Palliative Care Team: The First Year Audit in Japan

Transcription

1 458 Journal of Pain and Symptom Management Vol. 29 No. 5 May 2005 Original Article Palliative Care Team: The First Year Audit in Japan Tatsuya Morita, MD, Koji Fujimoto, RN, and Yo Tei, MD Palliative Care Team and Seirei Hospice, Seirei Mikatabara Hospital, Shizuoka, Japan Abstract In Japan, palliative care team (PCT) services have been covered by National Health Insurance since The primary aims of this study were to compare the characteristics of patients who received PCT services with those admitted to palliative care units (PCU), and to clarify the medical treatments and symptom improvement during the first week after consultation with the PCT. This was a prospective audit study of 111 consecutive cancer patients referred to the PCT in Seirei Mikatabara Hospital and a comparison group of 100 consecutive patients admitted to PCU. As a part of daily practice, we prospectively recorded patient symptoms on a structured data collection sheet at the initial assessment and one week later. Symptom severity was measured by the Japanese version of the Schedule for Team Assessment Scale. After PCT consultation, 25% were discharged to home, 43% died in hospital, 40% died after admission to PCU, and 14% were alive at the end of the study period. Compared with PCU patients, PCT patients were significantly younger, had better performance status, were more likely to be referred with the described aim of symptom palliation, and suffered from more serious pain, appetite loss, somnolence, insomnia, anxiety, and delirium. There were significant improvements in symptom scores of pain, nausea, vomiting, constipation, abdominal swelling, dyspnea, sputum, insomnia, and anxiety during the first week in the PCT group. However, no significant improvements were observed in symptom scores of fatigue, dry mouth, somnolence, and delirium. A median of 3 interventions was performed for each patient, and the most common interventions were administration of NSAIDs, opioids, centrally-acting antiemetics, and steroids. These data indicate that a PCT was successfully implemented in Seirei Mikatabara Hospital, and may contribute to symptom improvement in cancer patients. J Pain Symptom Manage 2005;29: U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Palliative care team, neoplasms, palliative care unit, audit Address reprint requests to: Tatsuya Morita, MD, Palliative Care Team and Seirei Hospice, Seirei Mikatabara Hospital, 3453 Mikatabara-cho, Hamamatsu, Shizuoka , Japan. Accepted for publication: August 7, U.S. Cancer Pain Relief Committee Published by Elsevier Inc. All rights reserved. Introduction The World Health Organization defines palliative care as an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, and states that this is achieved through the prevention and relief of suffering /05/$ see front matter doi: /j.jpainsymman

