Level of Palliative Care Complexity in Advanced Cancer Patients: A Multinomial Logistic Analysis
Abstract
:1. Introduction
2. Patients and Methods
2.1. Study Design, Setting and Participants
2.2. Data Collection and Measures
2.3. Statistical Analysis
2.4. Ethical Considerations
3. Results
3.1. Characteristics of the Study Population
3.2. Assessment of Complexity Level in Palliative Care
3.3. Factors Related to Complexity Level
4. Discussion
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
References
- Connor, S.; Sepulveda, C. The Global Atlas of Palliative Care at the End of Life, 1st ed.; Worldwide Hospice Palliative Care Alliance: London, UK, 2014; pp. 5–8. [Google Scholar]
- Kavalieratos, D.; Corbelli, J.; Zhang, D.; Dionne-Odom, J.N.; Ernecoff, N.C.; Hanmer, J.; Hoydich, Z.P.; Ikejiani, D.Z.; Klein-Fedyshin, M.; Zimmermann, C.; et al. Association between palliative care and patient and caregiver outcomes: A systematic review and meta-analysis. JAMA 2016, 316, 2104–2114. [Google Scholar] [CrossRef] [PubMed]
- Bakitas, M.; Lyons, K.D.; Hegel, M.T.; Balan, S.; Brokaw, F.C.; Seville, J.; Hull, J.G.; Li, Z.; Tosteson, T.D.; Byock, I.R.; et al. Effects of a palliative care intervention on clinical outcomes in patients with advanced cancer: The project ENABLE II randomized controlled trial. JAMA 2009, 302, 741–749. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Yennurajalingam, S.; Urbauer, D.L.; Casper, K.L.; Reyes-Gibby, C.C.; Chacko, R.; Poulter, V.; Bruera, E. Impact of a palliative care consultation team on cancer related symptoms in advanced cancer patients referred to an outpatient supportive care clinic. J. Pain Symptom Manag. 2011, 41, 49–56. [Google Scholar] [CrossRef]
- Gade, G.; Venohr, I.; Conner, D.; MacGrady, K.; Beane, J.; Richardson, R.H.; Williams, M.P.; Liberson, M.; Blum, M.; Della, P.R. Impact of an inpatient palliative care team: A randomized control trial. J. Palliat. Med. 2008, 11, 180–190. [Google Scholar] [CrossRef]
- Brumley, R.; Enguidanos, S.; Jamison, P.; Seitz, R.; Morgenstern, N.; Saito, S.; Mcllwane, J.; Hillary, K.; Gonzalez, J. Increased satisfaction with care and lower costs: Results of a randomized trial of in-home palliative care. J. Am. Geriatr. Soc 2007, 55, 993–1000. [Google Scholar] [CrossRef]
- Murtagh, F.E.M.; Bausewein, C.; Verne, J.; Groeneveld, E.I.; Kaloki, Y.E.; Higginson, I.J. How many people need palliative care? A study developing and comparing methods for population-based estimates. Palliat. Med. 2014, 28, 49–58. [Google Scholar] [CrossRef] [Green Version]
- Etkind, S.N.; Bone, A.E.; Gomes, B.; Lovell, N.; Evans, C.J.; Higginson, I.J.; Murtagh, F.E.M. How many people will need palliative care in 2040? Past trends, future projections and implications for services. BMC Palliat. Care 2017, 15, 102. [Google Scholar] [CrossRef] [Green Version]
- Morrison, R.S.; Meier, D.E. It’s all a matter of perspective. J. Palliat. Med. 2016, 19, 900–901. [Google Scholar] [CrossRef] [PubMed]
- Molin, Y.; Gallay, C.; Gautier, J.; Lardy-Cleaud, A.; Mayet, R.; Grach, M.C.; Guesdon, G.; Capodano, G.; Dubroeucq, O.; Bouleuc, C.; et al. PALLIA-10, a screening tool to identify patients needing palliative care referral in comprehensive cancer centers: A prospective multicentric study (PREPA-10). Cancer Med. 2019, 8, 2950–2961. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Bennett, M.; Adam, J.; Alison, D.; Hicks, F.; Stockton, M. Leeds eligibility criteria for specialist palliative care services. Palliat. Med. 2000, 14, 157–158. [Google Scholar] [CrossRef] [PubMed]
