commissioning Care Groups. Patients who died in hospital had significantly longer admissions than those who were discharged (discharged 19 days (IQR 11–28) vs died 28 days (IQR 18–42); p=0.039). This was entirely accounted for by increased numbers of days between admission and first suggestion of fast-track pathway discharge in those who died in hospital (discharged 9 days (IQR 5–19), died 15 days (IQR 9–33); p=0.003).
We demonstrated a delay in the fast-track pathway discharge process with significant variation in success of the discharge process at different geographical locations.
Appropriate and timely goals of patient care (GoPC) discussions are associated with improved health outcomes near the end-of-life among patients with serious illness, however, acute care clinicians report a lack of training in conducting GoPC conversations.
A half-day GoPC communication workshop for acute care clinicians was delivered and evaluated. Participants were instructed in the use of communication frameworks and practiced skills in clinical scenarios with a simulated patient.
Expert facilitators guided feedback towards learner identified goals during simulated GoPC discussions. Self-reported confidence in communication skills was measured with a pre-post questionnaire, which was repeated 2 months following the workshop.
50 clinicians completed the workshop and questionnaire. A mean improvement in confidence in communication skills of 35% (p<0.001) was identified following participation, which remained elevated at 2 months (p<0.001). All participants responded that they would recommend the workshop to a colleague, and more than two-thirds went on to share their learnings with other clinicians.
The use of a simulated patient, communication frameworks and an expert facilitator were associated with durable improvement in confidence in GoPC communication among acute care clinicians. A half-day workshop was feasible and acceptable to participants.
A prospective cohort study to evaluate clinical effectiveness of the enhanced supportive care (ESC) service at a comprehensive cancer centre and to explore the impact of the service on patient and caregiver outcomes and experience.
Patients who received care under the ESC service and their caregivers were eligible. Consented patients (n=184) and caregivers (n=67) completed questionnaires at baseline, 4 weeks and 8 weeks post-ESC. Patient questionnaires assessed quality of life (QOL), symptoms, experience of ESC and health service use. Caregiver questionnaires included QOL and needs assessment. Selected patients (n=13) participated in qualitative interviews. Quantitative analysis explored differences in questionnaire responses over time (p<0.05). Qualitative data were analysed thematically.
Patient quantitative data showed improvements in QOL (p=0.004 for European Quality of Life Questionnaire 5 dimensions (EQ5D) health index scores) and anxiety (p=0.006) at 4 weeks, reduction in some symptoms (pain p=0.02 at 4 weeks), improvement in self-efficacy, an increase in problems being addressed and a decrease in health service use (reduction in outpatient appointments). Qualitative findings suggested patients were generally satisfied with the ESC service but identified areas for improvement such as increased awareness of ESC and earlier referral. Fewer improvements were noted for caregivers; however, they did report a decrease in unmet needs.
The ESC service had a positive impact on various patient-reported and caregiver-reported outcomes. There were also positive impacts on health service use. Increasing awareness of ESC and engaging patients at an earlier stage in the disease trajectory may further improve patient satisfaction and outcomes.