2 Vol. 29 No. 5 May 2005 Palliative Care Team 459 by means of early identification and impeccable assessment and treatment (pp ). 1 Although palliative care is rooted in compassionate care for dying patients, the primary aim of palliative care is to minimize patient and family suffering at all stages of life-threatening illness. 1 To achieve maximum symptom palliation, the concept of palliative care teams (PCTs) has spread in the past decade, and PCTs are playing important roles in the UK, USA, Canada, and Australia. To date, the usefulness of PCTs has been investigated with a systematic review, 2 randomized controlled trials, 3,4 historical control studies, 5 8 audit surveys of symptom severity, 9,10 descriptive studies about the recommendations done by PCTs, satisfaction surveys of medical staffs, 14,15 an examination about the changes in insight of patients, 16 and a cost-effectiveness analysis. 17 In Japan, the Ministry of Health, Labor, and Welfare has strongly supported dissemination of specialized palliative care services. Coverage of palliative care units (PCUs) by National Health Insurance began in 1991, and the number of PCUs dramatically increased from only 5 in 1991 to 123 in Although Japanese PCUs are called a palliative care unit or hospice depending their religious affiliation, their clinical roles are the same: intensive symptom control and end-of-life care for incurable cancer patients. The majority of them belong to general hospitals, and provide integrated palliative care by interdisciplinary teams in cooperation with home-care services It recently has been well recognized that it is impossible to provide palliative care for all cancer patients using only PCUs, because many PCUs cannot treat patients receiving active anticancer treatments due to economic and staffing strains, because not all patients are willing to be admitted to PCUs, and because the coverage rate of PCU beds to all dying cancer patients is too low (3.6% in 2002). Thus, PCTs have been covered by National Health Insurance since 2002, with the expected role of provision of specialized palliative care to patients receiving active anticancer treatments, those who do not want to be admitted to PCUs, and those waiting for admission to PCUs. Seirei Mikatabara Hospital is 750-bed acute care general hospital, and Seirei Hospice has played an important role in providing specialized palliative care since 1983 as the firstestablished PCU in Japan. To provide more comprehensive cancer care, a PCT was implemented in 2003 after a one-year success in pilot testing. To date, there have been no empirical data available about the characteristics of patients treated by the PCT in comparison with the PCU (i.e., are patients treated by PCTs different from patients admitted to PCUs?). The primary aims of this study were to compare the characteristics of PCT patients with PCU patients, and to clarify the medical treatments and symptom improvement during the first week after consultation with the PCT. Methods The subjects of this prospective audit study were 111 consecutive cancer patients referred to our PCT between April 2003 and February 2004, and the comparison group consisted of 100 consecutive cancer patients admitted to the PCU in the same hospital. All patients were followed up until March As a part of our daily practice, we prospectively recorded patient symptoms on a structured data collection sheet at the initial assessment and one week later. We had decided to adopt the first week as an observation period because we assumed that a short-interval audit was the most sensitive measure of PCT interventions. In addition, we collected data on the therapeutic interventions after consultation with the PCT by a chart review. Severity of pain, fatigue, appetite loss, nausea, vomiting, constipation, diarrhea, abdominal swelling, dry mouth, dyspnea, cough, sputum, fever, incontinence, somnolence, and anxiety was rated by the PCT members on the Japanese version of the Schedule for Team Assessment Scale (STAS). 21,22 The reliability and validity of the Japanese version of the STAS has been confirmed, and we rated symptom levels as 0 (none), 1 (mild), 2 (moderate), 3 (severe), or 4 (extreme). Insomnia was clinically rated as none (0), mild (1), or moderate/severe (2), and depression was rated as present or absent according to a one-question interview. 23 Delirium was diagnosed using the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) and the symptom severity was rated as none (0), mild (1), or moderate to severe (2) on the basis of item 9 of the Memorial Delirium Assessment Scale (Japanese version). 24,25 This evaluation schedule was

3 460 Morita et al. Vol. 29 No. 5 May 2005 developed in a nationwide project to establish a standard assessment data sheet in palliative care settings, in which more than 20 palliative care units participated. Interventions The full-time members of the PCT are a palliative care physician and a nurse. The physician had 12 years of clinical experience as an attending physician in the PCU (in Japan, there was no certified system for palliative medicine), and the nurse was officially certified in palliative nursing care and had 19 years of clinical experience. In addition, the PCT has four part-time members: a psychiatrist, two pharmacists, and a liaison nurse. If the PCT requires anesthesiologists, psychologists, radiologists, or other medical specialists, they are available in the same hospital. All patients were followed every day after the initial assessment by at least one chief member of the PCT, and multidisciplinary rounds were performed for all patients once a week. The palliative care physician prescribed medications for symptom control in addition to written recommendations, if requested by primary physicians. In principle, all patients were continuously followed up to patient death or transfer to other institutions. If patients were discharged to home, follow-up was performed by an outpatient service. Analyses We compared patient backgrounds and symptom severity at the initial assessment between PCT and PCU patients. We also compared symptom severity between initial consultation and one week after the consultation for the patients who completed both evaluations. In addition, we investigated the changes in symptom severity during the first week in the patients whose symptom scores were moderate/severe (somnolence and delirium) and severe/extreme (other symptoms). This analysis was performed only for symptoms with 10% or more prevalence. Statistical analyses were performed with Student s t-test (non-paired, paired) and the chisquare test (Fisher s exact method), where appropriate. Results Of 111 patients referred to our PCT in the study period, 98 patients (88%) were referred from inpatient settings and 13 patients (12%) were from outpatient settings. After the PCT consultation, 28 patients (25%) were discharged to home. Eventually, 48 patients (43%) died in the hospital, 44 patients (40%) died after admission to the PCU, 16 patients (14%) were alive, 2 patients were transferred to other hospitals, and one patient dropped out from follow-up. As 11 patients died before the second evaluation, symptom severity was compared in the remaining 100 patients. Patient Backgrounds Table 1 summarizes the characteristics of the patients who were referred to the PCT and those who were admitted to the PCU. Compared with PCU patients, PCT patients were significantly younger, had better performance status, and were more likely to be referred with the described aim of symptom palliation. On the other hand, the described aims of referral to PCUs were significantly more likely to be endof-life care and transfer of care. Table 2 demonstrates that PCT patients suffered from more serious pain, appetite loss, somnolence, insomnia, anxiety, and delirium than PCU patients. On the other hand, constipation, dry mouth, and incontinence were observed significantly more frequently in PCU patients than in PCT patients. Symptom Changes in PCT Patients Table 3 summarizes the changes in symptom severity during the first week. There were significant improvements in symptom scores of pain, appetite loss, nausea, vomiting, constipation, abdominal swelling, dyspnea, sputum, insomnia, and anxiety. On the other hand, no significant improvements were observed in symptom scores for fatigue, dry mouth, cough, somnolence, or delirium. The reported prevalence of depression significantly increased during the first week. Table 4 shows the changes in severity of severe/extreme symptoms at the first assessment. The percentages of severe/extreme symptoms one week after the PCT consultation were 12% for pain, 21% for anxiety, 36% for somnolence, and 48% for appetite loss, whereas none of the patients continued to suffer from severe/extreme nausea, vomiting, or dyspnea. In addition, the percentages of moderate/ severe symptoms at the second evaluation in

