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.

 

17 June 2019

Advance care planning in different settings for people with dementia: A systematic review and narrative synthesis.

Kelly AJ, Luckett T, Clayton JM, Gabb L, Kochovska S, Agar M.

BACKGROUND:
Advance care planning (ACP) is identified as being an important process for people with dementia. However, its efficacy for improving outcomes relevant for the individual, carers and the health system has yet to be established.AimWe conducted a systematic review with the aims of testing the efficacy of ACP for people with dementia and describing the settings and population in which it has been evaluated.

METHODS:
A search was completed of electronic databases in August 2016. Articles were included if they described interventions aimed at increasing planning for future care of people with dementia, delivered to the person with dementia, their carers and/or health professionals.

RESULTS:
Of 4,772 articles returned by searches, 30 met the inclusion criteria, testing interventions in nursing home (n= 16) community (n = 10) and acute care (n = 4) settings. Only 18 interventions directly involved the person with dementia, with the remainder focusing on surrogate decision-makers. In all settings, interventions were found effective in increasing ACP practice. In nursing homes, ACP was found to influence care and increase the concordance between end of life wishes and care provided. Interventions in the community were found to improve patient quality of life but were not shown to influence concordance.

CONCLUSION:
Future research should focus on ways to involve people with dementia in decision-making through supported means.

17 June 2019

A Systematic Review and Meta-Analysis of Prostate Cancer Utility Values of Patients and Partners Between 2007 and 2016.

Magnus A, Isaranuwatchai W, Mihalopoulos C, Brown V, Carter R.

BACKGROUND
There is widespread agreement that both the length and quality of life matter when assessing new technologies and/or models of care in the treatment for cancer patients. Quality of life for partners/carers also matters, particularly for prostate cancer.

PURPOSE
This systematic review aims to provide up-to-date utility values along the prostate cancer care continuum (i.e., from prescreening through to palliative care) for use where future trial-based or modelled economic evaluations cannot collect primary data from men and/or partners.

DATA SOURCES
A protocol was developed and registered on the international register of systematic reviews-PROSPERO. Databases searched included EBSCO Information Services (CINAHL, EconLit, Global Health, HEED, MEDLINE Complete, PsycINFO), Cochrane Database of Systematic Reviews, Web of Science, and Embase.

STUDY SELECTION
Study selection terms included health-related quality of life, prostate cancer, and partners or carers.

DATA EXTRACTION 
The authors identified articles published between 2007 and 2016 that provided health state utility values, with statistical uncertainty, for men with or at risk of prostate cancer and/or their partner/carers.

DATA SYNTHESIS AND RESULTS
Study quality and generalizability of utilities was evaluated and meta-analysis conducted against prespecified criteria. From 906 original articles, 29 recent primary studies met the inclusion/exclusion criteria. We tabulate all the utility values with uncertainty, along with considerable methodological detail and patient population characteristics.

LIMITATIONS
Utility values pertaining to carers/partners were limited to one study.

CONCLUSIONS
Studies varied in design, measurement instruments utilized, quality, and generalizability. There is sufficient qualitative and quantitative detail for the reported utility values to be readily incorporated into economic evaluations. More research is needed with carers/partners and with newly developing prostate cancer-specific quality of life tools.
 

17 June 2019

Consumer and carer leadership in palliative care academia and practice: A systematic review with narrative synthesis.

Scholz B, Bevan A, Georgousopoulou E, Collier A, Mitchell I.

BACKGROUND:
Contemporary health policies call for consumers to be part of all aspects of service planning, implementation, delivery and evaluation. The extent to which consumers are part of the systemic decision-making levels of palliative care appears to vary between and within services and organisations.

AIM:
The aim of this systematic review is to develop understandings about consumer and carer leadership in palliative care.

DESIGN:
A systematic, narrative synthesis approach was adopted due to the heterogeneity of included studies. The review was registered on PROSPERO prospectively (PROSPERO 2018 CRD42018111625).

DATA SOURCES:
PubMed, Scopus and PsycINFO were searched for all studies published in English specifically focusing on consumers' leadership in palliative care organisations and systems. Articles were appraised for quality using a modified JBI-QARI tool.

