Posters

 Please note posters are listed here numerically.

 P1 Physiotherapy in Palliative Care maintains or improves mobility and reduces falls

Alicia Ludkin (Senior Palliative Care Physiotherapist), Concord Centre of Palliative Care, Concord Repatriation Hospital, Sydney Local Health District, NSW Alicia.ludkin@sswahs.nsw.gov.au, 02 97676101

WHY? BACKGROUND AND IDENTIFYING THE PROBLEM: Generalised weakness is a common problem amongst palliative care patients are they often at risk of falls. Often their mobility must be maintained or improved in order for discharge home, to rehabilitation or nursing home

WHAT? THE AIM OR PURPOSE OF THE INITIATIVE: To evaluate the effectiveness of physiotherapy on mobility, discharge destination, length of stay and fall reduction in palliative care in-patients.

WHO? TARGET GROUP OR POPULATION FOR THE INITIATIVE: All inpatients (N=271) at Concord Centre for Palliative Care. Data collection from 1/9/14 to 30/6/15 (10 months)

HOW? WHAT WERE THE METHODS AND STRATEGIES USED?

  • Outcome measures: Length of stay, measurement of falls: Incident measuring management system, discharge destination, Physical Mobility Scale (PMS)
  • Treatment: Walking, upper/ lower limb strength training, balance training
  • Therapy time: Part-time physiotherapy (N=159.6mins each patient), full-time physiotherapy (N=213mins each patient)

WHAT? DESCRIBE WHAT HAPPENED WHEN THE INITIATIVE WAS IMPLEMENTED – OUTCOMES AND IMPACT:

  • Out of the 112 patients that survived, 58 (51.7%) mobility was maintained, 45 (40.2%) improved, 9 (8%) worsened. For patients that improved, the change in PMS score had a statistically significant improvement of 5 points.
  • Reduction in length of stay: full-time physiotherapy (N=11days) versus part-time physiotherapy (N=14days), NSW average in Palliative Care Unit is (12.3days).
  • Decrease in falls: With no physiotherapy (average 6 per month), full-time physiotherapy (average 4 per month).
  • Discharge destination: Home (N=85/112, 31.4%), Nursing home (N=18/112, 6.6%), Rehabilitation (N=4/112, 1.5%).  With no Physiotherapy, the number of patients that went home was only 24/94 (25.5%). 

P2 How to promote brilliant palliative care within the community.

Dr Ann Dadich, Ms Kerrie Womsley, Mr Michael Hodgins, Ms Noemir Gonzalez, Ms Valerie Weller, Dr Aileen Collier, Ms Janeane Harlum, Ms Penny Waldon, Ms Therese Smeal, Prof. Meera Agar

Delivering brilliant palliative care is what every nurse strives to achieve – care that exceeds expectation and brings joy. Australian palliative care services demonstrate such brilliance. However, like beauty, brilliance is largely in the eye of the beholder. Although recognising and examining it can be difficult, these tasks become relatively more feasible when guided by the overarching purpose of a palliative care service and in New South Wales, that is to, ‘help… people with life-threatening conditions to maximise their quality of life… ensur[e]… comfort at the end of life… [and/or] give palliative care patients the opportunity to choose their services and decide where and how they will be cared for’1. Given increasing support for community-based healthcare, this study – which remains in progress – aims to promote brilliant community-based palliative care by: identifying exemplars; critiquing the effects; and determining the conditions associated with brilliance.

Accordingly, community nurses in south-western Sydney were invited to participate in a study using video reflexive ethnography (VRE). VRE encourages individuals to: feature in and/or gather visual data; interpret the data openly; and understand practices and experiences.

Reflexive sessions with the nurses were held to critique the video footage, and discuss their perspectives of the study. Findings reveal three themes. First, while some nurses were dubious about the motive for study and whether it was to identify adverse events, they came to appreciate the opportunity to view themselves and colleagues deliver brilliant palliative care – particularly because most of their care is delivered in isolation within client homes. Second, the study served to increase nurse recognition of their brilliant practices. Most nurses initially perceived their practices as routine – yet, they came to acknowledge brilliance in themselves and the team. Third, with greater recognition of brilliance, those who were dispassionate about palliative care became advocates for brilliant palliative care.

Within complex health services, there is a need to move from research that aims to find problems and focus on that which exceeds expectation and brings joy. Accordingly, this study demonstrated that VRE can help to meaningfully engage nurses in palliative care and related research, encourage reflexivity, and ultimately promote brilliant practices.

P3 What is required to improve the recognition and assessment of delirium by nurses in palliative care inpatient units? A mixed methods study.

Annmarie Hosie, Meera Agar, Elizabeth Lobb, Patricia Davidson, Jane Phillips

Objective: To identify what is required to improve inpatient palliative care nurses’ recognition and assessment of patients with delirium.

Methods: The DePAC project used a two-phase mixed methods approach to examine delirium epidemiology, health care system and nursing practice in palliative care inpatient settings. Phase one examined delirium epidemiology via a systematic review and cross sectional study, and organisational systems through an environmental scan methodology.  Phase two explored nurses’ delirium experiences, perceptions and capabilities using Critical Incident Technique and focus groups. Data were integrated at project conclusion to generate a more complete understanding of the impetus and way forward to improve delirium recognition and assessment in this setting.

Results: The systematic review reported delirium prevalence ranged internationally from 26% to 62% during admission to a palliative care unit, increasing to 88% in the last hours of life. Of 47 Australian palliative care inpatients with a mean age (SD) of 74 years (+10), one third screened positive and one in five were diagnosed with delirium in a 24-hour period.  Most delirium guidelines exclude evidence and recommendations related to end-of-life care, and delirium processes are absent within palliative care units. Nurses’ poor conceptual and diagnostic understanding of delirium and use of ambiguous terminology contributes to under-recognition and inadequate assessment.  Nurses report the Nursing Delirium Screening Scale is feasible for use in specialist palliative care. Optimal recognition and assessment of delirium requires a range of actions at the patient (routine screening/assessment with low burden delirium tools), clinician (build patient rapport, engage families and strengthen interdisciplinary collaboration) and system levels (develop point-of-care guidance and implement tailored educational strategies).

Conclusion: The DePAC project generated a broad understanding of the multi-level factors impacting on palliative care nurses’ delirium practice, resulting in ten interdisciplinary practice, policy and research recommendations to improve future care of palliative care inpatients.

P4 Measuring delirium point-prevalence in palliative care.

Annmarie Hosie, Meera Agar, Liz Lobb, Patricia Davidson, Richard Chye, Lawrence Lam, Jane Phillips

Objectives: To:

  1. scertain 24-hour delirium point-prevalence in an Australian palliative care inpatient population

  2. Test the feasibility and acceptability of the delirium measurement methodology

Methods: This was a pilot prospective cross sectional study of patients receiving care in two palliative care units in Sydney, Australia.  Delirium occurrence over 24-hours was measured using bedside nurses’ eight-hourly completion of the Nursing Delirium Screening Scale, researcher application of the Memorial Delirium Assessment Scale, and physician assignment of DSM-5 delirium diagnostic criteria for patients who screened positive for delirium. Patient demographics, palliative care phase, function, delirium measure completion, and proportion of patients with a positive screen and diagnosis of delirium were analysed using descriptive statistics.

Results: Patients (n=47) had a mean age of 74 years (SD +10), most were male (60%), and had a malignant diagnosis (96%). Five patients (11%) had a chronic cognitive impairment documented.  Only two were considered by clinicians to be in the last days of their life. The Nursing Delirium Screening Scale was completed for all patients at least once within the 24-hour measurement period, and 16 patients (34%) screened positive. There was a low completion rate of the Memorial Delirium Assessment Scale (n=2). Physicians applied delirium diagnostic criteria for all patients with a positive screen, with 9 (19%) diagnosed as delirious.

Conclusion: Nurse completion of the Nursing Delirium Screening Scale and physician application of DSM-5 diagnostic criteria for delirium appears feasible and acceptable in the palliative care inpatient population, while the Memorial Delirium Assessment Scale does not. Patients’ older age, various palliative care phase, and proportions who were experiencing cognitive, behavioural and/or attentional disturbances and diagnosed with delirium, highlight the need to develop delirium prevention, recognition, assessment and management strategies for patients receiving palliative care in the hospital setting.

P5 Integration of delirium knowledge tools in three palliative care units: an environmental scan.

Annmarie Hosie, Meera Agar, Liz Lobb, Patricia Davidson, Jane Phillips

Objective: To determine the extent of integration of knowledge tools supporting delirium recognition, assessment and diagnosis in adult inpatient populations within three highly resourced, leading palliative care inpatient units in Sydney, Australia.

Methods: This study employed environmental scanning methodology. Data were collected via: i) a snowball search of peer-reviewed and grey literature for delirium knowledge tools relevant to adult inpatient populations, including: guidelines, delirium and cognition assessment tools, and patient and family information resources; and ii) structured interviews with palliative care clinicians, educators and managers pertaining to delirium recognition, assessment and diagnostic systems within their workplaces. Systems for delirium care were mapped against the identified knowledge tools’ recommendations, suitability and availability.

Results: The literature search identified ten delirium guidelines, nine delirium and seven cognition assessment tools, and five patient and family information resources. Most delirium guidelines (n=7) excluded evidence related to palliative care populations and/or omitted end-of-life care recommendations. Two of the three remaining guidelines were not evidence-based. Despite all units being involved in delirium research and quality improvement, and participant (n=14) awareness of delirium being a serious problem, interviews revealed systems and practice rarely matched the available recommendations, tools and resources for: delirium risk assessment; screening, diagnosis and comprehensive assessment of cognitive dysfunction; and interdisciplinary teamwork, education and provision of information to patients and family. Delirium or cognition assessment tools were not routinely used, even when locally available. No unit provided patients and family with written information about delirium.

Conclusions: Knowledge tools supporting delirium recognition, assessment and diagnosis are under-utilized in three highly resourced Australian specialist palliative care inpatient units, contributing to many evidence-practice gaps. Findings highlight the need to include palliative care populations, evidence and recommendations in future delirium guidelines, and advocate for high-level organizational strategies to improve delirium care for palliative care inpatients.

P6 A Last Days of Life Toolkit: ensuring best possible death and bereavement care for patients and families.

Bernadette King1, Program Lead End of Life Program; A/Prof Amanda Walker, Clinical Director1

1Clinical Excellence Commission, NSW, Australia  Bernadette.King@health.nsw.gov.au 02 9269 5522

Background: A key function of the Clinical Excellence Commission’s End of Life (EOL) program is to develop tools and resources that support clinician’s safe practice in caring for patients and their families/ carers during the last days of life.