4 Vol. 29 No. 5 May 2005 Palliative Care Team 461 Table 1 Characteristics of Patients Referred to the PCT and the PCU PCT (n 111) PCU (n 100) P Age Sex n(%) Male 63 (57) Female 48 (43) 41 Primary site 0.25 Lung 22 (20) 30 Stomach 20 (18) 13 Liver, bile duct 16 (14) 9 Pancreas 11 (9.9) 14 Colon, rectum 10 (9.0) 10 Esophagus 7 (6.3) 2 Prostate, bladder 7 (6.3) 4 Ovary, uterus 4 (3.6) 3 Breast 3 (2.7) 2 Under examination 3 (2.7) 0 Others 8 (7.2) 13 Performance status 2 22 (20) (43) (37) 66 Receiving anti-cancer treatments 20 (18) Described aims of referrals Symptom palliation 105 (95) End-of-life care 28 (25) Transfer of care 2 (1.8) PCT Palliative Care Team; PCU Palliative Care Unit. patients who had moderate/severe symptoms at the initial assessment were 14% for insomnia and 60% for delirium (Table 5). Analyses of Unpalliated Symptoms All 7 patients who continued to suffer from severe/extreme pain at the second evaluation Table 2 Symptoms of Patients Referred to the PCT and the PCU Mean Symptom Scores a Prevalence b mean SD n (%) PCT (n 111) PCU (n 100) P PCT (n 111) PCU (n 100) P Pain (90) Fatigue (45) Appetite loss (84) Nausea (32) Vomiting (23) Constipation (17) Diarrhea (4.5) Abdominal swelling (21) Dry mouth (18) Dyspnea (28) Cough (19) Sputum (20) Fever (14) Incontinence (0.90) Somnolence (74) Insomnia (72) Anxiety (32) Delirium (33) Depression 14 (13) PCT Palliative Care Team, PCU Palliative Care Unit. a None (0) to moderate/severe (2) for insomnia and delirium; none (0) to extreme (4) for other symptoms on the Schedule for Team Assessment Scale. b Symptom scores of 1 or more.

