Palliative care outcomes in surgical oncology patients with advanced malignancies: a mixed methods approach

Abstract

Purpose To prospectively compare outcomes and processes of hospital-based early palliative care with standard care in surgical oncology patients (N = 152). Methods A randomized, mixed methods, longitudinal study evaluated the effectiveness of a hospital-based Pain and Palliative Care Service (PPCS). Interviews were conducted presurgically and at follow-up visits up to 1 year. Primary outcome measures included the Gracely Pain Intensity and Unpleasantness Scales and the Symptom Distress Scale. Qualitative interviews assessed social support, satisfaction with care, and communication with providers. Survival analysis methods explored factors related to treatment crossover and study discontinuation. Models for repeated measures within subjects over time explored treatment and covariate effects on patient-reported pain and symptom distress. Results None of the estimated differences achieved statistical significance; however, for those who remained on study for 12 months, the PPCS group performed better than their standard of care counterparts. Patients identified consistent communication, emotional support, and pain and symptom management as positive contributions delivered by the PPCS. Conclusions It is unclear whether lower pain perceptions despite greater symptom distress were clinically meaningful; however, when coupled with the patients’ perceptions of their increased resources and alternatives for pain control, one begins to see the value of an integrated PPCS.

Association Between Palliative Care and Patient and Caregiver Outcomes

“…Of the 23 trials, 13 were judged as high risk, 9,20,35,43–45,47,48,51,55,62–64 5 as unclear risk, 11,13,37,42,56 and 5 as low risk of bias. 12,57–60 Overall, 7 trials reported statistically significant improvements in mood related to palliative care 9,13,48,57–60 ; of these, 4 were at low risk of bias.…”

Strategies used in improving and assessing the level of reporting of implementation fidelity in randomised controlled trials of palliative care complex interventions: A systematic review

“…The latter could be via specifying the number of contacts 29,58 with a proviso that this could be increased when necessary, 38,46 or limiting the number of contacts (referring on if more is needed); [23][24][25][26] specifying a range of minutes to be spent; [48][49][50] using a 'structured-visit format'; 55 or promoting protocol adherence, such as early site visits, review of medical records 60 and conference calls. 55,60 Other key strategies identified include (1) specification of provider credentials needed, 47 (2) specification and incorporation of active ingredients, demonstrating treatment differentiation, 27,28,[34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][52][53][54]56,59 (3) use of expert/protocol review groups to determine implementation protocol fidelity to underlying theoretical model and (4) identification of potential confounders.…”

“…30,31,[61][62][63][64][65] Other strategies include role-play practice sessions with feedback to assess provider skill acquisition, [20][21][22]33 record and review of intervention sessions to assess provider skill maintenance, [20][21][22]33 assessment of providers' suitability for particular interventions 54 and appropriate training for trainees from different disciplines. 30,31,[61][62][63][64][65] For treatment delivery, key strategies are the usage of a treatment manual, [34][35][36] usage of an implementation checklist, [39][40][41][42][43][44] site visits/surveys to ensure adherence to intervention plan, 54,60 interviewing patients or caregivers on their experience, [23][24][25][26]29,32,45,[51][52][53]58 checking whether medications given were appropriate, 32,…”

The Growth of Palliative Care in the United States

“…As can be seen in Table 2, there is a paucity of articles describing specialtyspecific RCTs assessing palliative care. In surgery, the study by Wallen et al (101) of surgical oncology patients with advanced malignancies was hampered by high attrition rates owing to progression of disease or death, as well as crossover of usual care patients when they required more palliative care. The most palliative care RCT articles over the past decade were specific to oncology, but this is somewhat misleading because five of the seven articles were related to the landmark study on nonsmall-cell lung cancer (16).…”