Aim: To develop a last days of life toolkit that provides clinicians with tools to ensure that all dying patients are recognised early, receive optimal symptom control, have social, spiritual and cultural needs addressed, and bereavement support for families and carers occurs

Methods: Four working parties were convened in June 2015, made up of 71 expert clinicians from all relevant disciplines throughout NSW as well as consumer representatives, to review current practice and literature and make recommendations for tool development. After the initial workshop the toolkit development was continued through monthly teleconferences.

Results: Over the 6 month period 20 individual tools were developed. These include: a comfort observation and symptom assessment chart; tools to prompt communication and provide information; medication guidelines for a standardised approach to the five most common symptoms in the last days of life; and accelerated transfer to die at home plan.  Following a successful consultation process the tools will be piloted from July 2016 in metropolitan and rural settings. 

Discussion / Conclusion: The various charts, guidelines and flowcharts have been developed through consensus opinion and the review of current literature alongside current best practice from across NSW, Australia and internationally.  They are as evidence- based as possible and are in keeping with NSW Health policy and national requirements. The tools have been designed for use by generalist clinicians caring for dying patients in all in-patient hospital settings. The resources are not intended to replace either local Specialist Palliative Care guidelines or consult advice given by Specialist Palliative Care clinicians.

P7 Exploring the provision of “Palliative Care” in the Residential Care Home setting…What does “A Palliative Approach in Residential Care” really look like?

Bron Heron and Chris Lancaster, Clinical Nurse Consultants Palliative Care, Anglican Retirement Villages; Bronwyn.heron@arv.org.au, 02 8820 3015, 0438 279 455

Undertaking the position of Clinical Nurse Consultant providing Specialist Palliative Care Support embedded within an Aged Care Organisation has offered a unique and at times challenging journey of learning over the past 8 years.

This paper will explore and reflect on this journey of learning and the experience of providing Palliative Care in Aged Care. Sharing the stories of two (2) resident journeys’ will serve to highlight some of the challenges and key learning opportunities and offer insights, suggestions and resources that have transformed the way Palliative and End of Life care continues to be provided to those in our care in Residential care Homes.

P8 The BaptistCare Palliative Approach – a Model of Care within the context of residential aged care.

Carolyn Moir, Care Improvement Consultant, BaptistCare NSW &ACT, cmoir@baptistcare.org.au, 02 93461237, 040185319

Transforming Care Holistically within the context of residential aged care aligns to the BaptistCare Palliative Care Strategic plan, a journey beginning in late 2014 with the development of a specialised Palliative Care Program to be portable and implemented across all BaptistCare facilities. The BaptistCare model covers the continuum of each resident’s life-limiting illness and includes:-

  • a person centred approach, guided by an individual’s advanced care record, palliative care conferences and the use of end of life care pathways;
  • a family centred approach, through inclusion and engagement in care planning and provision of information and pastoral care;
  • highly skilled service provision, ensuring that all direct care staff are competent to provide palliative care and able to access specialist palliative services as required;
  • standardised policies, procedures, resources, and quality assurance across all BaptistCare facilities
  • networking with external agencies and service providers.

A key component is communication which is resident focused at all stages. All communication is open, clear, and meets their changing needs. The BaptistCare Palliative Approach focuses on three dynamic stages of care including:-

AFFIRM

  • Working together we affirm the importance of each resident’s quality of life. Staff will assist the resident to identify lifestyle choices and care related goals including the process of Advance Care Planning.

BALANCE

  • The Balance stage begins when the resident’s current condition is not responding as well as possible to current treatments and is deteriorating.At this time a review of lifestyle choices and care related goals occurs.

COMFORT

  • The Comfort stage focuses on the resident and family choices, religious and cultural beliefs and most importantly the right to die with dignity. Provided in the setting of choice an End of Life Care Pathway may be used to guide staff to support a comfortable natural death. The comfort stage includes care after death and bereavement support for families, friends, other residents and employees.

Each stage includes a comprehensive suite of resources including RN kits, guides, tools, eLearning, ‘MyCARE’ BaptistCare resident specific information and online quality monitoring and reporting tools.

P9 A literature review – End of Life Care (EoLC) in Advanced Dementia.

Carolyn Moir, Care Improvement Consultant, BaptistCare NSW &ACT, cmoir@baptistcare.org.au, 02 93461237, 040185319

It is widely recognised that dementia is a life-limiting illness and that a high percentage of the residents in the residential aged care setting have a diagnosis of dementia. Current challenges exist in the delivery of the palliative approach and the EoLC for residents with Advanced Dementia within the residential aged care setting. As the presenter is enrolled in a professional doctorate looking at EoLC in Advanced Dementia a systematic review of the literature is currently been undertaken and will inform the final thesis.

Drawing from a broad range of literature and current information the presentation will summarise the key themes emerging from current evidence in this specialty area. In the limited literature review thus far several themes have arisen and will be explored and expanded on including:-

  • Advanced care planning within the context of memory loss
  • Supporting families
  • Prognostication in advanced dementia and diagnosing terminal stage
  • Awareness of the terminal phase
  • Symptom management – particularly pain assessment and management.

P10 How to go peacocking in a New Palliative Care Centre.

Cathy McDonnell, Palliative Care Clinical Nurse Consultant, Concord Centre for Palliative Care, Concord Hospital Cathy.mcdonnell@sswahs.nsw.gov.au, catherinelouisa@gmail.com, 0297678232, 0412580092

Objective: Introducing the Palliative Care Outcomes Collaboration (PCOC) assessment tool to our new 20 bed Palliative Care Facility that opened in July 2014. Showing how it has been successfully integrated into everyday care for our patients.

Method: Ensuring buy in from the Palliative Care multidisciplinary team and Hospital administration for maximum support and effectiveness.

Development of ongoing education, mentoring, reviews, audits. Ensuring important partnerships developed with the hospital clinical data managers. Working side by side with our PCOC facilitator from University of Wollongong.

Results: Integrated use of PCOC tools within our Centre. Ongoing improvement in the management of symptoms and outcomes for our patients. Regular education sessions both in-house and at the PCOC education days. Development of PCOC Leaders on the Ward. Ongoing review of our documentation with the clinical data mangers to ensure correct collection and accuracy of data collected. Review of current data currently being use to review our models of care and nursing staff management.

Conclusion: PCOC has been successfully embedded into our facility, now utilized by all aspects of our multidisciplinary team, incorporated into our handovers, electronic patient records and has opened up many other opportunities to branch out with our current use of the tools.

P11 Succession Planning For Palliative Care Clinical Nurse Consultants.

O’Connor C1, Chapman A, Bowen C, West D, Hooper D, De Guzman D, Gordon K, McEvoy L, Astorga C, Peterman D, Glass A, Wright K, Chen T.

1Palliative Care Clinical Nurse Consultant, Liverpool Hospital, South Western Sydney Local Health District, NSW. Charmaine.O’Connor@sswahs.nsw.gov.au, 0439 815 660

Background: A Palliative Care Clinical Nurse Consultant (CNC) provides expert clinical advice to patients, families and carers and multidisciplinary members of the health care team. The role incorporates the organisation and delivery of specialist consultancy services, leadership, research and education.  CNCs are not always replaced when they take leave or are on secondment, hence, there is limited opportunity for aspiring staff to relieve and professionally develop in such roles. Essential patient care services, treatments and procedures, care coordination, discharges, length of stay, clinics, and key performance indicators can be impacted upon when the Palliative Care CNC is not replaced.

Aim: CNC Succession Planning Mentorship Program aimed to

  • Professionally develop and provide opportunity to nurses who may be considering Clinical Nurse Consultancycareer path
  • Provide mentorship, education and the skills to fulfil the CNC role

Method: 10 participants to the pilot program were recruited from services that can have a significant impact on KPIs, patient safety and patient flow, if not replaced, and included the Palliative Care stream. Participants attended a CNC School, scheduled five times throughout the year covering topics relevant to the 5 domains of the CNC. Unsuccessful candidates to full programme were able to attend education sessions.

The RN candidate spent 5 supernumerary days with their CNC to learn and experience the role in the form of an internship model. Learning goals were established, a reflective journal maintained by the RN, and an evaluation of learning. Resources included Information about using S.M.A.R.T framework to develop objectives, information about keeping a Reflective Journal and a Reflection framework. The CNC mentors were provided with mentor guidance.  A facilitated focus group elicited feedback from participants, mentors and working party members.

Results: 93 participants to 5 sessions received 71 completed feedback forms showed an overwhelming agreement that the topics were relevant and well-presented programme.

Conclusion: The CNC Succession Planning Program aligns to the 2014-2018 Operational Plan Corporate Action 4: Developing our Staff, by strengthening clinical succession planning via mentoring, providing workplace development and continued leadership training and NSQHS Standard 13, Workforce Planning and Management: Criterion 1, Workforce Planning.

P12 Transforming the future of end-of-life care in hospitals: Utilising patient and family identified areas of importance as the foundation for change.

Claudia Virdun (1); Tim Luckett(1, 2, 3); Jane Phillips (1, 2, 4, 5)

Affiliations:

  1. Faculty of Health, University of Technology Sydney, NSW, Australia
  2. Improving Palliative Care through Clinical Trials (ImPaCCT), Sydney, New South Wales (NSW), Australia
  3. South Western Sydney Clinical School, University of New South Wales (UNSW), Sydney, NSW, Australia
  4. Adjunct Professor, School of Nursing, The University of Notre Dame Australia, Sydney, NSW, Australia
  5. Adjunct Professor, School of Medicine, The University of Sydney, NSW, Australia

The majority of palliative care deaths in Australia occur in hospitals where optimal end-of-life care cannot be assured. Understanding what is important for patients and families receiving end-of-life care in hospital provides a foundation upon which to build improvement efforts. Enabling optimal end-of-life care within hospitals, based on consumer need, is our future.

Aim: To understand the care elements that are most important to patients and their families in relation to end-of-life care in the hospital setting.

Methods: Two systematic reviews: (1) a narrative synthesis of quantitative data (2) a metasynthesis of qualitative data. The metasynthesis focused on patient/family quotes rather than authors’ findings.

