New Zealand wins (again)

I have to confess I am a fan of the New Zealand health system from across the ditch. Sensible spending. strong palliative care health service connections… am I wrong Bro?

This article has not succeeded in reversing my bias in favour of New Zealand.

Palliative data nerds will no doubt recall this  fascinating study in Scotland by Professor Clark et al.  Published in Palliative Medicine, and quickly attaining the journal’s highest-ever Altmetrics score (1) , Clark showed that among 10,743 inpatients in 25 Scottish teaching and general hospitals on 31 March 2010,  3,098 (28.8%) patients died during the one-year follow-up period. The findings were replicated in 2013 with similar results.

The study by the fabulous  Professor  Merryn Gott et al showed that on the same date, the corresponding figure in New Zealand (including obstetrics) was about half at 14.5%. Patients at higher risk of dying were the elderly of over 80 years of age, Maori, those with cancer, those from socially disadvantaged backgrounds, and those admitted under medical specialties rather than surgical.

New Zealand seems to provide better end of life care outside the hospital setting, with stronger end-of-life care in the aged care setting. This has certainly been a focus for service development in Australia as well.

How would we rate in Australia I wonder?

I would love to hear from international colleagues

Ref (1)  https://www.gla.ac.uk/research/az/endoflifestudies/projects/imminence/

Sonia

Raise awareness for World #Delirium Day 15 March 2017

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Delirium is a favourite topic of ours at Palliverse – it is experienced by many people with palliative care needs, including at the end of life, and is often distressing to the person, their loved ones and health professionals providing care. Despite this, it remains poorly recognised, underdiagnosed and poorly treated – not least because the evidence base is still growing.

iDelirium, a federation of the Australasian Delirium Association, European Delirium Association and American Delirium Association, has launched World Delirium Day (#WDD2017) in an attempt to raise awareness of delirium and improve its management.

They have suggested some Actions to Take on #WDD2017. I’ve listed them below & with some thoughts on how to take action.

  • Commit to using the term ‘delirium’

If you hear someone using terms like “agitated”, “restless”, “aggressive” or “pleasantly confused”, think – could this be delirium? I use the term delirium, document it and make sure it’s communicated in the medical record and letters. Recognising and diagnosing delirium allows us to educate patients and their loved ones, as well as providing the best delirium care possible.

  • Screen your patients for delirium

People at risk of delirium, who should be screened, include those with serious illness, those aged over 65 years and those with underlying cognitive impairment. This includes many of the people cared for by palliative care services! The diagnosis of delirium may be missed, delayed or misdiagnosed without screening, as signs may be subtle (especially in hypoactive delirium).  There are multiple simple bedside screening tests for delirium, and although not all these have been validated in the specialist palliative care setting, they are still useful. The 4AT is a freely available screening tool that can be administered by any health professional and does not require training.

  • Listen to patient and family stories about the experience of delirium

What may seem “pleasantly confused” to staff members can be very distressing for the delirious person and their families. Being agitated, aggressive or “just not themselves” can be distressing for patients and families to witness – it is important to acknowledge these emotions and provide education about delirium. (See “Michael’s Story: the fear on his face was palpable” for a wife’s experience of her husband’s undiagnosed delirium.)

  • Engage your leadership in a discussion of delirium

If the above isn’t enough to convince your leadership to take note, delirium also increases the risk of health care complications like falls, pressure injuries, prolonged length of stay, and mortality. For those in Australia, World Delirium Day is a great time to introduce your leadership to the recently released Delirium Clinical Care Standard (which we’ve covered here before).

  • Educate health professionals about delirium

Delirium does not “belong” to just one group of health professionals or one specialty. It’s common, especially in palliative care, and important for us all to know about it.  Some of my favourite educational resources are freely available at the Scottish Delirium Association, plus this 5-minute video from UK-based  Delirium Champion Dr MS Krishnan. (I’ve shared this before but it’s worth sharing again!)

As a final bid to raise awareness, you can participate in a #WDD2017 Thunderclap via your Facebook, Twitter or Tumblr account, to alert your friends and followers to the importance of delirium.

Journal club on delirium #hpmjc

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Delirium is a syndrome associated with a sudden change in a person’s mental function that interferes with their thinking and awareness. It is a common problem that confronts many patients, families and clinicians in the palliative care setting. Delirium usually develops as a result of a serious medical condition, which can often be found and treated. However, the symptoms of delirium – such as fluctuating confusion, reduced attention, disturbed sleep-wake cycle, and/or hallucinations – can be very distressing for everyone involved, and may persist for many days to weeks.

Medications – including antipsychotics such as haloperidol and risperidone – are often used to manage the symptoms of delirium. But do they actually work?

To answer this question, Professor Meera Agar (@meera_agar) and colleagues from the Palliative Care Clinical Studies Collaborative (PaCCSC) conducted a study examining the use of these medications. The results of their research was published in JAMA Internal Medicine recently, and also discussed on various media platforms (examples here, here and here).

Please join Hospice and Palliative Medicine Journal Club (#hpmjc) in January 2017 for an in-depth discussion about this important study. The journal club will be hosted by Chi Li (@Dr_Chi_Li) from Palliverse and feature the paper’s first author, Meera Agar (@meera_agar)!

When? The hour-long online journal club will start at (please note the different dates):

  • Auckland: 9am, Tuesday 24th January
  • Sydney: 7am, Tuesday 24th January
  • London: 8pm, Monday 23rd January
  • New York / Toronto: 3pm, Monday 23rd January
  • Other cities

Who? Anyone and everyone who has:

  • Experienced delirium themselves
  • Cared for or lived with someone with delirium
  • An interest in improving the treatment of delirium
  • An interest in enhancing palliative care

How? It’s easy!

