Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and Operation of an Innovative Care Delivery Model
Tóm tắt
Early access to cancer palliative care is recommended. Descriptions of structures and processes of outpatient palliative care clinics operated within smaller hospitals are scarce. This paper presents the development and operation of a fully integrated cancer and palliative care outpatient clinic at a local hospital in a rural region of Mid-Norway offering palliative care concurrent with cancer treatment. A standardized care pathway was applied. Palliative care is in Norway part of the public healthcare system. Official recommendations recent years point out action points to improve delivery of palliative care. An integrated cancer and palliative care outpatient clinic at a local hospital and an innovative care delivery model was developed and operated in this setting. Patients were recruited for a descriptive study of the patient population. Clinical data were collected by clinical staff and 13 symptom intensities were reported by the patients. Cancer and palliative care were provided by one team of healthcare professionals trained in both fields. There was a close collaboration with the other departments at the hospital, with its affiliated tertiary hospital, and with community health and care services to provide timely referral, enhanced continuity, and improved coordination of care. Eighty-eight patients were included. Mean age was 65.6 years, the most common cancer diagnoses were digestive organs (22.7%), male genital organs (20.5%) or breast (25.0%), 75.0% had metastatic or locally advanced cancer, 59.1% were treated with non-curative intention and 93.1% had Karnofsky Performance Status ≥ 80%. Median scores of individual symptoms ranged from 0 to 3 (numerical rating scale, 0–10) and 61.0% reported at least one clinically significant symptom rating (≥ 4). This delivery model of integrated outpatient cancer and palliative care is particularly relevant in rural regions allowing cancer patients access to palliative care earlier in the disease trajectory and closer to home Palliative care is an important part of cancer care which aims at improving cancer patients’ symptom burden and quality of life and support their carers. Palliative care has traditionally been separated from cancer care. During the last decade, one has become aware of the benefits of introducing palliative care early and concurrent with cancer treatment. Most cancer patients are nowadays treated as outpatients. Availability of palliative care as a routine part of outpatient cancer clinics is therefore important. Most of the described models of early palliative care in cancer care are within large tertiary hospitals. Here it is described how early palliative care was delivered to cancer patients in an outpatient clinic in a smaller hospital in a rural region of Mid-Norway. In this integrated cancer and palliative care outpatient clinic, cancer and palliative care were provided by one team of healthcare professionals trained in both fields. The integrated outpatient clinic collaborated closely with the other hospital departments and with community health and care services. This was needed to be able to offer palliative care to all cancer patients in need of it, and closer to their home. Many of the patients attending the integrated outpatient clinic could not be cured for their cancer. They did not have many symptoms of their cancer, and they had a high functional status. This demonstrated that the integrated outpatient clinic in this local hospital was a relevant place to offer palliative care early and concurrent with cancer treatment before symptoms became severe.
Tài liệu tham khảo
World Health Organization. WHO Definition of Palliative Care: WHO. http://www.who.int/cancer/palliative/definition/en/. Accessed 4 Apr 2019.
Kaasa S, Loge JH, Aapro M, et al. Integration of oncology and palliative care: a Lancet Oncology Commission. Lancet Oncol. 2018;19(11):e588–653.
World Health Organization. WHA58.22 Resolution on Cancer Control: World Health Organization; 2005. http://www.who.int/cancer/eb1143/en/. Accessed 20 Sept 2019.
Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. Br Med J. 2005;330(7498):1007–11.
Hui D, Elsayem A, De la Cruz M, et al. Availability and integration of palliative care at US cancer centers. JAMA. 2010;303(11):1054–61.
Bakitas M, Lyons KD, Hegel MT, 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(7):741–9.
Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733–42.
Zimmermann C, Swami N, Krzyzanowska M, et al. Early palliative care for patients with advanced cancer: a cluster-randomised controlled trial. Lancet. 2014;383(9930):1721–30.
Hannon B, Swami N, Rodin G, Pope A, Zimmermann C. Experiences of patients and caregivers with early palliative care: a qualitative study. Palliat Med. 2017;31(1):72–81.
Vanbutsele G, Pardon K, Van Belle S, et al. Effect of early and systematic integration of palliative care in patients with advanced cancer: a randomised controlled trial. Lancet Oncol. 2018;19(3):394–404.
Hui D, Kim SH, Roquemore J, Dev R, Chisholm G, Bruera E. Impact of timing and setting of palliative care referral on quality of end-of-life care in cancer patients. Cancer. 2014;120(11):1743–9.
Gotfrit J, Jonker C, Zhang T, et al. Inpatients versus outpatients with advanced non-small cell lung cancer: characteristics and outcomes. Cancer Treat Res Commun. 2019;19:100130.