Results: Quantitative data were analysed from 1,141 patients and 3,117 family members across eight included studies. Qualitative data was analysed from 74 patient quotes and 282 family quotes across 16 included studies. Five themes were noted as important across both reviews: (1) Expert care (good physical care, symptom management and integrated care); (2) Effective communication and shared decision making; (3) Financial affairs; (4) Adequate environment for care (5) Respectful and compassionate care. Two additional themes from the quantitative data were: (1) Trust and confidence in clinicians; (2) Minimise burden. Seven additional themes from the qualitative data were: (1) Family involvement; (2) Maintenance of sense of self; (3) Maintenance of patient safety and prevention of harm; (4) Preparation for death; (5) Enabling patient choice (6) Care extending to the family after patient death.

Implications for practice: These reviews identify consistent patient and family priorities for end-of-life hospital care which must now guide care planning, care provision and service improvements. These priorities provide the foundation for transforming our future end-of-life care in hospitals.

Conclusion: Patients and families have outlined what is important for inpatient end-of-life care and have done so for over 25 years. Our challenge for the future is to systematically evaluate in line with such areas of importance so improvement efforts target areas that matter most to patients and families.

P13 Supporting adolescents and young adults whose parents are impacted by cancer.

Mrs D. Jerushah Connell, CanTeen Australia, 75 King Street, Newtown, Australia, 2042 jerushah.connell@canteen.org.au, 02 9007 0245

Background: Each year 21,000 adolescents and young adults (AYAs; 12-24 years) across Australia receive the devastating news that their parent has cancer, with many facing the additional challenge of parental death from cancer. Changes in family dynamics, social isolation, and loss of normalcy occur during both the palliative stage and post-bereavement, putting young people at risk for short- and long-term behavioural and emotional difficulties. Evidence suggests that AYA offspring and bereaved offspring are 3 to 6 times more likely to experience high levels of psychological distress compared to their peers. They also report high levels of psychosocial, support and informational unmet needs.

Objectives: This presentation will report information on service delivery within the context of CanTeen, the Australian youth cancer support organisation. CanTeen aims to develop and evaluate support resources that address the psychosocial needs of AYAs impacted by parental cancer or death.

Service delivery: All young people accessing CanTeen’s services are assessed on their levels of distress and unmet needs at baseline and 6-month review. Information on key areas of unmet need is used to guide service provision. CanTeen’s services for AYAs whose parents are in palliative care or who have died from cancer include: individual support, online and face-to-face counselling; peer support; recreational camps and activities; manualised psychosocial support programs; and medical and psychosocial information resources. Based on AYAs identified needs for information, specific resources have been developed in the area of palliative care. This includes a book, When Your Parents Cancer Can’t Be Cured, which provides age-specific psychoeducation and coping strategies. Psychosocial programs addressing the impact of parental cancer and the bereavement process have also been developed. Assessment findings indicate that AYA offspring and bereaved offspring report declines in levels of psychological distress and unmet needs after accessing CanTeen’s services.

Conclusions: CanTeen’s evaluation process enables health care professionals to provide optimal individual support, identify service limitations, and facilitate service planning and development for this vulnerable population. CanTeen provides targeted support services that are effective in reducing distress and unmet needs in young people seeking help to cope with the impact of their parent’s cancer diagnosis or death.

P14 The impact of community palliative care nurse practitioners in helping home-based dying patients, with the support of their care givers, make choices about their preferred place of death.

DAWN HOOPER Nurse Practitioner, Sydney Adventist Hospital, Wahroonga NSW, dawn.hooper@sah.org.au, 0438 839 538; JULIE EDWARDS Nurse Practitioner, Sydney Adventist Hospital, Wahroonga NSW

In 2013, a Cochrane review of 23 studies  on home-based palliative care found that when someone with an advanced illness gets home based palliative care their chances of dying at home more than double. In addition home-based palliative care also helps reduce the symptom burden people may experience as a result of an advanced illness, without increasing grief for family caregivers after the patient dies.  Its finding on the economic impact of home-based palliative care was inconclusive. There were just 6 studies that examined the total costs associated with home-based palliative care, looking at a range of resources in the hospital community and household sectors. There was only one full economic evaluation of the intervention. None of the studies examined the economic impact in the Australian context.
Funding from the Sydney Adventist Hospital (SAH) foundation has allowed for expansion of the community palliative care service. The aim of the service is to improve end-of–life symptoms and provide clinically, ethically and culturally appropriate care to patients in the final phase of their lives. The service has a two pronged approach. First to provide patients with a life-limiting illness choice as to where they have their care needs met, second to reduce the incidence of avoidable admission to the acute care setting. 

This on-going, pilot study will utilise the existing Palliative Care Outcomes Collaboration (PCOC) framework for the evaluation of palliative care and apply it to the northern Sydney setting. The purpose of the study is to assess the feasibility of and support for a larger, multi-centre trial that examines the clinical and economic impact of home-based palliative care in Australia. Data collected from this local clinical case series analysis will be used to mount the case to design a larger study that can answer the policy and funding questions posed by government, private health insurers and other agencies regarding home-based palliative care services.

P15 Emergency department presentations by community palliative care patients at end-of-life: A retrospective review.

Berry D1, Perey A2, Schofield K3, Glavan M3, Womsley K3, Smith L4, Everett B5, Sadozai A5, Parker D5.

  1. Primary and Community Health, South Western Sydney Local Health District, 1 Bolger Street Campbelltown, donna.berry@sswahs.nsw.gov.au, 0418464456
  2. Primary and Community Health, South Western Sydney Local Health District, 1 Bolger Street Campbelltown, ann.perey@sswahs.nsw.gov.au, 0418603573
  3. Primary and Community Health, South Western Sydney Local Health District, 1 Bolger Street Campbelltown
  4. Liverpool Hospital, South Western Sydney Local Health District
  5. Centre for Applied Nursing Research, South Western Sydney Local Health District and Western Sydney University

While many palliative patients wish to be cared for and to die at home, approximately one-third will present to the emergency department (ED) during the last days of life, and of these, 70% will result in an overnight admission. Reasons for ED presentation are varied but often relate to symptom control including uncontrollable pain, constipation and dyspnoea. These presentations are distressing for the patient and their family/carer and in many cases are avoidable. Appropriate home support and training of caregivers to manage symptoms can potentially avoid unnecessary ED presentations.

Aims: The aim of this study is to conduct a retrospective review of Emergency Department (ED) presentations by community palliative care patients in the last month of life in the South Western Sydney Local Health District (SWSLHD).

Specifically, this study seeks to identify:

  • Reason for ED presentation, management during ED presentation including clinical care and discharge destination
  • Whether the ED presentation was avoidable
  • Whether socio-demographic and clinical  circumstances influence ED presentation and outcomes
  • Whether carer or health service provision circumstances influence ED presentation and outcomes

Methods: All patients registered for palliative care with the SWSLHD community palliative care service that were deceased from July 2014 to June 2015 and who presented to the emergency department in their last month of life were considered for inclusion in the study. A random sample of up to 50 participants from each of the five participating sites was identified. Participant’s information is being collected from online and hard copy medical records.

Results: Data collection is currently underway and results will be available for presentation at the conference.

P16 Development of patient self-management resources to address patient, provider and systems barriers to cancer pain assessment and management.

Tim Luckett,1,2,3 Patricia M Davidson,2,4 Anna Green,2 Natalie Marie,2 Mary-Rose Birch,5 John Stubbs,6 Jane Phillips,2,7 Meera Agar,3,5,8 Frances Boyle,9,10 Annmarie Hosie,2 Melanie Lovell 5,10

AFFILIATIONS:

  1. Improving Palliative Care through Clinical Trials (ImPaCCT), the New South Wales (NSW) palliative care clinical trials collaborative, Sydney, NSW, Australia
  2. Centre for Cardiovascular and Chronic Care, University of Technology Sydney (UTS) Faculty of Health and St Vincent’s Hospital, Sydney, NSW, Australia
  3. University of New South Wales (UNSW), South Western Sydney Clinical School, Sydney, NSW, Australia
  4. School of Nursing, Johns Hopkins University, Baltimore, MA, USA
  5. HammondCare, Sydney, NSW, Australia
  6. CanSpeak, Sydney, NSW, Australia
  7. Faculty of Nursing, University of Notre Dame Sydney, Australia
  8. Ingham Institute for Applied Medical Research, Sydney, NSW, Australia
  9. Patricia Ritchie Centre for Cancer Care and Research, Mater Hospital, Sydney, NSW, Australia
  10. Sydney Medical School, The University of Sydney, Sydney, NSW, Australia

Background: Cancer pain is a common problem that is under-treated despite the availability of guidelines. A program was undertaken to develop patient self-management resources to support evidence-based, person-centred care for cancer pain and overcome barriers at the levels of the patient, provider and healthcare system. The resources were intended to supplement the Cancer Council New South Wales (NSW) patient education booklet, “Overcoming Cancer Pain” and Australian guidelines for “Cancer Pain Management in Adults” available from the Cancer Council Australia Cancer Guidelines Wiki.

Methods: The project used mixed methods, including: 1) a national online survey of current practice; 2) two systematic reviews; 3) a review of online patient diaries and resources; 4) a case study of barriers and facilitators to cancer pain assessment and management at a single palliative care unit; 5) consultation with stakeholders; and 6) interviews with patients regarding acceptability and usefulness of draft resources.

Results: Findings highlighted the need for resources to be tailored to patients’ needs, build patients’ sense of control, and support communication with health professionals and coordination between services. Patient-held resources were developed to include: 1) a template for setting specific, measureable, achievable, relevant and time-bound (SMART) goals of care, as well as identifying potential obstacles and ways to overcome these; 2) a pain management plan detailing exacerbating and alleviating factors, current strategies for management and contacts for support; and 3) alternative pain diary templates to allow for variability in preferences for content and format when monitoring pain and communicating this to providers.

Conclusion: Patient self-management resources have potential for addressing not only patient barriers to pain care but also barriers at the levels of the provider and healthcare system. A cluster randomised controlled trial is underway to test cost-effectiveness of the resources in combination with pain screening, audit and feedback, and health professional education. If found to be effective, all resources will be made freely available on the Cancer Council Australia Cancer Guidelines Wiki.

P17 Pilot of pain indicator audit tool as part of a complex intervention to improve cancer pain outcomes.