RESULTS:
Eleven studies met the inclusion criteria and quality assessment. Consumers are currently involved in leadership of palliative care teaching, research and services. Findings highlight the benefits of consumer leadership in palliative care including more relevant, higher-quality services, teaching and research. Across the included studies, it was not clear the extent to which consumer leaders had influence in relation to setting agendas across the palliative care sector.

CONCLUSION:
The findings suggest that more could be done to support consumer leadership within palliative care. Academics and clinicians might improve the relevance of their work if they are able to more meaningfully partner with consumers in systemic roles in palliative care.

KEYWORDS:
Palliative care; caregivers; leadership; patients; systematic review

11 June 2019

RedUSe: reducing antipsychotic and benzodiazepine prescribing in residential aged care facilities.

Westbury JL, Gee P, Ling T, Brown DT, Franks KH, Bindoff I, Bindoff A, Peterson GM.

OBJECTIVE:
To assess the impact of a multi-strategic, interdisciplinary intervention on antipsychotic and benzodiazepine prescribing in residential aged care facilities (RACFs). Design, setting: Prospective, longitudinal intervention in Australian RACFs, April 2014 - March 2016.

PARTICIPANTS:
150 RACFs (with 12 157 residents) comprised the main participant group; two further groups were consultant pharmacists (staff education) and community pharmacies (prescribing data). Data for all RACF residents, excluding residents receiving respite or end-stage palliative care, were included.

INTERVENTION:
A multi-strategic program comprising psychotropic medication audit and feedback, staff education, and interdisciplinary case review at baseline and 3 months; final audit at 6 months.

MAIN OUTCOME MEASURE:
Mean prevalence of regular antipsychotic and benzodiazepine prescribing at baseline, and at 3 and 6 months. Secondary measures: chlorpromazine and diazepam equivalent doses/day/resident; proportions of residents for whom drug was ceased or the dose reduced; prevalence of antidepressant and prn (as required) psychotropic prescribing (to detect any substitution practice).

RESULTS:
During the 6-month intervention, the proportion of residents prescribed antipsychotics declined by 13% (from 21.6% [95% CI, 20.4-22.9%] to 18.9% [95% CI, 17.7-20.1%]), and that of residents regularly prescribed benzodiazepines by 21% (from 22.2% [95% CI, 21.0-23.5%] to 17.6% [95% CI, 16.5-18.7]; each, P < 0.001). Mean chlorpromazine equivalent dose declined from 22.9 mg/resident/day (95% CI, 19.8-26.0) to 20.2 mg/resident/day (95% CI, 17.5-22.9; P < 0.001); mean diazepam equivalent dose declined from 1.4 mg/resident/day (95% CI, 1.3-1.5) to 1.1 mg/resident/day (95% CI, 0.9-1.2; P < 0.001). For 39% of residents prescribed antipsychotics and benzodiazepines at baseline, these agents had been ceased or their doses reduced by 6 months. There was no substitution by sedating antidepressants or prn prescribing of other psychotropic agents.

CONCLUSIONS:
The RedUSe program achieved significant reductions in the proportions of RACF residents prescribed antipsychotics and benzodiazepines.

TRIAL REGISTRATION:
Australian New Zealand Clinical Trials, ACTRN12617001257358.

3 June 2019

Differing Approaches to Managing the Chronic Breathlessness Syndrome in Advanced COPD: A Multi-National Survey of Specialists.

Smallwood N, Currow D, Booth S, Spathis A, Irving L, Philip J.

This study explored the approaches of respiratory and palliative medicine specialists to managing the chronic breathlessness syndrome in patients with severe chronic obstructive pulmonary disease.

A voluntary, online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom (UK). Five hundred and seventy-seven (33.0%) responses were received from 1,749 specialists, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors.

Palliative medicine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness, whereas respiratory and palliative medicine doctors had significantly different approaches (p < 0.0001). Both specialties most commonly recommended a combination of non-pharmacological and pharmacological breathlessness management strategies. Respiratory doctors focussed more on pulmonary rehabilitation, whereas palliative medicine doctors recommended breathing techniques, anxiety management and the handheld fan. Palliative medicine doctors (197 (74.9%)) recommended short acting oral morphine for breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001). Respiratory doctors cited opioid concerns related to respiratory depression and lack of knowledge. Nineteen (10.7%) respiratory doctors made no specific recommendations for managing chronic breathlessness. Both specialties reported actively managing chronic breathlessness, albeit with differing approaches.

