Integration of a Palliative Approach in the Care of Older Adults with Dementia in Primary Care Settings: A Scoping Review

A palliative approach to care aims to meet the needs of patients and caregivers throughout a chronic disease trajectory and can be delivered by non-palliative specialists. There is an important gap in understanding the perspectives and experiences of primary care providers on an integrated palliative approach in dementia care and the impact of existing programs and models to this end. To address these, we undertook a scoping review. We searched five databases; and used descriptive numerical summary and narrative synthesizing approaches for data analysis. We found that: (1) difficulty with prognostication and a lack of interdisciplinary and intersectoral collaboration are obstacles to using a palliative approach in primary care; and (2) a palliative approach results in statistically and clinically significant impacts on community-dwelling individuals, specifically those with later stages of dementia. There is a need for high-quality research studies examining the integrated palliative approach models and initiation of these models sooner in the care trajectory for persons living with mild and moderate stages of dementia in the community.

Jaundice, ascites, and encephalopathy

The development of jaundice, ascites, or encephalopathy in the context of chronic liver disease or malignancy is an ominous indicator of advanced disease. In two studies of individuals admitted to hospital with jaundice, up to 42% of patients with malignancy and up to 23% with cirrhosis died during their first admission. The necessity of a willingness to adopt a ‘palliative approach’ to the care of such individuals is obvious. This chapter discusses three features of liver impairment that may be encountered in those for whom palliative care is appropriate.

Integrating Palliative Care Assessment Tools to Enhance Understanding of Illness Trajectory in Post-Acute Care and Long-Term Care

Objectives: To determine whether education and integration of the Gold Standard Framework Proactive Identification Guidance (GSF-PIG) and the Palliative Performance Scale (PPS) into care rounds, in post-acute care settings, can facilitate communication between the interprofessional care team to enhance understanding of illness trajectories, identifying those who would benefit from a palliative approach to care. Methods: Interprofessional care teams received training on the GSF-PIG and PPS which were integrated into weekly care rounds and completed a post-evaluation survey. A chart review was conducted for the 40 patients and residents reviewed with the GSF-PIG and PPS. Data analysis included descriptive statistics and comparisons of characteristics between patients and residents who were grouped as positive or negative on the GFS-PIG surprise question using chi square analyzes and t-tests. Results: The GSF-PIG and PPS were found to enhance communication within care teams and enhance understanding of patient and resident’s illness burden. The chart review revealed that patients and residents whom the team would not be surprised if they died within 1 year were older (p = .002), had a lower PPS score (p = .002) and had more indicators of decline (p < .001) compared to patients and residents the team would be surprised if they died within the year. Conclusion: Training interprofessional care teams on the utilization and integration of the GSF-PIG and PPS during weekly care rounds helped increase the understanding of patient and resident illness burden and illness trajectory to identify those who may benefit from a palliative approach to care.

mHOMR: a prospective observational study of an automated mortality prediction model to identify patients with unmet palliative needs

ObjectiveIdentification of patients with shortened life expectancy is a major obstacle to delivering palliative/end-of-life care. We previously developed the modified Hospitalised-patient One-year Mortality Risk (mHOMR) model for the automated identification of patients with an elevated 1-year mortality risk. Our goal was to investigate whether patients identified by mHOMR at high risk for mortality in the next year also have unmet palliative needs.MethodWe conducted a prospective observational study at two quaternary healthcare facilities in Toronto, Canada, with patients admitted to general internal medicine service and identified by mHOMR to have an expected 1-year mortality risk of 10% or more. We measured patients’ unmet palliative needs—a severe uncontrolled symptom on the Edmonton Symptom Assessment Scale or readiness to engage in advance care planning (ACP) based on Sudore’s ACP Engagement Survey.ResultsOf 518 patients identified by mHOMR, 403 (78%) patients consented to participate; 87% of those had either a severe uncontrolled symptom or readiness to engage in ACP, and 44% had both. Patients represented frailty (38%), cancer (28%) and organ failure (28%) trajectories were admitted for a median of 6 days, and 94% survived to discharge.ConclusionsA large majority of hospitalised patients identified by mHOMR have unmet palliative needs, regardless of disease, and are identified early enough in their disease course that they may benefit from a palliative approach to their care. Adoption of such a model could improve the timely introduction of a palliative approach for patients, especially those with non-cancer illness.