- Quill, T.E.; Abernethy, A.P. Generalist plus specialist palliative care: Creating a more sustainable model. N. Engl. J. Med. 2013, 368, 1173–1175. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Arias-Casais, N.; Garralda, E.; Rhee, J.; Lima, L.; Pons-Izquierdo, J.; Clark, D.; Hasselaar, J.; Ling, J.; Mosoiu, D.; Centeno-Cortes, C. EAPC Atlas of Palliative Care in Europe; EAPC Press: Vilvoorde, Belgium, 2019. [Google Scholar]
- Hodiamont, F.; Jünger, S.; Leidl, R.; Maier, B.O.; Schildmann, E.; Bausewein, C. Understanding complexity-The palliative care situation as a complex adaptive system. BMC Health Serv. Res. 2019, 19, 157. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Pask, S.; Pinto, C.; Bristowe, K.; Van Vliet, L.; Nicholson, C.; Evans, C.J.; George, R.; Bailey, K.; Davies, J.; Guo, P.; et al. A framework for complexity in palliative care: A qualitative study with patients, family carers and professionals. Palliat. Med. 2018, 32, 1078–1090. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Carduff, E.; Johnston, S.; Winstanley, C.; Morrish, J.; Murray, S.A.; Spiller, J. What does ‘complex’ mean in palliative care? Triangulating qualitative findings from 3 settings. BMC Palliat. Care 2018, 17, 12. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Estrategia en Cuidados Paliativos del Sistema Nacional de Salud. Actualización 2010–2014. Ministerio de Sanidad, Política Social e Igualdad: Madrid, Spain, 2011. Available online: http://www.mscbs.gob.es/organizacion/sns/planCalidadSNS/docs/paliativos/cuidadospaliativos.pdf. (accessed on 26 November 2019).
- Martin-Roselló, M.L.; Sanz-Amores, M.R.; Salvador-Comino, M.R. Instruments to evaluate complexity in end-of-life care. Curr. Opin. Support. Palliat. Care 2018, 12, 480–488. [Google Scholar] [CrossRef]
- Esteban-Perez, M.; Graub, I.; Castells, G.; Bullich, Í.; Busquet, X.; Aranzana, A.; Besora, M.I.; Picaza, J.M.; Tuca, A.; Valverde, E. Complexity of end-of-life care: Criteria and levels of intervention in community health care. Med. Paliat. 2015, 22, 69–80. [Google Scholar] [CrossRef]
- Hui, D.; Mori, M.; Meng, Y.C.; Watanabe, S.; Caraceni, A.; Strasser, F.; Saarto, T.; Cherny, N.; Glare, P.; Kaasa, S.; et al. Automatic referral to standardize palliative care access: An international Delphi survey. Support. Care Cancer 2018, 26, 175–180. [Google Scholar] [CrossRef]
- Tuca, A.; Gómez, M.; Prat, A. Predictive model of complexity in early palliative care: A cohort of advanced cancer patients (PALCOM study). Support. Care Cancer 2018, 26, 241–249. [Google Scholar] [CrossRef] [PubMed]
- Martin-Roselló, M.L.; Fernández-López, A.; Sanz-Amores, R.; Gómez-García, R.; Vidal-España, F.; Cia-Ramos, R. IDC-Pal (Instrumento Diagnóstico de la Complejidad en Cuidados Paliativos) © Consejeria de Igualdad, Salud y Politicas sociales. Fundación Cudeca. 2014. Available online: https://www.juntadeandalucia.es/export/drupaljda/salud_5af1956edd07e_idc_pal_2014.pdf. (accessed on 20 December 2019).