Melanie Lovell,1,2,3 Mary-Rose Birch,3 Tim Luckett,1,4,5 Patricia M Davidson,4,6 John Stubbs,7 Jane Phillips,4,8 Meera Agar,3,5,9 Frances Boyle,2,10 Odette Spruyt.11

  1. Improving Palliative Care through Clinical Trials (ImPaCCT), the New South Wales (NSW) palliative care clinical trials collaborative, Sydney, NSW, Australia
  2. Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
  3. HammondCare, Sydney, NSW, Australia
  4. Centre for Cardiovascular and Chronic Care, University of Technology Sydney (UTS) Faculty of Health and St Vincent’s Hospital, Sydney, NSW, Australia
  5. University of New South Wales (UNSW), South Western Sydney Clinical School, Sydney, NSW, Australia
  6. School of Nursing, Johns Hopkins University, Baltimore, MA, USA
  7. CanSpeak, Sydney, NSW, Australia
  8. Faculty of Nursing, University of Notre Dame Sydney, Australia
  9. Patricia Ritchie Centre for Cancer Care and Research, Sydney, NSW, Australia
  10. Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
  11. Palliative Care Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia, University of Melbourne, Melbourne, Vic, Australia\

Background: Pain is under-managed in adults with cancer despite internationally available guidelines. Audit and feedback improves both the translation of guidelines into practice and pain outcomes. A set of indicators for pain has been developed and implemented using an audit tool in 22 sites in Victoria, Australia. The indicators are: use of validated pain scale (Indicator 1); assessment of pain at first presentation (Indicator 2); regular pain assessment (Indicator 3); bowel regime plan (Indicator 4); routine prescription of opioid analgesia for breakthrough cancer pain (Indicator 5); and the scheduling of pain medication for severe pain (Indicator 6).

Aims: To pilot the audit tool in for a planned multisite randomised controlled trial and estimate adherence to indicators in New South Wales (NSW) palliative care and oncology settings.

Method: The medical records of 35 patients with advanced cancer and pain from public palliative care (n=20) and private oncology (n=15) health services in NSW were audited. NSW data were compared with the data from Victoria (n= 278). The audit assessed adherence to key indicators of pain assessment and management. Feasibility for auditing in a clinical trial was judged against a median of 30 minutes per patient. 

Results: Compliance for: Indicator 1 was 90.6% across both services (compared with 96%Victoria), Indicator 2 was 95% of public palliative care of and 6.3% of private oncology patients, (87%Victoria). A pain chart greatly increased comprehensiveness of pain assessment. Indicator 3: 83% (96%Victoria) Indicator 4: 100% of public and 66% of private patients Indicator 5 and 6 were similar between services overall 71.4% (87%Victoria) and 94.3% (85%Victoria). The median audit time was 37.5 minutes (range 10 to 120 minutes). Variability arose from the number and type of record (outpatient or inpatient) and number from different parts of the service.

Implications: This study confirmed the need for strategies to implement evidence-based guidelines for cancer pain and demonstrated feasibility of using the audit for outpatient but not inpatient settings in a research context. Audit and feedback will be used in the trial alongside patient and health professional education.

P18 Self-management to reduce avoidable Emergency Department presentations for breathlessness: a strengths-based approach using qualitative methods.

Dr Tim Luckett,1 Prof Jane Phillips,1 Prof Miriam Johnson,2 Ms Maja Garcia,1 Ms Priyanka Bhattarai,1 Ms Anne Hutchinson,2 Prof David Currow,3 Dr Rebecca Disler,4 Prof Virginia Carrieri-Kohlman,5 Ms Bridget Whelan,6 Dr Phillip Newton,1 Prof Meera Agar,1 A/Prof Richard Chye,7 Dr Caitlin Sheehan,8 Ms Serra Ivynian,1 Prof Patricia Davidson9

Affiliations:

  1. Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney (UTS), Sydney, NSW, Australia
  2. Centre for Health and Population Sciences, Hull York Medical School, University of Hull, Hull, East Yorkshire, UK
  3. Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
  4. Sydney Nursing School, The University of Sydney, Sydney, NSW, Australia
  5. School of Nursing, University of California San Francisco, San Francisco, California, USA
  6. Consumer Panel, Improving Palliative Care through Clinical Trials (ImPaCCT)
  7. Sacred Heart Health Service, St Vincent’s Hospital, Sydney, NSW, Australia
  8. Department of Palliative Care, Calvary Health Care Sydney, Sydney, NSW, Australia
  9. School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA

Background: Breathlessness ‘crises’ in people with chronic respiratory conditions are a common cause of Emergency Department (ED) presentations, many of which could be avoided through better self-management and support. This study aimed to learn from patients and families with experience of an ED ‘near miss’ where they considered going to ED but instead successfully self-managed at home.

Methods: This qualitative study used semi-structured telephone interviews with patients who reported experiencing breathlessness on most days and having one or more ED near miss. Caregivers were eligible if they contributed to decision-making about whether to go to ED. Recruitment was via Lung Foundation Australia’s website and email lists (including support groups) and the pulmonary rehabilitation and community palliative care service at one hospital. Interview questions focused on breathlessness experience, ED-related decision-making, information finding, and self-management and support. Analysis used an integrative method (both deductive and inductive) and independent coding by two researchers. Sample size was determined by saturation.

Results: Interviews were conducted with 20 patients and 3 caregivers. Fifteen  patients had chronic obstructive pulmonary disease (COPD), 3 restrictive lung disease, 1 chronic thromboembolic pulmonary hypertension, and 1 bronchiectasis. Analysis identified self-efficacy in coping with a crisis to be the most important factor in avoiding ED.Whilst most patients had developed impressive self-management expertise, a minority appeared inappropriately confident in their ability to avoid medical attention in the absence of significant skills or support. Successful strategies used by expert patients included: taking a project management approach that included planning, monitoring, and risk management; managing the affective dimension of breathlessness separately from the sensory-perceptual; and building partnerships with health professionals who respect patient expertise and provide coordinated care across community and hospital settings.

Conclusions: Expert patients’ experiences and skills are instructive for supporting self-management by people with a history of avoidable ED presentations for breathlessness. Interventions to improve self-efficacy should ensure this is substantiated by transfer of self-management skills and support to ensure that  confidence is not misplaced and patients know when ED presentation is necessary.

P19 Clinical trials of medicinal cannabis for symptoms from advanced cancer: A survey of preferences, attitudes and beliefs among patients willing to consider participating.

Tim Luckett,1 Jane Phillips,1 Nicholas Lintzeris,2,3 David Allsop,4 Jessica Lee,5 Nadia Solowij,6 Jennifer Martin,7 Lawrence Lam,1 Rajesh Aggarwal,8 Nicola McCaffrey,9 David Currow,9 Richard Chye,10 Melanie Lovell,11,12 Iain McGregor,13 Meera Agar 1,14,15

AFFILIATIONS:

  1. Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney (UTS), Ultimo, New South Wales (NSW) Australia
  2. Discipline of Addiction Medicine, Central Clinical School, Sydney Medical School, Camperdown, NSW, Australia
  3. Drug and Alcohol Services, South East Sydney Local Health District (SESLHD), NSW Health, Surrey Hills, NSW, Australia
  4. School of Psychology, University of Sydney, Camperdown, NSW, Australia
  5. Palliative Care, Concord Repatriation General Hospital, Concord, NSW, Australia
  6. School of Psychology, University of Wollongong, Wollongong, NSW, Australia
  7. School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
  8. Liverpool Cancer Therapy Centre, Liverpool Hospital, Liverpool, NSW, Australia
  9. Palliative and Supportive Services, Flinders University, Daw Park, South Australia (SA), Australia
  10. Sacred Heart Supportive and Palliative Care, St Vincent's Hospital, Sydney, NSW, Australia,
  11. Palliative Care, Greenwich Hospital, HammondCare, Greenwich, NSW, Australia
  12. Sydney Medical School, Northern Clinical School, Greenwich, NSW, Australia
  13. Faculty of Science, University of Sydney, Camperdown, NSW, Australia
  14. The Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
  15. South Western Sydney Clinical School, University of New South Wales, NSW, Australia

Objective: To explore the preferences, attitudes and beliefs of patients eligible and willing to consider participation in a clinical trial of medicinal cannabis for symptoms from advanced cancer.

Design: Cross-sectional anonymous survey administered from July to December 2015.

Setting: Eight adult outpatient palliative care and/or cancer services, and online.

Participants: Respondents were eligible if they were ≥18 years, had advanced cancer and poor appetite, taste problems and/or weight loss, and might consider participating in a medicinal cannabis trial.

Main outcome measures: Survey items asked about previous medicinal cannabis use, preferences for delivery route, and invited comments and concerns. Items focused on medicinal rather than recreational cannabis use and did not specify botanical or pharmaceutical products.

Results: There were 204 survey respondents, of whom 26 (13%) reported prior medicinal cannabis use. Tablets/capsules were the preferred delivery mode (n=144, 71%), followed by mouth spray (n=84, 42%) and vaporiser (n=83, 41%). People who explained their preferences (n=134) most commonly cited convenience (n=66; 49%). Eighty-two percent (n=168) of respondents indicated they had no trial-related concerns, but a small number volunteered concerns about adverse effects (n=14) or wanted more information and advice (n=8). In comments, 6 respondents volunteered a belief that cannabis might cure cancer, while 2 wanted assurance of efficacy before participating in a trial.

Conclusion: Advanced cancer patients exhibit a range of delivery mode preferences for medicinal cannabis, with the oral route most popular. Justification of modes other than tablets/capsules and variable understanding about cannabis and trials may need addressing in trial-related information.

P20 Pragmatic cluster randomised controlled trial of facilitated family case conferencing versus usual care for people with advanced dementia living in aged care – effects on end of life care.

Prof Meera Agar,1,2,3 Dr Tim Luckett,1 Dr Georgina Luscombe,4 Prof Jane Phillips,1 Prof Elizabeth Beattie,5 Prof Dimity Pond,6 Prof Geoffrey Mitchell,7 Prof Patricia M Davidson,8 Ms Janet Cook,9 Ms Deborah Brooks,5 Dr Jennifer Houltram,9 A/Prof Stephen Goodall,9 Prof Lynnette Chenoweth10

AFFILIATIONS:

  1. Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney (UTS), NSW, Australia
  2. South Western Sydney Clinical School, University of New South Wales, NSW, Australia
  3. Ingham Institute of Applied Medical Research, NSW, Australia
  4. Sydney Medical School, The University of Sydney, NSW, Australia
  5. School of Nursing, Queensland University of Technology, Queensland, Australia
  6. School of Medicine and Public Health, The University of Newcastle, NSW, Australia
  7. Faculty of Medicine and Biomedical Sciences, The University of Queensland, Queensland, Australia
  8. School of Nursing, Johns Hopkins University, Maryland, USA
  9. Centre for Health Economics and Research Evaluation (CHERE), Faculty of Business, UTS, NSW, Australia
  10. Centre for Healthy Brain Ageing, University of New South Wales, NSW, Australia

Background: People with advanced dementia living in nursing homes sometimes receive suboptimal palliative care because of poor communication and limited care planning. The current study aimed to compare the effects of facilitated case conferencing (FCC) with usual care (UC) on end of life care.