Integrated services, which combine the complementary knowledge and approaches of both specialities, may overcome current gaps in care and improve the management of distressing, chronic breathlessness.

3 June 2019

Timing of palliative care referral and aggressive cancer care toward the end-of-life in pancreatic cancer: a retrospective, single-center observational study.

Michael N, Beale G, O'Callaghan C, Melia A, DeSilva W, Costa D, Kissane D, Shapiro J, Hiscock R.

BACKGROUND:
Pancreatic cancer is noted for its late presentation at diagnosis, limited prognosis and physical and psychosocial symptom burden. This study examined associations between timing of palliative care referral (PCR) and aggressive cancer care received by pancreatic cancer patients in the last 30 days of life through a single health service.

METHOD:
A retrospective cohort analysis of end-of-life (EOL) care outcomes of patients with pancreatic cancer who died between 2012 and 2016. Key indicators of aggressive cancer care in the last 30 days of life used were: ≥1 emergency department (ED) presentations, acute inpatient/intensive care unit (ICU) admission, and chemotherapy use. We examined time from PCR to death and place of death. Early and late PCR were defined as > 90 and ≤ 90 days before death respectively.

RESULTS:
Out of the 278 eligible deaths, 187 (67.3%) were categorized as receiving a late PCR and 91 (32.7%) an early PCR. The median time between referral and death was 48 days. Compared to those receiving early PCR, those with late PCR had: 18.1% (95% CI 6.8-29.4%) more ED presentations; 12.5% (95% CI 1.7-24.8%) more acute hospital admissions; with no differences in ICU admissions. Pain and complications of cancer accounted for the majority of overall ED presentations. Of the 166 patients who received chemotherapy within 30 days of death, 23 (24.5%) had a late PCR and 12 (16.7%) an early PCR, with no association of PCR status either unadjusted or adjusted for age or gender. The majority of patients (55.8%) died at the inpatient palliative care unit.

CONCLUSION:
Our findings reaffirm the benefits of early PCR for pancreatic cancer patients to avoid inappropriate care toward the EOL. We suggest that in modern cancer care, there can sometimes be a need to reconsider the use of the term 'aggressive cancer care' at the EOL when the care is appropriately based on an individual patient's presenting physical and psychosocial needs. Pancreatic cancer patients warrant early PCR but the debate must thus continue as to how we best achieve and benchmark outcomes that are compatible with patient and family needs and healthcare priorities.

3 June 2019

Palliative Care: A Systematic Review of Evidence-Based Interventions.

Riahi S, Khajehei M.

The authors conducted an integrative review to determine evidence-based and most efficient strategies for improving the palliative care of patients at the end-of-life stage. Thirteen articles that met the overall inclusion criteria were evaluated. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart approach was used for the screening process. The Critical Appraisal Skill Program and the Mixed-Methods Appraisal Tool were also used for the critical appraisal of the data. Full reports of relevant articles were retrieved, and data were extracted by 2 reviewers independently. The quality of studies was appraised in reference to Consolidated Criteria for Reporting Qualitative Research guidelines. Key aspects included communication and coordination among the team members-patient-centered approach. The major theme was the application of a holistic approach to palliative care consisting of providing comfort to the dying patient. It was identified that relationships, which were identified as spiritual needs, are also crucial to the improvement of palliative care. Improving nursing education in this area, undertaking appropriate curriculum development, and providing coordination among training programs will help knowledgeable health care providers deliver compassionate, affordable, sustainable, and high-quality care to a growing population of aging patients facing the end of their lives.

27 May 2019

Harms from haloperidol for symptom management in palliative care; a post hoc pooled analysis of three randomized controlled studies and two consecutive cohort studies.

Matsuoka H, Agar M, Vandersman Z, Good P, Fazekas B, Brown L, Janet H, Weil J, Currow DC.