- De Miguel, C.; Ruiz, S.; De la Uz, A.; Merino, E.; Gutierrez, A.; Sanz, L.; Molinero, E.; Sanz, E.; Navarro, A.; Riestra, A. Are the patients attended by home care support teams complex? Med. Paliat. 2018, 25, 7–16. [Google Scholar] [CrossRef]
- Salvador, M.R.; Garrido, N.; Perea, I.; Martín, M.L.; Regife, V.; Fernández, A. The value of the Diagnostic Tool for complexity in Palliative Care for the assessment of palliative patients. Med. Paliat. 2017, 24, 196–203. [Google Scholar] [CrossRef]
- Llobera, J.; Sansó, N.; Ruiz, A.; Llagostera, M.; Serratusell, E.; Serrano, C.; Martín, M.L.; Benito, E.; Castaño, E.J.; Leiva, A. Strengthening primary health care teams with palliative care leaders: Protocol for a cluster randomized clinical trial. BMC Palliat. Care 2018, 17, 4. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Mahoney, F.I.; Barthel, D.W. Functional evaluation: Barthel index. Md State Med. J. 1965, 14, 61–65. [Google Scholar]
- Anderson, F.; Downing, G.M.; Hill, J.; Casorso, L.; Lerch, N. Palliative Performance Scale (PPS): A New Tool. J. Palliat. Care 1996, 12, 5–11. [Google Scholar] [CrossRef] [PubMed]
- Hosmer, D.W.; Lemeshow, S.; Sturdivant, R.X. Applied Logistic Regression, 3rd ed.; John Wiley & Sons: Hoboken, NJ, USA, 2013. [Google Scholar]
- Hui, D.; Anderson, L.; Tang, M.; Park, M.; Liu, D.; Bruera, E. Examination of referral criteria for outpatient palliative care among patients with advanced cancer. Support. Care Cancer 2020, 28, 295–301. [Google Scholar] [CrossRef] [PubMed]
- Lau, F.; Maida, V.; Downing, M.; Lesperance, M.; Karlson, N.; Kuziemsky, C. Use of the Palliative Performance Scale (PPS) for end-of-life prognostication in a palliative medicine consultation service. J. Pain Symptom Manag. 2009, 37, 965–972. [Google Scholar] [CrossRef] [PubMed]
- Baik, D.; Russel, D.; Jordan, L.; Dooley, F.; Bowles, K.; Masterson, R.M. Using the Palliative Performance Scale to estimate survival for patients at the end of life: A systematic review of the literature. J. Palliat. Med. 2018, 21, 1651–1660. [Google Scholar] [CrossRef]
- Sutradhar, R.; Seow, H.; Earle, C.; Dudgeon, D.; Atzema, C.; Husain, A.; Howell, D.; Liu, Y.; Sussman, J.; Barbera, L. Modeling the Longitudinal Transitions of Performance Status in Cancer Outpatients: Time to Discuss Palliative Care. J. Pain Symptom Manag. 2013, 45, 726–734. [Google Scholar] [CrossRef]
- Seow, H.; Barbera, L.; Sutradhar, R.; Howell, D.; Dudgeon, D.; Atzema, C.; Liu, Y.; Husain, A.; Sussman, J.; Earle, C. Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J. Clin. Oncol. 2011, 29, 1151–1158. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Olajide, O.; Hanson, L.; Usher, B.M.; Qaqish, B.F.; Schwartz, R.; Bernard, S. Validation of the Palliative Performance Scale in the Acute Tertiary Care Hospital Setting. J. Pall Med. 2007, 10, 111–117. [Google Scholar] [CrossRef]
- Weissman, D.E.; Meier, D.E. Identifying patients in need of a palliative care assessment in the hospital setting: A consensus report from the center to advance palliative care. J. Palliat. Med. 2011, 14, 17–23. [Google Scholar] [CrossRef] [Green Version]
- Hui, D.; Mori, M.; Watanabe, S.M.; Caraceni, A.; Strasser, F.; Saarto, T.; Glare, P.; Kaasa, S.; Bruera, E. Referral criteria for outpatient specialty palliative cancer care: An international consensus. Lancet Oncol. 2016, 17, 552–559. [Google Scholar] [CrossRef] [Green Version]
- Glare, P.; Plakovic, K.; Scholoms, A.; Egan, B.; Epstein, A.; Kelsen, D.; Saltz, L. Study using the NCCN guidelines for palliative care to screen patients for palliative care needs and referral to palliative care specialists. J. Natl. Compr. Cancer Netw. 2013, 11, 1087–1096. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Highet, G.; Crawford, D.; Murray, S.A.; Boyd, K. Development and evaluation of the Supportive and Palliative Care Indicators Tool (SPICT): A mixed-methods study. BMJ Support. Palliat. Care 2014, 4, 285–290. [Google Scholar] [CrossRef] [PubMed]