Hannon B, Swami N, Pope A, et al. The oncology palliative care clinic at the Princess Margaret Cancer Centre: an early intervention model for patients with advanced cancer. Support Care Cancer. 2015;23(4):1073–80.
Rocque GB, Mullvain JA, Eickhoff J, Cleary JF, Campbell TC. Integrating palliative care into the oncology clinic: a joint management approach. Palliat Med. 2016;30(5):510–2.
Blackhall LJ, Read P, Stukenborg G, et al. CARE track for advanced cancer: impact and timing of an outpatient palliative care clinic. J Palliat Med. 2016;19(1):57–63.
Strasser F, Sweeney C, Willey J, Benisch-Tolley S, Palmer JL, Bruera E. Impact of a half-day multidisciplinary symptom control and palliative care outpatient clinic in a comprehensive cancer center on recommendations, symptom intensity, and patient satisfaction: a retrospective descriptive study. J Pain Symptom Manag. 2004;27(6):481–91.
Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661–8.
Rabow MW, Smith AK, Braun JL, Weissman DE. Outpatient palliative care practices. Arch Intern Med. 2010;170(7):654–5.
Stjernsward J. Palliative care: the public health strategy. J Public Health Policy. 2007;28(1):42–55.
Jordhoy MS, Fayers P, Saltnes T, Ahlner-Elmqvist M, Jannert M, Kaasa S. A palliative-care intervention and death at home: a cluster randomised trial. Lancet. 2000;356(9233):888–93.
Morita T, Miyashita M, Yamagishi A, et al. Effects of a programme of interventions on regional comprehensive palliative care for patients with cancer: a mixed-methods study. Lancet Oncol. 2013;14(7):638–46.
Holmenlund K, Sjogren P, Nordly M. Specialized palliative care in advanced cancer: what is the efficacy? A systematic review. Palliat Support Care. 2017;15(6):724–40.
Hui D, Bruera E. Models of integration of oncology and palliative care. Ann Palliat Med. 2015;4(3):89–98.
European Pathway Association. Care Pathways. http://e-p-a.org/care-pathways/. Accessed 29 Feb 2020.
Rotter T, Kinsman L, James E, Machotta A, Steyerberg EW. The quality of the evidence base for clinical pathway effectiveness: room for improvement in the design of evaluation trials. BMC Med Res Methodol. 2012;12:80.
Collins A, Sundararajan V, Burchell J, et al. Transition points for the routine integration of palliative care in patients with advanced cancer. J Pain Symptom Manag. 2018;56(2):185–94.
Ringard Å, Sagan A, Sperre Saunes I, Lindahl A. Norway: health system review. Health Syst Transit. 2013;15(8):1–162.
The Norwegian Directorate of Health. Fastlegestatistikk (In Norwegian) 2019 [updated 30.04.19. https://www.helsedirektoratet.no/statistikk/statistikk/fastlegestatistikk. Accessed 8 Oct 2019.
Kaasa S, Jordhoy MS, Haugen DF. Palliative care in Norway: a national public health model. J Pain Symptom Manag. 2007;33(5):599–604.
Official Norwegian Report. NOU 2017: 16 På liv og død- Palliasjon til alvorlig syke og døende (In Norwegian). Oslo: Departementenes sikkerhets- og serviceorganisasjon; 2017.
Helse Vest IKT. Nasjonalt register over palliative virksomheter (In Norwegian): Helse Vest; 2019. https://www.pallreg.no/. Accessed 17 Sept 2019.
The Norwegian Directorate of Health. Nasjonalt handlingsprogram for palliasjon i kreftomsorgen (In Norwegian) [Norwegian National Guidelines]. Oslo: The Norwegian Directorate of Health; 2019. https://www.helsedirektoratet.no/tema/palliasjon. Accessed 18 Oct 2019.
Norwegian Ministry of Health and Care Services. Together-against cancer National Cancer Strategy 2013-2017: Norwegian Ministry of Health and Care Services; 2013. https://www.regjeringen.no/contentassets/07cd14ff763444a3997de1570b85fad1/i-1158_together-against_cancer_web.pdf. Accessed 11 Dec 2017.
Norwegian Ministry of Health and Care Services. Leve med kreft- Nasjonal kreftstrategi (2018–2022) (In Norwegian): Norwegian Ministry of Health and Care Services; 2018. https://www.regjeringen.no/contentassets/266bf1eec38940888a589ec86d79da20/regjeringens_kreftstrategi_180418.pdf. Accessed 14 Apr 2019.