(Excerpt) Symptom control for people with cancer improves quality of life. Haloperidol is a key drug in palliative care and is frequently used for the treatment of delirium, nausea and vomiting.[1] Haloperidol, a butyrophenone, is a more potent D2 receptor antagonist than other antiemetics such as prochlorperazine, olanzapine or chlorpromazine.

The adverse events associated with haloperidol are like those of the phenothiazines, except that haloperidol potentially causes less sedation and hypotension. However, haloperidol is more strongly associated with extrapyramidal symptoms especially compared with newer drugs such as quetiapine or risperidone, and patients with Parkinson disease or Lewy body dementia may be more sensitive to its adverse events.[2] Haloperidol is inexpensive and has several routes of administration. Only a few studies focus on patients with life-limiting illnesses. The aim of this study was to determine whether the doses of haloperidol used in palliative care cause immediate and short-term harms and, if so, what is their severity?

27 May 2019

Novel application of discrete choice experiment methodology to understand how clinicians around the world triage palliative care needs: A research protocol.

Russell B, Vogrin S, Philip J, Hennessy-Anderson N, Collins A, Burchell J, Le B, Brand C, Hudson P, Sundararajan V.

OBJECTIVE:
As referrals to specialist palliative care (PC) grow in volume and diversity, an evidence-based triage method is needed to enable services to manage waiting lists in a transparent, efficient, and equitable manner. Discrete choice experiments (DCEs) have not to date been used among PC clinicians, but may serve as a rigorous and efficient method to explore and inform the complex decision-making involved in PC triage. This article presents the protocol for a novel application of an international DCE as part of a mixed-method research program, ultimately aiming to develop a clinical decision-making tool for PC triage.

METHOD:
Five stages of protocol development were undertaken: (1) identification of attributes of interest; (2) creation and (3) execution of a pilot DCE; and (4) refinement and (5) planned execution of the final DCE.

RESULT:
Six attributes of interest to PC triage were identified and included in a DCE that was piloted with 10 palliative care practitioners. The pilot was found to be feasible, with an acceptable cognitive burden, but refinements were made, including the creation of an additional attribute to allow independent analysis of concepts involved. Strategies for recruitment, data collection, analysis, and modeling were confirmed for the final planned DCE.

SIGNIFICANCE OF RESULTS:
This DCE protocol serves as an example of how the sophisticated DCE methodology can be applied to health services research in PC. Discussion of key elements that improved the utility, integrity, and feasibility of the DCE provide valuable insights.

27 May 2019

Meaning and Purpose (MaP) therapy II: Feasibility and acceptability from a pilot study in advanced cancer.

Kissane DW, Lethborg C, Brooker J, Hempton C, Burney S, Michael N, Staples M, Osicka T, Sulistio M, Shapiro J, Hiscock H.

OBJECTIVE:
Meaning and Purpose (MaP) therapy aims to enhance meaning-based coping through a life review that focuses on the value and worth of the person, key relationships, sources of fulfillment, roles, and future priorities in living life out fully. We sought to test the feasibility and acceptability of a six-session model of MaP therapy against a wait-list control cohort in a pilot study seeking effect sizes on measures of adaptation.

METHOD:
We randomized patients with advanced cancer to MaP therapy or wait-list control, with measures administered at baseline and after 6-8 weeks. Wait-list patients could then crossover to receive therapy, with further measures collected postintervention. Adherence to the manualized model was sustained through weekly supervision and fidelity coding of recorded sessions. We used generalized estimating equations to control for baseline and any correlation of data.

RESULT:
From 134 eligible participants, 57 (43%) consented, and 40 of 45 (89%) offered therapy completed 6 sessions. Key barriers to consenting patients were poor health (15 refusers and 4 withdrawals) and death intervened in 6 participants. MaP therapy generated adequate effect sizes in posttraumatic growth (new possibilities, appreciation of life, and personal strength) and life attitudes (choices and goal seeking) to permit calculation of power for a formal randomized, controlled trial.

SIGNIFICANCE OF RESULTS:
Delivery of this model of existentially oriented therapy is feasible and acceptable to patients. A properly powered randomized controlled trial is justified to examine the efficacy of this intervention.

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