- O’Callaghan, A.; Laking, G.; Frey, R.; Robinson, J.; Gott, M. Can we predict which hospitalised patients are in their last year of life? A prospective crosssectional study of the Gold Standards Framework Prognostic Indicator Guidance as a screening tool in the acute hospital setting. Palliat. Med. 2014, 28, 1046–1052. [Google Scholar] [CrossRef] [PubMed]
- Gómez, X.; Martínez, M.; Blay, C.; Amblàs, J.; Vila, L.; Costa, X.; Villanueva, A.; Espaulella, J.; Espinosa, J.; Figuerola, M.; et al. Identifying patients with chronic conditions in need of palliative care in the general population: Development of the NECPAL tool and preliminary prevalence rates in Catalonia. BMJ Support. Palliat. Care 2013, 3, 300–308. [Google Scholar] [CrossRef] [Green Version]
- Tuca, A.; Gómez, X.; Espinosa, J.; Martínez, M.; Cordorniu, N.; Porta, J. Structure, organisation and clinical outcomes in cancer patients of hospital support teams in Spain. BMJ Support. Palliat. Care 2012, 2, 356–362. [Google Scholar] [CrossRef] [PubMed]
- Ryan, T.; Ingleton, C.; Gardiner, C.; Parker, C.; Gott, M.; Noble, B. Symptom burden, palliative care need and predictors of physical and psychological discomfort in two UK hospitals. BMC Palliat. Care 2013, 12, 11. [Google Scholar] [CrossRef] [Green Version]
- Teunissen, S.C.; Wesker, W.; Kruitwagen, C.; De Haes, H.C.; Voest, E.E.; De Graeff, A. Symptom prevalence in patients with incurable cancer: A systematic review. J. Pain Symptom Manag. 2007, 34, 94–104. [Google Scholar] [CrossRef]
Variables | Value |
---|---|
Age, mean (standard deviation) | 71.5 (±12.3) |
Sex, n (%) | |
Male | 303 (60.5) |
Female | 198 (39.5) |
Marital status, n (%) | |
Married or with partner | 292 (61.0) |
Widowed | 99 (20.7) |
Divorced/separated | 49 (10.2) |
Single | 39 (8.1) |
Main carer, n (%) | |
Female | 323 (72.9) |
Male | 93 (21.0) |
No carer | 27 (6.1) |
Relationship with carer, n (%) | |
Partner | 167 (37.2) |
Child (son/daughter) | 154 (34.3) |
Agency referring for PC, n (%) | |
Oncology service | 274 (66.5) |
Other specialities | 78 (18.9) |
Primary care | 60 (14.6) |
Primary cancer, n (%) | |
Gastrointestinal | 153 (33.8) |
Lung | 108 (23.8) |
Breast-Gynaecological | 59 (13.0) |
Genito-Urinary | 51 (11.3) |
Head and neck | 24 (5.3) |
Haematological | 21 (4.6) |
Other | 37 (8.2) |
Cancer dissemination, n (%) | |
Metastasis | 365 (76.8) |
Local | 110 (23.2) |
Cancer treatment, n (%) | |
Yes | 322 (66.4) |
No | 163 (33.6) |
Barthel Index, n (%) | |
100 | 62 (13.3) |
≥60 | 188 (40.4) |
40–55 | 115 (24.7) |
20–35 | 55 (11.8) |
≤20 | 45 (9.7) |
PPS, n (%) | |
≥70% | 125 (26.0) |
50–60% | 227 (47.2) |
≤40% | 129 (26.8) |
Most frequent symptoms, n (%) | |
Pain | 259 (52.6) |
Asthenia | 175 (35.6) |
Constipation | 139 (28.3) |
Dyspnoea | 99 (20.1) |
Insomnia | 92 (18.7) |
Anorexia | 69 (14.0) |
Nausea/Vomiting | 66 (13.4) |
Somnolence | 40 (8.1) |
Depression | 36 (7.3) |
Anxiety | 35 (7.1) |
Place of death, n (%) | |
Home | 234 (46.7) |
Public hospital | 148 (29.6) |
Inpatient Unit at Cudeca | 119 (23.7) |
Items of High Complexity | N (%) |
---|---|
The patient is a child or adolescent | 0 (0.0) |
Symptoms difficult to control | 82 (17.3) |
Refractory symptoms | 8 (1.7) |
Urgent situation in the terminal cancer patient | 14 (3.0) |
Last hours/days of life difficult to control | 7 (1.5) |
Clinical situation due to difficult-to-control cancer progression | 53 (11.2) |