Methods: A two arm parallel cluster randomized controlled trial in 20 Australian nursing homes. In each intervention nursing home (N=10), registered nurses were appointed as Palliative Care Planning Coordinators (PCPCs) two days a week for 18 months. They facilitated family case conferences and trained nursing home staff in person-centred palliative care. The primary outcome was family-rated quality of end of life care (End of Life Dementia [EOLD] Scales). Secondary outcomes included nurse-rated EOLD scales, resident quality of life (Quality of Life in Late-stage Dementia [QUALID]) and quality of care over the last month of life (Emergency presentations/hospital admissions, life-sustaining treatments, pharmacological/non-pharmacological management).

Results: Two-hundred-eighty-six people with advanced dementia took part but only 131 died (64 in UC and 67 in FCC), rendering the primary analysis under-powered. No group effect was observed on the EOLD scales, but significant differences were found in pharmacological (P < .01) and non-pharmacological (P < 0.05) management during the last month of life. Having one or more inter-current acute comorbidity was associated with lower family ratings of EOLD Satisfaction with Care (coefficient 2.97, P < 0.05) and lower staff ratings of EOLD Comfort Assessment with Dying (coefficient 4.37, P < 0.01). Per protocol analyses showed positive relationships between EOLD and staff hours to bed ratios, proportion of residents with dementia and staff attitudes.

Conclusion: While the primary analysis was under-powered, differences in care over the last month of life suggest FCC may have facilitated a palliative approach to care. Future trials of case conferencing should consider reassessment and planning for acute illness and measure a greater variety of processes and outcomes.

P21 A Mapping Study of Palliative and End of Life Care in Far West NSW.

Dr Emily Saurman, Research Fellow-Rural Health; Broken Hill University Department of Rural Health, Corrindah Court PO BOX 457, Broken Hill NSW 2880; emily.saurman@sydney.edu.au 08 8080 1206

Dr Sarah Wenham, Specialist Palliative Care Physician; Far West Local Health District, PO BOX 457, Broken Hill NSW 2880; sarah.wenham@health.nsw.gov.au 08 8080 1357

Ms Melissa Cumming, Director Cancer Services, Innovation & Palliative Care; Far West Local Health District, PO BOX 457, Broken Hill NSW 2880; melissa.cumming@health.nsw.gov.au 08 8080 1452

Prof David Lyle, Head of Department; Broken Hill University Department of Rural Health, Corrindah Court PO BOX 457, Broken Hill NSW 2880; david.lyle@health.nsw.gov.au 08 8080 1200

Background: The National Palliative Care Strategy promotes “a coordinated and consistent approach to the delivery of high-quality palliative care across Australia”. The Far West Local Health District (FWLHD) in NSW serves 30,000 residents across 195,000km2. However, there is has previously been no formal pathway to direct the delivery of quality palliative and end-of-life care (PEoLC) across all settings and providers in remote NSW.

There are approximately 300 deaths each year in FWLHD, with just over half of the expected deaths accessing the Specialist Palliative Care Team.  A new integrated needs-based model of care is being developed in the FWLHD to support the provision of quality PEoLC and enable access to a consistent palliative approach to care for all patients regardless of their age, diagnosis, care provider, or setting. This mapping study will inform the development and implementation of the new model of care.

Methods: We conducted interviews with 15 key generalist and specialist providers to determine and understand the current process of providing PEoLC in the FWLHD. The aim was to describe the current process of care provision, including who is involved and what care is provided.

Key Findings: A network of services is already involved in the provision of PEoLC in the FWLHD, but their connections are tenuous. Initial results demonstrate that generalist providers are each using different criteria to identify and manage patients or refer them to specialist services. All generalist interviewees voiced a need for further training and education to increase their knowledge and improve their confidence to provide a palliative approach. Everyone identified the need for supported collaboration and communication across services to improve care.

The challenge for the model is to ensure that all patients get access to quality care regardless of their age, diagnosis, care provider, or setting. The next step is to map this information against process elements of the new model to identify how the new model will fit and fill current gaps or areas for improvement.

P22 Transforming Conversations: enabling stories around death and dying.

Gabrielle Asprey*, Telephone and Internet Group Facilitator; Sally Carveth*, Assistant Coordinator Cancer Support Group Leader Program; Kim Pearce*, Coordinator Cancer Support Group Leader Program

*Cancer Council NSW, 153 Dowling Street, Woolloomooloo NSW 2011, tsg@nswcc.org.au 1300 755 632.

Background: Telephone support groups (TSGs) are beneficial for people diagnosed with cancer, those who care for them and those who are bereaved1.  Connecting with others affected by cancer helps ease feelings of isolation, enhances sense of control, helps integrate losses and brings relief through sharing concerns of lifelong changes.  TSGs particularly benefit people who are geographically, socially or medically isolated. For 15 years Cancer Council NSW’s TSGs have enabled Transforming Conversations between people across Australia diagnosed, or who are (or were) caring for someone, with a life limiting cancer.

Methods: The model of TSG utilised is Mutual Aid/Peer Support.  Importantly, facilitators are professionally trained health professionals, acknowledged as providing positive benefits to group members.2 In addition to the psychosocial and emotional benefits, group members learn from each other about available services and support, and can talk in a safe space about the realities of end of life issues. Facilitators observe many group members have misconceptions about Palliative Care, assuming it is only for people about to die.  Members are therefore reluctant to ask about the service. One regular group member said “palliative care wasn’t a ‘death blow’ after all but a life-enriching experience”.  Stories about death and dying are shared in a supportive, safe and caring way.

Results: In terms of death and dying, TSG conversations follow themes of unawareness, hesitation, reluctance, fear of not being positive and unknowingness. By participating in TSGs, members learn from each other about services and support available and have a safe space to talk about the realities of end of life. Cancer Council therefore has a unique opportunity to change perceptions of Palliative Care and enable conversations about death and dying.

1 Ussher, Jane, et al. (2006). What do cancer support groups provide which other supportive relationships do not? The experience of peer support groups for people with cancer. Social Science & Medicine, 62, 2565-2576

2 Dunn, J., et al (2003). A review of peer support in the context of cancer. Journal of Psychosocial Oncology, 21, 55-67

P23 Title: Enhancing patient and family quality of life in a palliative care setting through music.

Mary Ashton, Pastoral Care Manager, Helen Dawson, Social Work Head of Department, Anne Johnson, Social Worker, Mary McEnearney, Pastoral Care Worker, Calvary Health Care Kogarah, New South Wales, Helen.dawson@health.nsw.gov.au, (02) 95533498

Abstract: This abstract outlines a poster presentation on the introduction of music options for patients and their family members in the Palliative Care Unit at Calvary Health Care Kogarah. In 2015, 2 portable harps were purchased following a submission to management by the social work and pastoral care teams. The aim of their introduction was to provide a positive addition to patient and family care, which is in keeping with the conference theme of Transforming the Landscape of Dying. These harps are light weight and able to be played by anyone, regardless of musical knowledge. They are particularly suited to frail people as they can be played whilst lying down. The poster will outline the aims of introducing the harps, the consideration of practical and infection control issues, the way pastoral care workers and social workers have integrated the harps into their work and discussion of the impact of the harps. The poster will particularly highlight the use of the harps with families through case studies, including with children, as well as future plans to more formally evaluate patient and family feedback.

P24 EMU:  The End-of-life Minimum Universal clinical quality and outcomes reporting tool.

Dr Inca Hutchinson, Junior Medical Officer; Dr Emily Saurman, Research Fellow-Rural Health, Broken Hill University Department of Rural Health; Dr Sarah Wenham, Specialist Palliative Care Physician, Far West Local Health District.

Background: Data reporting the quality and outcomes of palliative and end-of-life care (PEoLC) is limited to collections for Specialist Palliative Care Services (SPCS). However, not everyone with a life-limiting illness will need or access specialist care, and there is little evidence for the quality and outcomes of care for those patients that receive PEoLC from non-specialist providers. The End-of-life Minimum Universal clinical reporting tool (EMU) has been developed to help measure, report, and benchmark outcomes for all patients receiving PEoLC in all care settings. While created within the structure of the Far West NSW Palliative and End-of-Life Model of Care, the EMU is designed for universal application.

Methods: The development of EMU was conducted in two steps. Step one was a review of:

  1. information and data currently recorded in patient records across four care settings: general practice; residential aged care facility; hospital in-patient; and SPCS
  2. international and Australian literature to identify tools and other recommendations for reporting quality PEoLC.

Step two aligned the recommended tools with the model structure and current practice ensuring feasibility and relevance while minimising duplication in clinical documentation. The tools and indicators were chosen for application within context and in line with current aims, indicators, and tools for a palliative approach to care.

Key Findings: EMU identifies indicators of effect that relate to seven aims for a palliative approach to care. These aims align to the Model of Care, respond to the National Palliative Care Strategy, and are aligned to the NSW Agency for Clinical Innovation’s Essential Components in the Palliative and End-of-Life Care: Blueprint for Improvement. The recommended clinical tools are open access, relevant and validated, however the EMU may be effectively used with local substitutes.

EMU is designed for universal application and has translational potential to be embedded within current clinical documentation and demonstrate a quality palliative approach to care for all patients, from any provider, in any setting. The next step is to test the EMU in practice.

P25 What is the evidence for conducting family meetings in palliative care? –  A systematic review.

Cahill PJ1, Phillips JL2, Lobb EA3, Sanderson CR4

1 Philippa Cahill, PhD candidate, University of Notre Dame Australia, Sydney, NSW

2 Professor Jane Phillips, Professor of Nursing, Director Centre for Cardiovascular and Chronic Care, University of Technology Sydney and Adjunct Professor, School of Nursing, University of Notre Dame Australia, Sydney and School of Medicine, University of Sydney, Sydney, NSW, Telephone: +61 2 9514 4822

3 Professor Elizabeth Lobb, Professor of Palliative Care, Calvary Health Care Kogarah and Adjunct Professor, School of Medicine, University of Notre Dame Australia, Sydney, NSW

4 Associate Professor Christine Sanderson, School of Medicine, University of Notre Dame Australia, Sydney, NSW and Palliative Care staff specialist, Calvary Health Care Kogarah, NSW

AIMS: This systematic aimed to examine the evidence to support the use of family meetings in the inpatient palliative care setting as a strategy to address the needs of patients and their families and to determine the impact of these meetings on those participating.
 
