Background: Delirium is a common and distressing neurocognitive condition that frequently affects patients in palliative care settings and is often underdiagnosed. Aim: Expanding on a 2013 review, this systematic review examines the incidence and prevalence of delirium across all palliative care settings. Design: This systematic review and meta-analyses were prospectively registered with PROSPERO and included a risk of bias assessment. Data sources: Five electronic databases were examined for primary research studies published between 1980 and 2018. Studies on adult, non-intensive care and non-postoperative populations, either receiving or eligible to receive palliative care, underwent dual reviewer screening and data extraction. Studies using standardized delirium diagnostic criteria or valid assessment tools were included. Results: Following initial screening of 2596 records, and full-text screening of 153 papers, 42 studies were included. Patient populations diagnosed with predominantly cancer ( n = 34) and mixed diagnoses ( n = 8) were represented. Delirium point prevalence estimates were 4%–12% in the community, 9%–57% across hospital palliative care consultative services, and 6%–74% in inpatient palliative care units. The prevalence of delirium prior to death across all palliative care settings ( n = 8) was 42%–88%. Pooled point prevalence on admission to inpatient palliative care units was 35% (confidence interval = 0.29–0.40, n = 14). Only one study had an overall low risk of bias. Varying delirium screening and diagnostic practices were used. Conclusion: Delirium is prevalent across all palliative care settings, with one-third of patients delirious at the time of admission to inpatient palliative care. Study heterogeneity limits meta-analyses and highlights the future need for rigorous studies.

Background Physicians experience high rates of burnout, which may negatively impact patient care. Palliative care is an emotionally demanding specialty with high burnout rates reported in previous studies from other countries. We aimed to estimate the prevalence of burnout and degree of resilience among Canadian palliative care physicians and examine their associations with demographic and workplace factors in a national survey. Methods Physician members of the Canadian Society of Palliative Care Physicians and Société Québécoise des Médecins de Soins Palliatifs were invited to participate in an electronic survey about their demographic and practice arrangements and complete the Maslach Burnout Inventory for Medical Professionals (MBI-HSS (MP)), and Connor-Davidson Resilience Scale (CD-RISC). The association of categorical demographic and practice variables was examined in relation to burnout status, as defined by MBI-HSS (MP) score. In addition to bivariable analyses, a multivariable logistic regression analysis, reporting odds ratios (OR), was conducted. Mean CD-RISC score differences were examined in multivariable linear regression analysis. Results One hundred sixty five members (29%) completed the survey. On the MBI-HSS (MP), 36.4% of respondents reported high emotional exhaustion (EE), 15.1% reported high depersonalization (DP), and 7.9% reported low personal accomplishment (PA). Overall, 38.2% of respondents reported a high degree of burnout, based on having high EE or high DP. Median CD-RISC resilience score was 74, which falls in the 25th percentile of normative population. Age over 60 (OR = 0.05; CI, 0.01–0.38), compared to age ≤ 40, was independently associated with lower burnout. Mean CD-RISC resilience scores were lower in association with the presence of high burnout than when burnout was low (67.5 ± 11.8 vs 77.4 ± 11.2, respectively, p < 0.0001). Increased mean CD-RISC score differences (higher resilience) of 7.77 (95% CI, 1.97–13.57), 5.54 (CI, 0.81–10.28), and 8.26 (CI, 1.96–14.57) occurred in association with age > 60 as compared to ≤40, a predominantly palliative care focussed practice, and > 60 h worked per week as compared to ≤40 h worked, respectively. Conclusions One in three Canadian palliative care physicians demonstrate a high degree of burnout. Burnout prevention may benefit from increasing resilience skills on an individual level while also implementing systematic workplace interventions across organizational levels.

Background: The COVID-19 pandemic has caused millions of deaths worldwide, leading to symptoms of grief among the bereaved. Neither the burden of severe grief nor its predictors are fully known within the context of the pandemic. Aim: To determine the prevalence and predictors of severe grief in family members who were bereaved early in the COVID-19 pandemic. Design: Prospective, matched cohort study. Setting/Participants: Family members of people who died in an acute hospital in Ottawa, Canada between November 1, 2019 and August 31, 2020. We matched relatives of patients who died of COVID (COVID +ve) with those who died of non-COVID illness either during wave 1 of the pandemic (COVID −ve) or immediately prior to its onset (pre-COVID). We abstracted decedents’ medical records, contacted family members >6 months post loss, and assessed grief symptoms using the Inventory of Complicated Grief-revised. Results: We abstracted data for 425 decedents (85 COVID +ve, 170 COVID −ve, and 170 pre-COVID), and 110 of 165 contacted family members (67%) consented to participate. Pre-COVID family members were physically present more in the last 48 h of life; the COVID +ve cohort were more present virtually. Overall, 35 family members (28.9%) had severe grief symptoms, and the prevalence was similar among the cohorts ( p = 0.91). Grief severity was not correlated with demographic factors, physical presence in the final 48 h of life, intubation, or relationship with the deceased. Conclusion: Severe grief is common among family members bereaved during the COVID-19 pandemic, regardless of the cause or circumstances of death, and even if their loss took place before the onset of the pandemic. This suggests that aspects of the pandemic itself contribute to severe grief, and factors that normally mitigate grief may not be as effective.

Background: Although focused practice within family medicine may be increasing globally, there is limited research on the factors contributing to decisions to focus practice. Aim: We aimed to examine the factors influencing resident and early-career family physician choices of focused practice across three Canadian provinces. Design and Setting: We analyzed a subset of qualitative interview data from a study across British Columbia, Ontario, and Nova Scotia. Method: A total of 22 resident family physicians and 38 early-career family physicians in their first 10 years of practice who intend to or currently practice in a focused area were included in our analysis. We compared participant types, provinces, and the degree of focused practice while identifying themes related to factors influencing the pursuit of focused practice. Results: We identified three key themes of factors contributing to choices of focused practice: self-preservation within the current health care system, support from colleagues, and experiences in medical school and/or residency. Minor themes included alignment of practice with skills, personal values, or ability to derive professional satisfaction; personal lived experiences; and having many attractive opportunities for focused practice. Conclusion: Both groups of participants unanimously viewed focused practice as a way to circumvent the burnout or exhaustion they associated with comprehensive practice in the current structure of the health care system. This finding, in addition to other influential factors, was consistent across the three provinces. More research is needed to understand the implications of resident and early-career family physician choices of focused practice within the physician workforce.