Norwegian Ministry of Health and Care Services. The Coordination Reform Proper Treatment—at the right place and right time: Norwegian Ministry of Health and Care Services; 2009. Report No. 47 (2008–2009) to the Storting. https://www.regjeringen.no/contentassets/d4f0e16ad32e4bbd8d8ab5c21445a5dc/en-gb/pdfs/stm200820090047000en_pdfs.pdf. Accessed 11 Dec 2017.
Statistics Norway. Population and population changes, Q2 2015 2015. https://www.ssb.no/en/befolkning/statistikker/folkendrkv/kvartal/2015-08-20?fane=tabell&sort=nummer&tabell=236795. Accessed 9 Oct 2019.
Cancer Registry of Norway. Cancer Registry of Norway; 2015. https://www.kreftregisteret.no/en/The-Registries/data-and-statistics/. Accessed 4 Apr 2019.
Beishon M. Stein Kaasa: let me show you what integrated palliative care can do. Cancer World. 2012;46:4–11.
Ringdal GI, Jordhoy MS, Ringdal K, Kaasa S. The first year of grief and bereavement in close family members to individuals who have died of cancer. Palliat Med. 2001;15(2):91–105.
Jordhoy MS, Fayers P, Loge JH, Ahlner-Elmqvist M, Kaasa S. Quality of life in palliative cancer care: results from a cluster randomized trial. J Clin Oncol. 2001;19(18):3884–94.
European Society for Medical Oncology. ESMO Designated Centres of Integrated Oncology & Palliative Care: European Society for Medical Oncology. https://www.esmo.org/Patients/Designated-Centres-of-Integrated-Oncology-and-Palliative-Care. Accessed 13 May 2019.
The Norwegian Cancer Society. Kreftkoordinatorsatsingen (In Norwegian) 2019. https://kreftforeningen.no/vi-pavirker/kreftforeningen-mener/viktige-politiske-saker/kreftkoordinatorsatsingen/. Accessed 17 Sept 2019.
Yates JW, Chalmer B, McKegney FP. Evaluation of patients with advanced cancer using the Karnofsky performance status. Cancer. 1980;45(8):2220–4.
Watanabe SM, Nekolaichuk C, Beaumont C, Johnson L, Myers J, Strasser F. A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients. J Pain Symptom Manag. 2011;41(2):456–68.
Sigurdardottir KR, Kaasa S, Rosland JH, et al. The European Association for Palliative Care basic dataset to describe a palliative care cancer population: results from an international Delphi process. Palliat Med. 2014;28(6):463–73.
Raj SX, Thronaes M, Brunelli C, Hjermstad MJ, Klepstad P, Kaasa S. A cross-sectional study on prevalence of pain and breakthrough pain among an unselected group of outpatients in a tertiary cancer clinic. Support Care Cancer. 2014;22(7):1965–71.
St. Olavs Hospital Trondheim University Hospital. Standardisert pasientforløp: Den palliative kreftpasient i Orkdalsregionen. Trondheim 2014 [updated Feb 23, 2018. https://data.stolav.no/eqspublic/pasientforlop/docs/doc_25343/index.html. Accessed 7 Mar 2020.
Fulton JJ, LeBlanc TW, Cutson TM, et al. Integrated outpatient palliative care for patients with advanced cancer: a systematic review and meta-analysis. Palliat Med. 2019;33(2):123–34.
Hui D, Bruera E. Integrating palliative care into the trajectory of cancer care. Nat Rev Clin Oncol. 2016;13(3):159–71.
Hui D, Bansal S, Strasser F, et al. Indicators of integration of oncology and palliative care programs: an international consensus. Ann Oncol. 2015;26(9):1953–9.
Bakitas M, Lyons KD, Hegel MT, et al. The project ENABLE II randomized controlled trial to improve palliative care for rural patients with advanced cancer: baseline findings, methodological challenges, and solutions. Palliat Support Care. 2009;7(1):75–86.
Norwegian Institute of Public Health. “De fleste dør på sykehjem, få dør hjemme” (In Norwegian): Norwegian Institute of Public Health; 2018 [updated 2019 Jan 24]. https://www.fhi.no/nyheter/2018/de-fleste-dor-pa-sykehjem/. Accessed 19 Sept 2019.
Chukwusa E, Verne J, Polato G, Taylor R, Higginson IJ, Gao W. Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK. Int J Health Geogr. 2019;18(1):8.
Aldridge MD, Hasselaar J, Garralda E, et al. Education, implementation, and policy barriers to greater integration of palliative care: a literature review. Palliat Med. 2016;30(3):224–39.
Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol. 1982;5(6):649–55.
Ewing G, Brundle C, Payne S, Grande G, National Association for Hospice at H. The Carer Support Needs Assessment Tool (CSNAT) for use in palliative and end-of-life care at home: a validation study. J Pain Symptom Manag. 2013;46(3):395–405.