METHODS: The PRISMA statement informed the review.  Studies were identified that described planned or unplanned family meetings conducted for patients with advanced cancer or other life limiting conditions receiving primary or specialist palliative care. The meetings required attendance by family and palliative care team members and the patient might also have participated.  The included studies provided a rationale for family meetings and the processes involved, and also described the outcomes and/or outcome measures.  Six specialist medical and psychosocial databases and Caresearch were used to identify studies reporting empirical data published in English language peer-reviewed journals from 1980 to March 2015.  Randomised controlled trials, non-randomised or qualitative studies were eligible. All study abstracts were screened for inclusion. Data was extracted and the Cochrane Collaboration tool assessed risk of bias.

RESULTS: Thirteen studies met the inclusion criteria out of 5051 identified studies. Of the ten quantitative studies, one study surveyed clinicians’ family meeting practice, two studies undertook a retrospective chart review of meeting components, three studies used pre-post test family outcome measures and four were prospective observational studies. Three qualitative studies described family meeting models. Two studies used a validated tool to assess family outcomes but only one study demonstrated significant results.

CONCLUSIONS: Few studies generated high-level evidence or evaluated family meetings from the patient, family or clinician perspective. No study used validated measures to report patient, clinician or service outcomes. Overall there is a paucity of evidence to support the routine use of family meetings in the inpatient palliative care context.  Further research using robust designs including validated outcome measures and economic analysis is required to build the evidence base.

Funding acknowledgement: This project was supported through the Australian Government’s Collaborative Research Networks (CRN) program.

P26 Exploring the sleep of caregivers looking after someone in palliative care for advanced cancer.

Ms Kirstin F Maltby – University of Notre Dame Australia, 160 Oxford St, Darlinghurst 2010, Australia. Kirstin.maltby1@my.nd.edu.au, 0433778438

A/Prof Christine Sanderson – University of Notre Dame Australia, 160 Oxford St, Darlinghurst 2010, Australia. Christine.sanderson@health.nsw.gov.au, 02 9553 3111

Prof Elizabeth A Lobb – University of Notre Dame Australia, 160 Oxford St, Darlinghurst 2010, Australia. Liz.lobb@sesiahs.health.nsw.gov.au, 02 9553 3093

Prof Jane L Phillips – University of Technology Sydney, PO Box 123, Ultimo 2007, Australia. Jane.phillips@uts.edu.au, 02 9514 4822

Background: The round-the-clock care needs of patients with advanced cancer can mean that caregivers sleep can become compromised. The impact and consequences of sleep disturbances on health and wellbeing are well documented in healthy adults subjects. A systematic review performed to inform this protocol identified 10 international studies assessing the sleep of caregivers of advanced cancer patients. These studies found that 72-100% of the caregivers reported moderate to severe sleep disturbances. Caregivers also did not achieve the recommended 7-8 hours of sleep with most caregivers averaging 270.14 minutes (± 53.76) over a 24-hour period. These results demonstrate the need to investigate whether sleep disturbances are a burden for Australian caregivers.

Aim: The aim of this project is to describe the methods that will be undertaken to investigate caregivers’ perception of their sleep, the burden, and consequences of sleep disturbances.

Methods: This study is the first part of a three-phase exploratory mixed methods project exploring the sleep of caregivers of patients receiving palliative care for advanced cancer.  40 caregivers will be recruited from community palliative care services at three Sydney hospitals: Sacred Heart, Calvary Health Care Sydney, and Hammond Care Greenwich. Of the 40 caregivers recruited 30 will live at the same residence as the patient and 10 will live separately.

Caregivers will complete questionnaires that measure their sleep quality (Pittsburgh Sleep Quality Index), level of depression (Center for Epidemiological Studies – Depression), and level of burden (Zarit Burden Interview – Short). After these are completed caregivers will take part in semi-structured interviews investigating their perceptions of their sleep.

Descriptive and correlational statistics will also be performed between caregivers’ sleep quality and their results depression and burden results.  Comparative analysis will also be performed between caregivers living with the patient and apart. Analysis of transcripts will use open, axial coding guided by theoretical and procedural direction from grounded theory to generate study themes.

Results: Findings from this project are designed to provide an understanding of caregivers’ perception of their sleep and whether sleep disturbances are a burden for caregivers that requires assistance from palliative services to optimise their sleep.

P27 Exploring how education strategies can address barriers to early implementation of palliative care.

Miss Laura Southam, Registered Nurse, Western Australia Country Health Service, 14 Clint Way, Calista, 6167, 0424172446, laura_southam8@hotmail.com

Introduction: Early implementation of palliative care is beneficial for patients, leading to an increased quality of life and potentially better outcomes. Despite this there is limited evidence to show that early implementation is occurring.

Aims: The aim of this literature review is to firstly identify the importance of palliative care, then to identify common barriers to early implementation of palliative care and to discuss the importance of education strategies that may overcome these barriers.

Approach: The literature assessed in this study was gathered through a search of the CINAHL plus, Proquest and Medline databases using the key terms: palliative care, end of life care, barriers, education. This process identified a number of relevant articles, whose reference lists supplied further pertinent documents. Additional articles were also acquired through targeted web based searches using the same terms.

Findings: One potential barrier to early implementation could be the perception of patients that the receipt of palliative care means that death is imminent. Other barriers may include health care professional perception and knowledge, such as a belief that treatment may not continue under palliative care, which potentially leads to incomplete information given to patients and reluctance to refer patients to palliative care.

Discussion: As an inaccurate perception can be a barrier to patients accessing palliative care, it is imperative that health professionals receive education that challenges their current perceptions of palliative care, which can then impact upon patient perceptions through education.

Conclusion: Improving education delivery to health professionals will lead to an improved perception of palliative care and thus an increase in accurate patient education and referrals to palliative care.

Conflict of interest: This presentation has been prepared as a part of the requirements for the graduate diploma in nursing by the University of Notre Dame Australia.

P28 WITHDRAWN

P29 Death Anxiety from Avicenna and Ellis viewpoint: comparative-eclectic approach.

Mahmood Azadi, Phd Student of Psychology Email : mahmoodazadi@rihu.ac.ir , Research Institute of Hawzah and University , Address: Iran- Qum- Pardisan. M: +989158051520

The certain occurrence of death for all people distinguished this anxiety from health anxiety or phobias and other anxiety disorders which are possible. One of the most widely used theory investigating the role of irregular beliefs on anxiety, is rational emotional theory of Albert Ellis. According to Ellis, negative emotions like stress are often associated with irrational beliefs that generally based on an event.Avicenna also as one of the leading Muslim medieval philosophers suggests that death anxiety was caused by irrational beliefs.The study is citation analysis, analyzing the Arabic Book of Avicinna titiled "al-Shifa- Men- Khaf- mawt" examining the theory of Avicenna about death anxiety comparing to rational emotional theory of Albert Ellis. Some similarities found between two theories were both suggest that the causes of death anxiety are irrational beliefs but the difference between the two theories emerged from the word “reality” as Ellis doesn’t consider it  in the treatment, whereas, Avicenna regards objective reality in his theory.

Conclusion : four themes as the causes of death anxiety are emerged from Avicienna Therory which are : 1.If I  die i will be destroyed completely. 2 Dying associated with severe pain 3. If I  die , I will be tormented for my sins in the next world 4. If I die, my family, possessions will be lost and no one is able to care them . Recommendations: Based on the results, it is suggested that Muslim therapists and palliative care providers having special attention to the iratinal beliefs expressed in opinions of Avicenna regarding Muslim near death exprencice, as his ideas rooted in Islamic culture.

P30 GET READY, GET SET, GO! An exploration into patient access to a Specialist Palliative Care Unit.

Marie Chapman – Clinical Coordinator, Inpatient Palliative Care Unit, Calvary Health care Kogarah

Introduction: Access to Palliative Care is advocated as “a legal obligation and a human right” (European Association for Palliative Care, 2016). The Palliative Care Outcomes Collaboration (PCOC) is a national program that utilises standardised clinical assessment tools to measure and benchmark patient outcomes in palliative care. During 2014 – 2015, it became evident that our Palliative Care Unit (PCU) was not achieving Benchmark 1 – Time From Date Ready For Care To Episode Start. This benchmark is a measurement of the responsiveness of the Palliative Care Service to meet patients’ access needs.

Objective: To investigate why the PCU was not meeting the National PCOC Benchmark Outcome Measure 1 – Time From Date Ready For Care To Episode Start.

Method: The Palliative Care Clinical Co-ordinator investigated the existing referral process through a retrospective review of the clinical records of two hundred and twenty four patients admitted to the unit from June 2013 to June 2015.

Results: It was identified that there were many inconsistencies in the way that referrals to the unit were being received, triaged, and documented. It was identified that:

  1. Patients were often being identified by the referrer early i.e. before they were actually ready for admission to the unit. The referrer was using the referral process as a form of “Get Set” notification, whereas the PCU viewed the referral as a “Go” call i.e patient was ready for admission on receipt of referral.
  2. When a referral was received there was often no contact or triage opportunity with the sender, before the referral was added to the Waiting list.

Conclusion: From these results, strategies were implemented that included liaising directly with the referrer at the time of referral, to establish the patient’s readiness for care. By enabling a more collaborative response to the referral process the national benchmark has now been achieved. 

P31 Sleep disturbance of adults with brain tumour and their family caregivers: A Systematic review.

Ms Megan Soohwa Jeon *, South Western Sydney Clinical School, The University of New South Wales, Ingham Institute, Liverpool Hospital, m.jeon@student.unsw.edu.au, +61 433 920 860

Dr Haryana M Dhillon, Centre for Medical Psychology & Evidence-based Decision-making, The University of Sydney, The Lifehouse, The University of Sydney, haryana.dhillon@sydney.edu.au  +61 2 9036 5392 | F +61 2 9036 5420 | M +61 421 867 180

A/Prof Meera Agar, South Western Sydney Clinical School, The University of New South Wales, Ingham Institute, Liverpool Hospital, Meera.Agar@sswahs.nsw.gov.au, +61 430 212 912

Background: The incidence and psychophysiological morbidities of sleep disturbance in cancer have been increasingly recognised. Yet, understanding sleep disturbance and options for management have been neglected areas in both clinical care and research. Brain tumour patients have been particularly overlooked.

