Latest Australian Research

The following lists palliative care research primarily conducted by Australian research groups. The list is based on application of the CareSearch search filter for palliative care to identify articles held within the PubMed database and corresponding to the strongest evidence. Articles have been selected based on relevance and new articles are added on a weekly basis.

Whilst not an exhaustive list, the aim is to keep the community informed by providing a snapshot of recent research findings and planned studies in the Australian setting.

 

13 July 2020

The Compassionate Communities Connectors model for end-of-life care: a community and health service partnership in Western Australia

Aoun SM, Abel J, Rumbold B, Cross K, Moore J, Skeers P, Deliens L.

Background:
There is an international drive towards increasing provision of community-led models of social and practical support for people living with advanced illness.

Aim:
This feasibility project aims to develop, implement and evaluate a model of community volunteers, identified as Compassionate Communities Connectors, to support people living with advanced life limiting illnesses/palliative care needs. The aims also include the development and evaluation of a training programme for volunteers and assessment of the feasibility, acceptability and preliminary effectiveness of this model of care.

Methods:
The approach seeks to map and mobilise people’s personal networks of care through the Connectors enlisting Caring Helpers (community volunteers). Up to 10 Connectors will be trained to work with at least 30 families selected by the palliative care service as requiring support. The primary outcome is the effect of the intervention on social connectedness. Secondary outcomes are the intervention’s effect on unplanned hospital utilisation, caregiver support needs, advance care plans and satisfaction with intervention for patients/carers, volunteers and service providers.

Conclusion:
It is expected that this intervention will enhance patient, carer and family social, psychological and practical support and reduce the need for dying people to be admitted to a hospital.

13 July 2020

The Role of Methadone in Cancer-Induced Bone Pain: A Retrospective Cohort Study

Sulistio M, Wojnar R, Key S, Kwok J, Al-Rubaie Z, Michael N.

Purpose:
Cancer-induced bone pain (CIBP) can be challenging to manage in advanced cancer. The unique properties of methadone may have a role in refractory CIBP. We aimed to evaluate the analgesic effects of methadone for CIBP when other opioids are ineffective or intolerable.

Methods:
A retrospective study of palliative care inpatients rotated to methadone from another opioid for CIBP over a 4-year period. Primary outcome was ≥ 30% reduction in pain intensity (11-point numeric rating scale) from baseline to completion of methadone rotation (MR). Secondary outcomes were ≥ 50% reduction in pain intensity and changes in long-acting and breakthrough opioid requirements.

Results:
Ninety-four eligible patients completed MR for the following reasons: poor pain control (72.3%), opioid toxicities (4.3%) or both (23.4%). On completion of MR, 70.2% and 53.2% achieved a ≥ 30% and ≥ 50% reduction in pain respectively, with mean pain intensity score reduced from 5.6 (SD = 2.1) at baseline to 2.6 (SD = 2.5) (p < 0.001). Mean calculated daily methadone dose pre-MR was 25.7 mg (SD = 10.9), with 72.3% of patients requiring a lower dose on completion of MR (mean 17.0 mg, SD = 8.5). The mean number of breakthrough opioid analgesia used a day reduced from 3.4 (SD = 2.3) to 1.8 (SD = 1.7) (p < 0.001).

Conclusions:
MR for CIBP may result in reduction in pain intensity, when other opioids are ineffective or intolerable, with patients requiring reduced overall dosing of their long-acting opioid and frequency of breakthrough opioid use.

13 July 2020

Palliative Care in Hepatocellular Carcinoma

Laube R, Sabih AH, Strasser SI, Lim L, Cigolini M, Liu K.

Hepatocellular carcinoma is a common cancer with a poor prognosis, associated with high economic costs and a significant burden of disease. While it is often asymptomatic in the early stages, patients may experience great discomfort from advanced disease, treatment adverse effects or decompensation of underlying cirrhosis. Palliative care has the potential to markedly improve quality of life, physical and psychological symptoms in patients with end-stage liver disease, and has been shown to prolong survival in some non-hepatocellular carcinoma malignancies. However, this service is underutilized in hepatocellular carcinoma and referrals are frequently late due to factors such as stigmatization, inadequate resources, lack of education for non-palliative care physicians and inadequate modelling for integration of palliative and supportive care within liver disease services. In the future, education workshops, population-based awareness campaigns, increased funding and improved models of care, may improve the uptake of palliative care and subsequently optimize patient care, particularly towards the end of life.