What? We will be discussing the following topics during the journal club

  • Topic 1: Why was the study conducted? Are the study questions / aims relevant to you and/or your work?
  • Topic 2: How was the study conducted? What did you like about the study methodology? Would you have done anything differently?
  • Topic 3: What were the main findings from the study? Were you surprised by any of the study results?
  • Topic 4: Has this study changed the way you think about delirium in the palliative care setting? Why and why not? What’s next?

If you would like more information, or are having trouble accessing the paper, please feel free to contact us via Twitter (@Dr_Chi_Li or @palliverse) or by email (chi.li.australia@gmail.com or palliverse@gmail.com).

We hope you can join us for a great discussion about this important study!

 

“Failure to maintain”: do hospitals cause suffering in older people?

Today Palliverse talks to Assistant Professor Kasia Bail (@Kasia_Bail) from the University of Canberra. Kasia is a nurse, a researcher, a kung fu instructor and a drummer in a metal band. She came to our attention via social media when we noticed her crowdfunding campaign for the next stage of her research into nursing care of complex, hospitalised older people. Here at Palliverse we are fans of crowdfunding, although we’re yet to use it for research purposes!

Kasia’s research aims to improve sustainable acute care health delivery for an ageing population, while her clinical experience includes general medical and acute palliative care. In her PhD, Kasia developed an approach to measure nurse-sensitive outcomes, which is currently being used to evaluate a Government-funded implementation of a cognitive identifier. Kasia has a passion for identifying and researching the structures and processes which impede or enable quality patient care, and sharing her learning and inquiry with nursing students, industry and professional groups. Here, Palliverse asks her about her latest research project and dipping her toe into the world of social media.

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Dr Kasia Bail (image via Dr Bail)

Your research has led to a new concept in the care of older people with complex medical problems, “Failure to Maintain”. What does this mean? Continue reading

interview – Giovanni Galvis, palliative and oncology fellow from Sweden

Hi Giovanni!

Tell us about yourself . What are you doing in Australia?

Hello, my name is Giovanni Galvis. I was born in Caracas-Venezuela. I studied Medicine in Bogota-Colombia. After my graduation I decided to go to Europe. I have always been fascinated with the history and architecture and of course the good level in research and clinical medicine there. I spent some time in Germany but in 2007 I moved to Sweden where I did research in the beginning and then started my specialty in Clinical Oncology.  I am doing a placement at Peter MacCallum Cancer Centre attending the department of Pain and Palliative Care, the breast clinic and the melanoma clinic.

What is your impression of palliative care and cancer care in Australia? Is it different from that in Sweden? How? Continue reading

Modern dying from a doctor’s perspective

 

A thoughtful article regarding our modern attitudes to dying by Dr Craig Bowron, an internist (i.e. physician in internal medicine for us Down Under, or general medicine consultant)

Opting to try all forms of medical treatment and procedures to assuage this guilt is also emotional life insurance: When their loved one does die, family members can tell themselves, “We did everything we could for Mom.”

In my experience, this is a stronger inclination than the equally valid (and perhaps more honest) admission that “we sure put Dad through the wringer those last few months.”

I agree with Dr Bowron, that sometimes we may not consider the cost to the person (not the financial cost, other costs) of being able to say, “We did everything we could.”

What do you think? Does this apply where you are?

Regards, Sonia

PS Thanks to Tegan, a social worker I work with, for pointing me to this article.

I think therefore I am? – Palliative Care for Chinese People: An insider’s look

Hiya folks,

I’m presenting at Grand Round tomorrow on the above subject.

Pasted below are the Tipsheets I prepared as a take-away for the presentation.

At the bottom is a link for printable PDF versions.

Enjoy, James.

1

2Chinese Culture Tipsheet PDF Version

Review article concerning hospital end of life care in NEJM

Not the traditional festive season article perhaps, but this review article by Dr Blinderman and the late Dr Billings provides a good summary in a very reputable and widely read journal concerning end of life care in hospitals in the United States.

Is end of life care in hospital in the US different?

The article reports that 29% of deaths take place in hospitals in America, a bit lower than I would have expected. In Australia, 54% die in hospital but this includes inpatient palliative care deaths which are excluded from the US figure of 29%.

According to AIHW, 42% of the Australians who died in hospital had some involvement from palliative care  (42% of 54% in hospital deaths is 23%) About a third of patients who died as an admitted patient in hospital (a third of 54% is about 15%) died in inpatient palliative care. That still leaves us behind the US, with around 36% dying in a non palliative inpatient Australian hospital bed compared to 29% in the USA.

Interestingly the NEJM article does not refer to subcutaneous medications which are the mainstay of terminal care medication administration in Australia, New Zealand and the UK. Do US practitioners use less SC medication?

Personally I don’t find that cough and nausea are so troubling at the end of life, and we would promote meticulous mouth care for dry mouth ahead of pharmacological management.

The article also advises us to avoid benzodiazepines for delirium including at the end of life, which I found surprising.

Dear reader, do you have any thoughts? What is end of life care like in hospitals in your neck of the woods?

 

beautiful essay on a doctor’s perspective on end of life care

This really resonated with me… well worth a read.

A young doctor describing her developing perspective on a “good death”; on dying and end of life care in our healthcare system.

http://www.vox.com/2015/10/19/9554583/doctor-good-death

Sonia

Shifting the focus of care from disease to people – heartfelt article about dying in acute hospitals

This article is going a bit viral on social media. Does it mirror your experiences? It certain does mine, having worked for a long time in consultation services in acute hospitals. There have been a number of comments and letters to the Age supporting the message of the article, written by a senior doctor about the death of his father. http://www.theage.com.au/comment/hospitals-must-shift-focus-of-endoflife-care-from-disease-to-people-20150707-gi6joz