Aim: This review evaluated existing evidence for sleep disturbance in adults with primary or secondary brain tumour and their family caregivers. It focused on identifying the; 1) prevalence and clinical variables associated with sleep disturbance, 2) relationship between objective and patient-reported outcomes, 3) available sleep interventions; and, 4) association between patient-caregiver dyad’s sleep.

Methods: A systematic search of 7 empirical databases and grey literature from 1990 to 2015 was conducted. The evidence was independently reviewed by the authors and underwent quality assessments.

Results: Of the 50 studies that met the inclusion criteria, all were descriptive in design (12 focused on sleep, 37 reported sleep items within a health-related quality of life measure and 1 reported caregivers’ sleep). No sleep intervention was found to have been developed or tested for people with brain tumours. Five main sleep complaints were identified: i) dissatisfaction with sleep quality; ii) non-specific disturbed sleep; iii) insomnia symptoms; iv) sleep apnoea; and, v) somnolence. Non-specific disturbed sleep and somnolence were most prevalent across the disease course or treatments, along with fatigue and poorer quality of life. Studies using objective sleep assessments yielded inconsistent results in small samples of mostly benign brain tumours. Caregivers had disturbed sleep and poor sleep quality at the time of the patient’s diagnosis, and sleep complaints were associated with their level of self-reported anxiety. There was a lack of data to determine associations in the patient-caregiver sleep.

Conclusions: Studies included highly heterogeneous samples with diverse clinical features. Methodological issues, such as high attrition rates and use of single-item sleep assessments in longitudinal, observational designs, make the evidence from these studies weak. A more systematic examination of sleep disturbance in brain tumour patients and caregivers is warranted to build the evidence base for suitable interventions.

P32 Where’s the competency? Allied health involvement in palliative care in rural and remote settings.

Melanie Blair and Danielle Kennedy

Symptom management and quality of life are important facets of palliative care. Oral food and fluid intake form an integral part of this across several of the palliative care phases. This is related to the core skills of the often lesson known allied health disciplines of speech pathology and dietetics.

Speech pathology and dietetics play an active role in the palliative care multidisciplinary team in Broken Hill Health Service.  Referral of palliative care clients for individual assessment and intervention forms a significant portion of adult outpatient referrals for both departments, 12/27 (44%) speech pathology and 31/210 (15%) dietetics in 2015. Additionally allied health clinicians act as a resource person to the specialist palliative care service allowing for continuity of care.

In rural and remote settings, clients often need to access tertiary referral sites to have radical surgery or treatment however return to smaller local sites with symptom management needs, requiring local clinicians to continue care often with a palliative approach.

Despite palliative care involvement forming a significant caseload for both departments minimal palliative care education in receiving during university training for both professions and limited opportunities exist to access specialist training. Instead the roles of speech pathology and dietetics in palliative care remain undefined and health professionals find themselves being asked to increase their input when their formal training has ended.

In transforming the local landscape of allied health involvement in palliative care in a rural setting, a larger question is posed, how do we transform the much larger landscape of university level competencies and or availability of training?   

P33 Changing Landscapes – From arid to bountiful Allied Health education in Palliative Care.

Michael Bayley Michael.bayley@sswahs.nsw.gov.au 8738 7432, Claire Tamone, Claire.tamone@sswahs.nsw.gov.au , 8738 6556

Background: Allied Health clinicians not working regularly in a Palliative Care setting reported not feeling confident in their skills in Allied Health assessment, monitoring and documentation to meet evidence based practice and medico-legal requirements for palliative patients. There were no Allied Health specific palliative care professional development opportunities in The South Western Sydney Local Health District (SWSLHD).

Aim: To organise an education forum for Allied Health clinicians to learn about the fundamentals of palliative care. These included symptom management, enhancing quality of life, psychosocial and spiritual support, bereavement and family support for clients at the end of life. It was also important to offer education aimed at developing skills in communication. The aim of an education forum was to learn about the Allied Health role in managing symptoms in patients who are palliative such as pain management, pressure care, oral hygiene/comfort, dysphagia, constipation, breathlessness, anxiety and depression.

Setting/participants:  96 participants with an Allied Health background participated an education forum. The forum was aimed at clinicians from SWSLHD although it was also opened to those working outside the district. 42 of these completed a pre and post forum evaluation.

Results: A total of 96 clinicians participated in the education day, with 42 respondents completing an evaluation. 21 of these respondents reported an increase both knowledge of palliative care and an increase in their confidence to initiate interventions in Palliative Care from low to high on a Likert scale. Only 3 respondents did not report a significant difference, and these were clinicians already working in Palliative Care and reported that they had high amount of knowledge prior to the forum.

Conclusion: Results from the evaluations show a definite need for this kind of education forum. The results also suggest that the forum was successful in tailoring education to Allied Health clinicians. A second Allied Health education forum will be held later this year at Liverpool Hospital. 

P34 The Memory Garden Series: Transforming the Landscape of Paediatric Death.

Natasha Samy, Bereavement Coordinator & Elizabeth Shepherd, Program Development & Quality Manager – Children’s Hospital at Westmead.

Grief and bereavement can be a very isolating experience for many adults. This can be an even greater challenge for children who are experiencing grief around their own death or that of their sibling. Terminal care and the subsequent death of a child is a distressing and confronting time for a family and their wider community.

There can be pressure on parents, carers and health professionals to talk to children in the ‘right’ way about death. Ideally, children have the best psychological outcomes if open and honest communication is facilitated to help them understand what is happening rather than shielding them from the truth. Starting these conversations and finding the right words is difficult. It is even more challenging for parents/carers who are themselves trying to process and conceptualise a prognosis or a death, to then have to explain this to their children.

There are limited age appropriate resources available for parents/carers to help them begin conversations with their children about death and dying. To address this gap and to begin transforming the landscape of childhood death, the Palliative Care Service at the Children’s Hospital at Westmead has developed a three-story series that normalises death for children and also provides an opportunity to begin conversations about death and grief.

The Memory Garden Series are three fictional stories about a dying child, Iris, and her two siblings, Hazel and Leo. All three books have the same plot, but the unique story is told through the eyes of each child. Using bright illustrations, age-appropriate language to incorporate the concepts of grief and loss, this resource aims to help children aged 5-12 years understand death and dying. They can be used by health professionals, teachers and family members.

Reflecting our diverse paediatric palliative care patient population, the characters depicted in the stories have no identifiable illness or cultural background, making them relatable to all children.

The Memory Garden Books are a new resource to assist in transforming the landscape of palliative care by normalising death and grief for children by speaking about it in an open and honest manner.

P35 Identifying opioid medication error types, incidence and patient impact in adult palliative care and cancer services: a systematic review.

Ms Nicole Heneka1, Prof Tim Shaw2, Adjunct A/Prof Debra Rowett3, Prof Jane Philips1,4.

  1. University of Notre Dame Australia, Darlinghurst NSW
  2. University of Sydney, Sydney NSW
  3. Repatriation General Hospital, Adelaide SA
  4. University of Technology Sydney, Sydney NSW

Background: In Australia, the majority of patients utilising palliative care services have a primary diagnosis of cancer, and are likely to receive opioids for pain or symptom management at some point in the course of their illness. Opioids are a high risk medicine and one of the most frequently reported drug classes in medication errors causing patient harm. Despite their widespread use, little is known about the incidence, error types and patient impact of opioid medication errors in palliative and cancer services. Aim: To identify the incidence, types and patient impact of opioid medication errors in adult palliative care and cancer services reported in the peer reviewed literature. Methods: A systematic literature review was undertaken from 1980 to 2014. Empirical studies, published in English, reporting data on opioid medication error incidence, types or patient impact, in adult palliative care and/or cancer services were included. Results: This is the first review to systematically identify opioid errors reported in adult palliative care and cancer services. Of 133 potential studies, five studies met the inclusion criteria. These studies reported patient data from the clinical setting (n=3), the home care setting (n=1) and palliative care clinicians’ perceptions of opioid errors (n=1). The predominant opioid error type in the clinical setting was deviation from opioid prescribing guidelines, reported in 81% of patients. Deviations included incorrect opioid dosing intervals (11%–81%), no ‘as needed’ (PRN) analgesia ordered for patients with regular opioid orders (17%–29%), no pre-emptive prescribing of anti-emetics and/or laxatives to treat opioid side effects (15%–24%). An administration error incidence of 49% by non-professional family caregivers in the home was reported, however, no studies reporting opioid administration errors in the clinical setting were identified. Patient harm resulting from opioid errors in the clinical setting was not reported in the included studies. Conclusions: Opioid error reporting in palliative care and cancer services is an under-explored area of patient safety. Future research which explores and quantifies other opioid error types, e.g., administration errors, device errors and near-misses, and assesses the degree of patient harm from opioid errors in palliative care and cancer services is warranted.

P36 Identifying opioid error types and patient impact in specialist palliative care services – preliminary results from a multi-site quality audit.

Authors: Ms Nicole Heneka1, Prof Tim Shaw2, Adjunct A/Prof Debra Rowett3, Dr Sam Lapkin4, Prof Jane Philips1,4.

1. University of Notre Dame Australia, Darlinghurst NSW

2. University of Sydney, Sydney NSW

3. Repatriation General Hospital, Adelaide SA

4. University of Technology Sydney, Sydney NSW

Background: Medication errors disproportionately affect patients at the end of life, due to their frailty, seriousness of their illnesses and the complexity of their treatment regimens. Opioids are a high-risk medicine, used routinely in palliative care services to manage complex pain and symptoms such as dyspnoea and cough at the end of life. Varying routes of opioid administration, numerous dosage forms with differing potencies, similar drug names, and routine dose calculation/conversion all compound the risk of error with opioids. Despite their widespread use, there is little empirical research on opioid medication error types and patient impact in palliative care services, beyond deviations from opioid prescribing guidelines.

Aim: To identify the types, frequency and patient impact of reported opioid medication errors in three specialist, adult palliative care services in New South Wales (NSW).

Methods: A quality audit of incidents and errors involving opioids, reported via the internal incident management system over 24 months, in three specialist palliative care services in NSW.

Results:  Preliminary data analysis identified 128 incidents involving opioids across the three services. All errors were categorised as either severity assessment code (SAC) 3 (55%) or SAC 4 (45%), with  55% (n=70) of errors reaching the patient. Morphine (32%) and hydromorphone (30%) were implicated in the majority of opioid errors. The predominant error type reported were administration errors (44%, n=56), followed by controlled drug discrepancy errors (27%, n=34), drug storage/wastage errors (12%, n=15) and prescribing errors (7%, n=9). The three most common administration error types were: omitted opioid doses (14%, n=18), wrong dose administered (12%, n=15) or wrong drug  administered (9%, n=12). Errors with transdermal patches accounted for 6% (n=8) of administration errors. Missed opioid administration (under-dose) accounted for 46% of the errors that reached the patient, contributing to 18% of these patients experiencing sub-optimal pain management and requiring additional analgesia administration.