13 July 2020

Health Economic and Health Service Issues of Palliative Radiotherapy

Barton M, Batumalai V, Spencer K.

Palliative radiotherapy (PRT) makes up about half of all courses delivered in radiotherapy departments. It is effective in the management of common complications of cancer and is relatively inexpensive. About one third of cancer patients receive PRT within the last 2 years of life. One quarter of all patients who receive radiotherapy will undergo a second or subsequent course, mostly for palliative indications. There is considerable variation in practice, both within and between jurisdictions. This has been attributed to inconsistencies in guidelines, physician variation and differing financial incentives. Because of the widespread use of hypofractionation, variation in PRT fractionation has a lower effect on departmental capacity than variation in radical and adjuvant treatments. Excessive fractionation places an unnecessary burden on frail patients at the end of their lives and uses scarce healthcare resources. With appropriate case selection, the increased cost of fractionation or more conformal treatments can be justified where clinical benefit is expected.

13 July 2020

Initiating Tuberculosis Treatment at End of Life - Balancing Patient and Infection Control Interests

Stewart AG, Wright H.

13 July 2020

Elective Withdrawal of Non-Invasive Ventilation in Motor Neuron Disease: A Neuropalliative Care Perspective

Runacres FI, Hearn R, Howe J, Mathers S.

13 July 2020

Patients With Fibrotic Interstitial Lung Disease Receive Supportive and Palliative Care Just Prior to Death

Smallwood N, Mann J, Guo H, Goh N.

Background:
Fibrotic interstitial lung diseases (f-ILDs) are often progressive and incurable. As patients experience significant symptoms and have a poor prognosis, early palliative care referral is recommended.

Objective:
To examine the care delivered to patients with f-ILD during the terminal hospital admission and the past 2 years of life.

Methods:
A retrospective audit was performed for consecutive patients who died from f-ILD at 2 Australian teaching hospitals between January 1, 2012, and December 31, 2016.

Results:
Of 67 patients, 44 (66%) had idiopathic pulmonary fibrosis. Median age was 78 years. Median respiratory function: forced expiratory volume in 1 second 69.0% predicted (interquartile range [IQR]: 58.0%-77.0%), forced vital capacity 64.0% predicted (IQR = 46.8%-74.3%), and diffusing capacity of carbon monoxide 36.0% predicted (IQR = 31.0%-44.0%). In the 2 years prior to the terminal admission, 38 (57%) patients reported severe breathlessness and 17 (25%) used opioids for symptom relief. Twenty-four (36%) patients received specialist palliative care (SPC) and 11 (16%) completed advance care planning. During the terminal admission, 10 (15%) patients were admitted directly under SPC. A further 33 (49%) patients were referred to SPC, on average 1 day prior to death. Sixty-three (94%) patients received opioids and 49 (73%) received benzodiazepines for symptom management. Median starting and final opioid doses were 10 and 23 mg oral morphine equivalent/24 hours, respectively. Opioids were commenced on average 2 (IQR 1-3) days prior to death.

Conclusions:
Although most patients were identified as actively dying in the final admission, referral to SPC and use of palliative medications occurred late. Additionally, few patients accessed symptom palliation earlier in their illness.

13 July 2020

Clinicians' Accounts of Communication With Patients in End-Of-Life Care Contexts: A Systematic Review

Scholz B, Goncharov L, Emmerich N, Lu VN, Chapman M, Clark SJ, Wilson T, Slade D, Mitchell I. 

Objective:
Communication between patients and end-of-life care providers requires sensitivity given the context and complexity involved. This systematic review uses a narrative approach to synthesise clinicians' understandings of communication in end-of-life care.

