The Lancet Commission on Palliative Care and Pain Relief—findings, recommendations, and future directions

Knaul, Felícia Marie; Bhadelia, Afsan; Rodríguez, Natalia Martínez; Arreola-Ornelas, Héctor; Zimmermann, Camilla

doi:10.1016/s2214-109x(18)30082-2

Cited by 79 publications

(72 citation statements)

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“…The associations between serious illness, disability burden and long illness prior to death and higher utilisation are not surprising but nevertheless reinforce the widely observed imperative that systems must be reformed from a focus on acute, episodic care to the appropriate treatment and support of chronic long-term disease [7,[49][50][51].…”

Section: Interpretation and Policy Implicationsmentioning

confidence: 99%

End-of-life experience for older adults in Ireland: results from the Irish longitudinal study on ageing (TILDA)

May

Roe

McGarrigle

et al. 2020

BMC Health Serv Res

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Background: End-of-life experience is a subject of significant policy interest. National longitudinal studies offer valuable opportunities to examine individual-level experiences. Ireland is an international leader in palliative and end-of-life care rankings. We aimed to describe the prevalence of modifiable problems (pain, falls, depression) in Ireland, and to evaluate associations with place of death, healthcare utilisation, and formal and informal costs in the last year of life. Methods: The Irish Longitudinal Study on Ageing (TILDA) is a nationally representative sample of over-50-year-olds, recruited in Wave 1 (2009-2010) and participating in biannual assessment. In the event of a participant's death, TILDA approaches a close relative or friend to complete a voluntary interview on end-of-life experience. We evaluated associations using multinomial logistic regression for place of death, ordinary least squares for utilisation, and generalised linear models for costs. We identified 14 independent variables for regressions from a rich set of potential predictors. Of 516 confirmed deaths between Waves 1 and 3, the analytic sample contained 375 (73%) decedents for whom proxies completed an interview. Results: There was high prevalence of modifiable problems pain (50%), depression (45%) and falls (41%). Those with a cancer diagnosis were more likely to die at home (relative risk ratio: 2.5; 95% CI: 1.3-4.8) or in an inpatient hospice (10.2; 2.7-39.2) than those without. Place of death and patterns of health care use were determined not only by clinical need, but other factors including age and household structure. Unpaid care accounted for 37% of all care received but access to this care, as well as place of death, may be adversely affected by living alone or in a rural area. Deficits in unpaid care are not balanced by higher formal care use. Conclusions: Despite Ireland's well-established palliative care services, clinical need is not the sole determinant of end-of-life experience. Cancer diagnosis and access to family supports were additional key determinants. Future policy reforms should revisit persistent inequities by diagnosis, which may be mitigated through comprehensive geriatric assessment in hospitals. Further consideration of policies to support unpaid carers is also warranted.

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Section: Interpretation and Policy Implicationsmentioning

confidence: 99%

End-of-life experience for older adults in Ireland: results from the Irish longitudinal study on ageing (TILDA)

May

Roe

McGarrigle

et al. 2020

BMC Health Serv Res

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“…Minor changes were made to the manuscript between versions 1 and 2, in line with reviewer comments (see responses to reviewers for consideration of each specific change). The most substantial changes were (1) amending "palliative and end-of-life care" to "palliative care" throughout, starting with the title, as a reviewer found the original confusing; (2) a more detailed justification for exclusion of decedent cohort study designs in Methods>Eligibility criteria>Types of studies and reports.…”

Section: Amendments From Versionmentioning

confidence: 99%

“…Background Improving care for people with serious and complex medical illness is a health system priority worldwide. Between 2016 and 2060 there will be an estimated 87% increase globally in the number of deaths that occur following serious health-related suffering, with low-income countries experiencing the largest proportional increases 1 . Health systems originally configured to provide acute, episodic treatment often provide poor-value care to complex multimorbid populations 2 .…”