Conclusions: This preliminary data has identified the range of opioid errors reported in specialist palliative care extends beyond deviations from opioid prescribing guidelines, and provides a starting point for targeted quality improvement initiatives to support safe opioid medication practices in specialist palliative care services.

P37 Transforming the Palliative Approach in Residential Aged Care Facilities in Broken Hill.

Ms Rebecca Dalwood, Palliative Care Clinical Nurse; Broken Hill Palliative Care Team. PO BOX 457, Broken Hill NSW 2880; rebecca.dalwood@health.nsw.gov.au 08 80801645

Dr Sarah Wenham, Specialist Palliative Care Physician; Far West Local Health District, PO BOX 457, Broken Hill NSW 2880; sarah.wenham@health.nsw.gov.au 08 8080 1357

Ms Melissa Cumming, Director Cancer Services, Innovation & Palliative Care; Far West Local Health District, PO BOX 457, Broken Hill NSW 2880; melissa.cumming@health.nsw.gov.au 08 8080 1452

Ms Elizabeth (Liz) Perrie, Quality and Education Manager: Southern Cross Care Broken Hill, PO BOX 695, Broken Hill NSW 2880; lperrie@sccbh.com.au 08 80801800

Background: In 2015, the Far West LHD Specialist Palliative Care Team (SPCT) obtained an $80,000 grant under the ‘Decision Assist Linkages Project’ to enhance linkages between RACFs and SPCT to;

  • facilitate quality end of life care for RACF residents
  • reduce unnecessary hospital transfers (hospital avoidance model)
  • promote a palliative approach and dying in usual place of residence
  • avoid inappropriate referrals to SPCT

This poster outlines the successes of the Broken Hill-arm of the project.  

Methods: A systems approach was used to make sustainable changes to the way palliative and end of life care is provided across the three Southern Cross Care RACFs. Planning meetings to engage key stakeholders and a mapping day to scope the current resident journey in end of life care were held. Baseline data was collected to measure outcomes at the project’s conclusion.

A Palliative Care Link-Nurse was seconded from the SPCT to work 0.5 FTE for 12 months. The link-nurse was “not there to do the work” but to provide education, mentorship and ‘modelling’ a palliative approach to care in RACFs. Emphasis was placed on identifying residents who required a palliative approach, arranging family meetings, liaising with the GP, advance care planning, and anticipatory planning. ‘Palliative Approach’ champions were identified across the facilities, and these roles have been further developed. A local toolkit and suite of documentation was developed to assist staff provide a palliative approach to care for residents with non-complex needs.   

Key Findings:

  • Comparison data between 2013 and 2015 demonstrates that the SPCT received more appropriate and timely referrals for residents with complex needs and that more RACF residents died in the RACF with fewer dying in hospital indicating greater confidence in RACF staff to manage end of life care.
  • 0.5 FTE ‘Palliative Approach Coordinators” have been appointed by the RACF to continue the implementation of a Palliative Approach across the three facilities.
  • The project is sustainable and transferable, with work continuing to adapt the project for other non-specialist settings in the Far West.

P38 The Supportive and Palliative Care Indicators Tool (SPICT):  can it be used to trigger transition to a palliative approach and improve care for patients with a non-malignant life-limiting disease in a remote care setting?

Mr Jeffrey Duncan, Medical Student, University of Wollongong, Extended Clinical Placement Program, Broken Hill University Department of Rural Health, Corrindah Court PO BOX 457, Broken Hill, NSW 2880; jd340@uowmail.edu.au  08 8080 1206.

Dr Sarah Wenham, Specialist Palliative Care Physician, Far West Local Health District, PO BOX 457, Broken Hill NSW 2880; sarah.wenham@health.nsw.gov.au  08 8080 1357.

Dr Emily Saurman, Research Fellow-Rural Health, Broken Hill University Department of Rural Health, Corrindah Court PO BOX 457, Broken Hill, NSW 2880; emily.saurman@sydney.edu.au  08 8080 1206.

Background: The Australian Commission on Safety and Quality in Healthcare National Consensus Statement (2015) purports ‘a fundamental first step in providing safe and high-quality end -of-life care is to recognise those patients who would likely to benefit from such care’, and recommends the use of a recognition system to assist identifying patients who are likely to die within the next 12 months.

The Supportive and Palliative Care Indicators Tool (SPICT) is a validated tool that has been demonstrated to assist clinicians in identifying and assessing patients with life-limiting disease who may have unmet supportive and palliative care needs.

Aim: To assess:

  • the sensitivity of the SPICT to trigger an early transition to a palliative approach in patients with non-malignant life-limiting disease in a remote LHD
  • the impact that such an approach has on clinical outcomes

Method: A retrospective cross-sectional case note audit was undertaken for all adult patients with a non-malignant life-limiting disease who died within a remote LHD over a 12 month period.  Analysis of the quality of palliative and end-of-life care received by ‘SPICT positive’ patients was undertaken using Auret’s validated tool.  Data was analysed using descriptive statistics and Fischer Exact Chi Square tests. Human Research Ethics Committee approval was granted.

Results: 112 eligible patients; 40% total deaths. 60% SPICT positive; 40% received palliative approach (77% and 40% identified in last month and week of life respectively).  55% were male; mean age at death was 81.2 years. 

Identification and transition to a palliative approach demonstrated statistically significant improvements including:

  • Reduced ICU admissions
  • Increased documentation of advance care planning and resuscitation status
  • Increased provision of comfort measures and effective symptom management in the last days of life
  • Provision of end-of-life care in line with patients wishes, including place of death

Conclusion: The SPICT can be used to effectively identify patients with non-malignant life-limiting disease in a remote care setting, facilitating the transition to a palliative approach with demonstrated improvements in quality of care.  The next step is to implement the use of SPICT across the LHD to assist earlier identification of patients in the last year of life.

P39 Developing Rural and Remote Palliative and End-of-Life Care Research in Far West NSW:  the story so far…

Dr Sarah Wenham, Specialist Palliative Care Physician, Far West Local Health District, PO BOX 457, Broken Hill NSW 2880; sarah.wenham@health.nsw.gov.au  08 8080 1357.

The Far West Local Health District (FWLHD) is a remote region with approximately 30,000 people living across 194,949kms.  Twenty-four hour palliative and end-of-life care (PEoLC) services are provided throughout the region by community services, healthcare organisations, and specialist palliative care service.  Whilst it is known that a palliative approach improves patient care and outcomes, previously there was no formal structure to guide the delivery in the FWLHD.

However, that landscape is changing with the development of the Far West Palliative and End-of-Life Model of Care (FWPEoLMoC), specifically designed to address the needs of a rural and remote population, offering a unique whole-of-system response, integrating generalist and specialist services, ensuring patients receive high-quality needs-based care from the right provider, at the right time, in the place of their choosing, regardless of age or diagnosis.  Learning lessons from others, the Far West team is committed to ensure any new intervention implemented is underpinned with independent robust formal prospective assessment.  This ignited the desire to create a palliative care research culture in Far West NSW.

The palliative care research relationship began between the FWLHD and the Broken Hill University of Sydney Department of Rural Health (UDRH) in 2007, with a research capacity building project.  Since 2013, these relationships have developed with a number of research activities to support and evaluate the development and implementation the FWPEoLMoC; these will be presented in detail.

Success factors to date include:

  • A clear and shared vision to improve care and enhance the evidence-base in line with state, national, and international strategy, policy and best practice.
  • Integration between co-located healthcare organisations, facilitated by supportive working relationships that develop in a small rural town
  • Commitment from partner organisations to support a research culture, even when research grant funding was not forthcoming
  • Facilitation of medical student research projects with joint supervision by FWLHD Palliative Care Team and UDRH Research Team
  • Collaboration with external research partners, including Australian Rural Health Research Collaborative (ARHRC) and Flinders University
  • The Far West PEoLC research journey continues, now travelling beyond the model of care, as the clinical and research teams grow and the enthusiasm spreads.

P40 Assessment and Treatment of Lower Limb Radiation Induced Fibrosis and Lymphoedema in Palliative Care.

Tara Quinn – Senior Occupational Therapist – Ramsay Healthcare, John Flynn Private Hospital, 42 Inland Drive, Tugun 4224, (07) 5598 9763 Email: quinntara@ramsayhealth.com.au

Subcutaneous Radiation induced fibrosis (RIF) is a serious but uncommon complication of radiotherapy which causes local, late and unavoidable damage to normal tissue, which can lead to pain, neuropathy, decreased range of movement (ROM) and lymph node swelling. Lymphoedema is the accumulation of excessive amounts of protein-rich fluid resulting in swelling in one or more regions of the body. It is due to a mechanical failure of the lymphatic system and occurs when the demand for lymphatic drainage exceeds the capacity of the lymphatic circulation.

This poster will explore how a multi-disciplinary team approach to an unusual presentation can transform individual care holistically.  A case study of a 62 year old man diagnosed with large cell lung cancer (LCLC) and subsequent diagnosis of a lytic lesion in the left femur will be explored. Eight months post-insertion of an intramedullary nail, this man presented with a hard, fibrotic area of induration on his left posterior-lateral thigh, subsequent left thigh swelling and increased pain.. No significant change in swelling upon commencement of diuretic, and a Complex Lymphoedema Treatment (CLT) program was established. This included manual lymphatic drainage (MLD), multi-layer lymphoedema bandaging (MLLB) and gentle AROM exercises. Upon specialist review the patient was diagnosed with subcutaneous radiation induced fibrosis of his left thigh as a result of both high dose radiotherapy and subsequent surgery.

There may have been an element of lymphoedema that responded to conventional treatment which then helped to expose the presence of RIF.

Fortnightly follow up to assess subjective and objective measures, and ongoing physiotherapy and occupational therapy treatment, including exercises, manual techniques and kinesiotaping.

Differential diagnosis was stalled by the commonality of risk factors (RT, surgery, cancer) and symptoms (swelling, tightness, decreased ROM, decreased function, fibrotic skin changes, positive Stemmers sign) of lymphoedema and RIF, and limited clinician experience of the latter.

The implications of this experience are that the MDT should be aware of the variability of presentations of RIF / lymphoedema and their associated symptoms in order to guide management – providing a patient with appropriate, timely therapy and optimising the time invested by clinicians.