Methods:
A systematic, narrative synthesis approach was adopted given the heterogeneity across the 83 included studies. The review was registered prospectively on PROSPERO (ID: CRD42019125155). Medline was searched for all articles catalogued with the MeSH terms "palliative care," "terminal care" or "end-of-life care," and "communication". Articles were assessed for quality using a modified JQI-QARI tool.

Results:

The findings highlight the centrality and complexity of communication in end-of-life care. The challenges identified by clinicians in relation to such communication include the development of skills necessary, complexity of interpersonal interactions, and ways in which organisational factors impact upon communication. Clinicians are also aware of the need to develop strategies for interdisciplinary teams to improve communication.

Conclusion:
Training needs for effective communication in end-of-life contexts are not currently being met.

Practice implications:
Clinicians need more training to address the lack of skills to overcome interactional difficulties. Attention is also needed to address issues in the organisational contexts in which such communication occurs.

9 July 2020

Oral Medicinal Cannabinoids to Relieve Symptom Burden in the Palliative Care of Patients With Advanced Cancer: A Double-Blind, Placebo-Controlled, Randomised Clinical Trial of Efficacy and Safety of 1

Hardy J, Haywood A, Gogna G, Martin J, Yates P, Greer R, Good P.

Background:
Despite improvements in medical care, patients with advanced cancer still experience substantial symptom distress. There is increasing interest in the use of medicinal cannabinoids but little high-quality evidence to guide clinicians. This study aims to define the role of a 1:1 delta-9-tetrahydrocannabinol/cannabidiol (THC/CBD) cannabinoid preparation in the management of symptom burden in patients with advanced cancer undergoing standard palliative care.

Methods and design:
One hundred fifty participants will be recruited from five sites within the Queensland Palliative Care Research Group (QPCRG) and randomly assigned to an active treatment or placebo group. This study is a pragmatic multicentre, randomised, placebo-controlled, two-arm trial of escalating doses of an oral 1:1 THC/CBD cannabinoid preparation. It will compare efficacy and safety outcomes of a titrated dose (10 mg/10 mg/mL oral solution formulation, dose range 2.5 mg/2.5 mg-30 mg/30 mg/day) against placebo. There is a 2-week patient-determined titration phase, using escalating doses of 1:1 THC/CBD or placebo, to reach a dose that achieves symptom relief with tolerable side effects. This is then followed by a further 2-week assessment period on the stable dose determined in collaboration with clinicians. The primary objective is to assess the effect of escalating doses of a 1:1 THC/CBD cannabinoid preparation against placebo on change in total symptom score, with secondary objectives including establishing a patient-determined effective dose, the change in total physical and emotional sores, global impression of change, anxiety and depression, opioid use, quality of life and adverse effects.

Discussion:
This will be the first placebo-controlled clinical trial to rigorously evaluate the efficacy, safety and acceptability of 1:1 THC/CBD for symptom relief in advanced cancer patients. This study will allow the medical community to have some evidence to present to patients wishing to access cannabis for their symptoms caused by advanced malignancy.

29 June 2020

Extended-hours Palliative Care Service With a Hospital-Avoidance and Enhanced-Care Approach: Report of a Quality Improvement Project

Keall R, Lovell M

Background:
A community palliative care service (CPCS) identified its after-hours support as sub-optimal in avoiding acute hospitalisation and supporting patients to remain at home. It created and conducted a pilot of an extended hours palliative care service (EHPCS) using current resources.

Aims:
To evaluate the efficacy of an extended hours palliative care service pilot.

Methods:
Retrospective chart review of after-hours calls taken before the trial, usual care, was undertaken. During the trial, quantitative data was gathered of the outcome of each after-hours call, including outcomes of occasion of service, reason for and length and times of calls.

Findings:
The extended hours palliative care service, compared with usual care, showed an almost 50% decrease in acute hospitalisation, nearly doubled after-hours palliative care unit admission and a 17% increase in patients staying in their home. EHPCS was positively received by CPCS staff, despite cost and workforce impact.

Conclusions:
EHPCS can positively impact on reducing avoidable hospitalisations and facilitate palliative care patients to be in their preferred place of care.

12345