“Towards Integration of Palliative Care in Patients with Chronic Heart Failure and Chronic Obstructive

Pulmonary Disease: A Systematic Literature Review”.

Siouta N, Van Beek K, Hughes S, Preston N, van der Eerden M, Groot M, Garralda E, Hodiamont F, Dybek E, Busa C, Kiss Z, Ildiko R, Zsuzsanna Kiss, Payne S, Hasselaar J, Centeno C, Benjamin Ewert, Radbruch L, Csikoska A, Jelle van Gurp, Juliano Ferreira Arcuri, Menten J.

On behalf of the FP7-Insup C consortium

Naouma Siouta, BA, M.Sc.University Hospital Leuven, BelgiumE-mail: naouma.siouta@ppw.kuleuven.be

Abstract number:FC07.2

InSup-C

Lancaster

Leuven

Nijmegen, Rotterdam

Bonn

Pecs

Pamplona

Aim

•How to measure integration of PC in COPD and CHF?•Guidelines and pathways offer a concrete framework for identifying current practices, their advantages and their deficiencies.

Aim: identify existing guidelines and pathways of integrated PC for people with CHF and COPD via a systematic review.

Search Strategy

• Cochrane, PubMed, EMBASE, CINAHL, AMED, BNI, Web of Science, NHS Evidence, National Guidelines Clearinghouse.

• Hand search journals: BMJ Supportive & Palliative care, European Journal of Palliative Care, Journal of Pain and Symptom Management, Palliative Medicine, Medicina Paliativa.

• Citation and reference tracking.

• Grey literature search.

Inclusion Criteria

• Studies published 1995-2013.• English, French, German, Dutch, Hungarian or

Spanish.• Patients ≥18 y old, with CHF or COPD.• Completeness of the content of integrated PC

was measured with a tool based on Emanuel’s integrated palliative care (IPC) criteria.

Selection, extraction and analysis: PRISMA guidelines

Integrated Palliative Care (IPC) Criteria

1. Discussion of illness limitations and prognosis.2. Holistic patient assessment (physical, social, psychological,

and spiritual issues).3. Recommendations on when to make these assessments.4. Recommendations on when palliative care should be

integrated.5. Assessment of the patient’s goals for care.6. Continuous goal adjustment as the illness progresses.7. Palliative care interventions to reduce suffering. 8. Advance care planning (ACP).9. Recommendation of involving a palliative care team.10. Recommendations on care during the last hours of living.11. Recommendations on grief and bereavement care.

Evidence Quality Assessment

High QualityEvidence

Medium QualityEvidence

Low QualityEvidence

Very Low QualityEvidence

systematic reviews and consensus methods (e.g. nominal group techniques, Delphi rounds, expert consultations) or those developed by following the NICE protocol.

systematic reviews only or based on other types of well referenced evidence.

consensus methods only.

unclear (e.g. apparently evidence based but failing to clarify how this was obtained).

4 Likert scale tool created by the InSup-C consortium

Records identified through database searching

(n = 28,277)

Records after duplicates removed (n =26256)

Records excluded by title (n =25,259)

Records included by title (n =997)

Additional records identified through grey literature (n=3,021)

Full-text articles excluded (n =798)

Full-text screened records assessed for eligibility (n =199)

Studies included in qualitative synthesis n = 55

Iden

tifica

tion

Scre

enin

g El

igib

ility

In

clude

d RESULTS

Results- IPC Criteria

60%

74,5%

34,5%

54,5%

71%

44%

67%71% 70%

60%53%

0%

10%

20%

30%

40%

50%

60%

70%

80%

Emanuel’s Integrated Palliative Care Criteria

Perc

enta

ges o

f gui

delin

es/

path

way

s

Referral Criteria

9%

13.00%

7.00%

11.00%

14.50%

2.00%

0%

2%

4%

6%

8%

10%

12%

14%

16%

Terminally ill <6 months Surprisequestion

GSF (III/IV inthe NYHA)

Diagnosis orASAP

Family andpatient needs

Perc

enta

ges o

f gui

delin

es/

path

way

s

Quality Assessment of the Evidence

11%

47%

7%

34.50%

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

Very low Low Medium High

Perc

enta

ges o

f gui

delin

es/

path

way

s

Top 6 guidelines/pathways

“6/55 guidelines/pathways fulfilled at least 10 out of 11 IPC Criteria”

Top 6 guidelines/pathways IPC Criteria

1. Discussion of illness limitations and prognosis:• open communication with patient and family, based on their needs, • surprise question• Palliative Performance Scale

2. Holistic assessment: unanimous consensus on the physical, psychological, social and spiritual assessment.

3. Timing of the holistic assessments:• “at any time of day or night” • vary depending on changes in the disease • application of e.g. a ‘distress thermometer’ • collaboration of the clinicians in order to identify indicators and

triggers of when to assess patient’s PC needs.

Top 6 guidelines/pathways IPC Criteria

4. Exact timing of introducing PC:• surprise question• evaluation of the patient’s and the family’s needs• disease prognostic indicators (e.g. III/ IV NYHA stages, Gold

stage IV)

5. Patient’s goals assessments: continuous communication between the patient and the PC specialists to identify patient goals.

6. Continuous goal adjustment: PC specialists should regularly consult the patient and adjust goals accordingly.

Top 6 guidelines/pathways IPC Criteria

7. Suffering reduction: use of timely and appropriate medication and strategies for reducing both physical and psychological suffering.

8. Advance care planning (ACP): should be based on patient’s wishes and preferences.

9. Involvement of PC team: multidisciplinarity!• physicians• nurses • other health professionals (psychologists, mental health

counsellors, social workers, spiritual counsellors)

Top 6 guidelines/pathways IPC Criteria

10. Care during the last hours of living: • identification of the dying phase• communication• support based on patients and family’s needs and wishes • symptom control• available care 24 hours a day

11. Grief and bereavement care: immediate and ongoing bereavement, emotional and spiritual support appropriate to the family’s needs and preferences.

Remark:

“A perfectly developed guideline/ pathway that scores highly in IPC criteria

does not mean that it will have automatically the same high-quality

in its clinical implementation”

Conclusions• The majority of the studies highlight the importance of:

I. holistic approach, II. reduction of suffering, III. assessment of the patients’ goals of care,IV. advanced care planning,V. involvement of a PC team.

• Discrepancies concerning the referral criteria hint that the implementation aspects are obscure.

Suggestion: Top 6 guidelines/pathways scored 10/11 in IPC criteria: benchmarks for future IPC guidelines/pathways!

Top 6 References• Van den Eynden B et al. Palliative care pathway in General Practice;

2012. (score: 11/11)• National Institute for Health and Care Excellence. Services for

people with chronic obstructive pulmonary disease CMG43; 2011. (score: 11/11)

• Scottish Partnership for Palliative Care. Living and dying with advanced heart failure: a palliative care approach; 2008. (score: 10/11)

• Arrieta Ayestarán M et al. Guía de Práctica Clínica sobre CuidadosPaliativos; 2008. (score: 10/11)

• National Institute for Health and Care Excellence. CMG42 End of life care for adults; 2011. (score: 11/11)

• Royal College of General Practitioners and Royal College of Nursing. Matters of life and death: helping people to live well until they die. General practice guidance for implementing the RCGP/RCN end of life care patient charter; 2012. (score: 11/11)

Thank you!