Risk of patient committing suicide | 4 (0.8) |
Patient requests the process of death to be hastened | 2 (0.4) |
Patient presents existential distress and/or spiritual suffering | 7 (1.5) |
Absence or insufficiency of family support and/or caregivers | 115 (24.3) |
Family members and/or caregivers not competent to give care | 12 (2.5) |
Dysfunctional family | 6 (1.3) |
Family and/or caregiver burden | 6 (1.3) |
Structural limitations of environment for the patient | 8 (1.7) |
Application of palliative sedation difficult to manage | 0 (0.0) |
Total of patients with at least one item of high complexity | 216 (44.8) |
Items of Complexity | N (%) |
---|---|
The patient is a healthcare professional | 3 (0.6) |
Social-family role performed by the patient | 74 (15.6) |
Previous physical, psychological or sensorial disability | 23 (4.9) |
Recent and/or active addiction problems | 7 (1.5) |
Previous mental illness | 12 (2.5) |
Acute decompensated organ insufficiency in non-oncological terminal patient | 0 (0.0) |
Severe cognitive failure | 23 (4.9) |
Abrupt change in level of functional autonomy | 225 (47.6) |
Presence of difficult-to-control comorbidity | 19 (4.0) |
Severe constitutional syndrome | 62 (13.1) |
Clinical management difficult due to repeated non-compliance with therapy | 15 (3.2) |
Communication conflicts between patient and family | 56 (11.8) |
Communication conflicts between patient and healthcare team | 17 (3.6) |
Inadequate emotional coping by patient | 3 (0.6) |
Complex bereavement | 5 (1.1) |
Difficulty in the indication and/or management of medication | 2 (0.4) |
Difficulty in the indication and/or management of interventions | 1 (0.2) |
Limitations of professional competence to address situations | 0 (0.0) |
Difficulty in managing or acquiring instrumental techniques and/or specific material at home | 3 (0.6) |
Difficulty in managing coordination and logistic needs | 2 (0.4) |
Total of patients with at least one item of complexity | 212 (44.0) |
Independent Variable | OR (95% CI) High Complexity | OR (95% CI) Complexity |
---|---|---|
Age | 0.96 (0.93–0.99) * | 0.98 (0.95–1.01) |
Sex | ||
Female | 1.12 (0.55–2.50) | 1.23 (0.56–2.70) |
Male | 1 | 1 |
Agency referring for PC | ||
Primary care | 2.17 (0.48–9.87) | 1.11 (0.24–5.10) |
Oncology | 1.35 (0.51–3.57) | 1.26 (0.49–3.22) |
Other hospital service | 1 | 1 |
Metastasis | ||
Yes | 1.01 (0.44–2.71) | 1.27 (0.52–3.12) |
No | 1 | 1 |
PPS | ||
PPS < 40% | 10.68 (2.81–40.52) *** | 7.98 (2.11–30.22) ** |
PPS 50–60% | 3.27 (1.45–7.35) ** | 3.58 (1.26–7.90) ** |
PPS > 70% | 1 | 1 |
Pain | ||
Yes | 1.26 (0.59–2.71) | 0.93 (0.44–1.97) |
No | 1 | 1 |
Dyspnoea | ||
Yes | 2.55 (0.82–7.97) | 3.24 (1.06–9.91) * |
No | 1 | 1 |
Asthenia | ||
Yes | 1.14 (0.51–2.53) | 1.18 (5.54–2.61) |
No | 1 | 1 |
© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
Share and Cite
Carrasco-Zafra, M.I.; Gómez-García, R.; Ocaña-Riola, R.; Martín-Roselló, M.L.; Blanco-Reina, E. Level of Palliative Care Complexity in Advanced Cancer Patients: A Multinomial Logistic Analysis. J. Clin. Med. 2020, 9, 1960. https://doi.org/10.3390/jcm9061960
Carrasco-Zafra MI, Gómez-García R, Ocaña-Riola R, Martín-Roselló ML, Blanco-Reina E. Level of Palliative Care Complexity in Advanced Cancer Patients: A Multinomial Logistic Analysis. Journal of Clinical Medicine. 2020; 9(6):1960. https://doi.org/10.3390/jcm9061960
Chicago/Turabian StyleCarrasco-Zafra, Maria Isabel, Rafael Gómez-García, Ricardo Ocaña-Riola, Maria Luisa Martín-Roselló, and Encarnación Blanco-Reina. 2020. "Level of Palliative Care Complexity in Advanced Cancer Patients: A Multinomial Logistic Analysis" Journal of Clinical Medicine 9, no. 6: 1960. https://doi.org/10.3390/jcm9061960