Section: Introductionmentioning

confidence: 99%

Improving palliative care with machine learning and routine data: a rapid review

et al. 2019

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Introduction: Improving palliative care is a priority worldwide as this population experiences poor outcomes and accounts disproportionately for costs. In clinical practice, physician judgement is the core method of identifying palliative care needs but has important limitations. Machine learning (ML) is a subset of artificial intelligence advancing capacity to identify patterns and make predictions using large datasets. ML has the potential to improve clinical decision-making and policy design, but there has been no systematic assembly of current evidence. Methods: We conducted a rapid review, searching systematically seven databases from inception to December 31st, 2018: EMBASE, MEDLINE, Cochrane Library, PsycINFO, WOS, SCOPUS and ECONLIT. We included peer-reviewed studies that used ML approaches on routine data to improve palliative care for adults. Our specified outcomes were survival, quality of life (QoL), place of death, costs, and receipt of high-intensity treatment near end of life. We did not search grey literature. Results: The database search identified 426 citations. We discarded 162 duplicates and screened 264 unique title/abstracts, of which 22 were forwarded for full text review. Three papers were included, 18 papers were excluded and one full text was sought but unobtainable. One paper predicted six-month mortality, one paper predicted 12-month mortality and one paper cross-referenced predicted 12-month mortality with healthcare spending. ML-informed models outperformed logistic regression in predicting mortality where data inputs were relatively strong, but those using only basic administrative data had limited benefit from ML. Identifying poor prognosis does not appear effective in tackling high costs associated with serious illness. Conclusion: While ML can in principle help to identify those at risk of adverse outcomes and inappropriate treatment, applications to policy and practice are formative. Future research must not only expand scope to other outcomes and longer timeframes, but also engage with individual preferences and ethical challenges.

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“…More recently, the Lancet Commission on Palliative Care and Pain Relief has proposed an “Essential Package” of PC services that is designed to be affordable even in the poorest countries. The package includes access to essential medicines, basic medical equipment, and supplies, and describes the basic minimum competencies that PC providers across the spectrum of care should achieve, clearly addressing the critical role of provider training 13 . Despite this increased attention regarding the importance of incorporating PC into health care systems, to the best of our knowledge as of 2016, only 20 of 234 countries globally have achieved high‐level integration of PC into mainstream health care, and only 1 of these countries (Uganda) is a LMIC 14 …”

Section: Introductionmentioning

confidence: 99%

The central role of provider training in implementing resource‐stratified guidelines for palliative care in low‐income and middle‐income countries: Lessons from the Jamaica Cancer Care and Research Institute in the Caribbean and Universidad Católica in Latin America

Stoltenberg

Spence

Daubman

et al. 2020

Cancer

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Individuals in low‐income and middle‐income countries (LMICs) account for approximately two‐thirds of cancer deaths worldwide, and the vast majority of these deaths occur without access to essential palliative care (PC). Although resource‐stratified guidelines are being developed that take into account the actual resources available within a given country, and several components of PC are available within health care systems, PC will never improve without a trained workforce. The design and implementation of PC provider training programs is the lynchpin for ensuring that all seriously ill patients have access to quality PC services. Building on the Breast Health Global Initiative's resource‐stratified recommendations for provider education in PC, the authors report on efforts by the Jamaica Cancer Care and Research Institute in the Caribbean and the Universidad Católica in successfully developing and implementing PC training programs in the Caribbean and Latin America, respectively. Key aspects of this approach include: 1) fostering strategic academic partnerships to bring additional expertise and support to the effort; 2) careful adaptation of the curriculum to the local context and culture; 3) early identification of feasible metrics to facilitate program evaluation and future outcomes research; and 4) designing PC training programs to meet local health system needs.

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The Lancet Commission on Palliative Care and Pain Relief—findings, recommendations, and future directions

Cited by 79 publications

References 1 publication

End-of-life experience for older adults in Ireland: results from the Irish longitudinal study on ageing (TILDA)

End-of-life experience for older adults in Ireland: results from the Irish longitudinal study on ageing (TILDA)

Improving palliative care with machine learning and routine data: a rapid review

The central role of provider training in implementing resource‐stratified guidelines for palliative care in low‐income and middle‐income countries: Lessons from the Jamaica Cancer Care and Research Institute in the Caribbean and Universidad Católica in Latin America

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