5 462 Morita et al. Vol. 29 No. 5 May 2005 Table 3 Changes in Symptom Severity During the First Week (n 100) Initial Assessment Day 7 mean SD mean SD Pain Fatigue Appetite loss Nausea Vomiting Constipation Diarrhea Abdominal swelling Dry mouth Dyspnea Cough Sputum Fever Incontinence Somnolence Insomnia Anxiety Delirium Depression 13% 32% (presence) None (0) to moderate/severe (2) for insomnia and delirium; none (0) to extreme (4) for other symptoms on the Schedule for Team Assessment Scale. received maximum titration of opioids until opioid toxicity occurred, in addition to NSAIDs (n 6), adjuvant analgesics (n 3), steroids (n 2), and anesthesiological procedures (n 2). Eventually, 2 patients achieved good pain control and were discharged to home. Two patients received symptomatic sedation, and 4 patients fell into an unconscious state before achieving adequate pain control due to organ failure. Among 12 patients with unpalliated severe/ extreme appetite loss, 6 patients received steroids, but steroids were not prescribed in the P remaining 6 patients due to medical contraindications including gastrointestinal bleeding, uncontrolled blood sugar, and existing or high risk of delirium. Among 4 patients with unpalliated severe/extreme somnolence, none received methylphenidate due to lack of oral route and/or existing or high risk of delirium. All 3 patients with unpalliated severe/extreme anxiety received benzodiazepines (with antidepressant in 2 patients) and psychological support by mental health professionals (a psychiatrist and/or a liaison nurse). Of 5 patients with unpalliated insomnia, 3 patients received benzodiazepines and/or antipsychotics, and 2 patients received specialized psychiatric consultation. Of 9 patients with unpalliated delirium (hypoactive, n 2; hyperactive, n 4; mixed, n 3), 4 patients received antipsychotic medications during the first week. Medical Treatments Table 6 summarizes the therapeutic interventions performed after referral to the PCT. The most frequent interventions were administration of NSAIDs and opioids (fentanyl, n 33; morphine, n 13). Steroids and centrallyacting antiemetics were used in about 30% of the patients. Of the patients studied, 10 20% received opioid rotation, peripheral-acting antiemetics, laxatives, benzodiazepines, neuroleptics, and radiation therapy. Anesthesiological procedures included intrathecal permanent block (n 3), occipital nerve block (n 2), celiac plexus block (n 1), and trigger point injection (n 1). Discussion This audit study suggests that the PCT contributed to successful palliation of many symptoms. Table 4 Changes in Symptom Severity for Patients with Severe/Extreme Symptoms Day 7 Number of Patients with Severe/Extreme Symptoms None/Mild n (%) Moderate n (%) Severe/Extreme n (%) Pain (58) 18 (30) 7 (12) Appetite loss 25 8 (32) 5 (20) 12 (48) Nausea (82) 3 (18) 0 Vomiting (83) 2 (17) 0 Dyspnea (71) 4 (29) 0 Somnolence 11 4 (36) 3 (27) 4 (36) Anxiety 14 7 (50) 4 (29) 3 (21) Rated on the Schedule for Team Assessment Scale.

6 Vol. 29 No. 5 May 2005 Palliative Care Team 463 Table 5 Changes in Symptom Severity for Patient with Moderate/Severe Insomnia and Delirium Number of Patients with Day 7 Moderate/Extreme Symptoms None n (%) Mild n (%) Moderate/Severe n (%) Insomnia (39) 17 (47) 5 (14) Delirium 15 2 (13) 4 (27) 9 (60) Based on clinical evaluation. Pain, nausea, vomiting, constipation, dyspnea, insomnia, and anxiety were generally well-controlled during the first week. On the other hand, fatigue, dry mouth, somnolence, and delirium were not sufficiently palliated. In addition, about half of patients with severe/ extreme appetite loss at the first assessment still continued to suffer severe/extreme appetite loss one week after PCT consultation, although the mean scores significantly decreased. This Table 6 Therapeutic Interventions Performed After PCT Consultations n (%) Pharmacological treatments NSAIDs 61 (55) Opioids Weak opioids 11 (10) Strong opioids New administration 44 (40) Dose titration 8 (7.2) Changes to other opioids 17 (15) Adjuvant analgesics Steroids 31 (28) Antidepressants 3 (2.7) Antiarrhythmics 6 (5.4) Anticonvulsants 6 (5.4) NMDA antagonists (e.g., ketamine) 5 (4.5) Bisphosphonate 5 (4.5) Antiemetics Peripherally acting 11 (10) (e.g., metoclopramide) Centrally acting 34 (31) (e.g., butylphenone, antihistaminic) Somatostatin 4 (3.6) Laxatives 12 (11) Antisecretants Hyoscine hydrobromide 2 (1.8) Psychotropics Benzodiazepines 13 (12) Neuroleptics 15 (14) Methylphenidate 5 (4.5) Invasive treatments Anesthesiological procedures 7 (6.3) Radiation therapy 12 (11) Artificial hydration therapy Initiation 1 (0.90) Volume reduction or withdrawing 11 (10) Specialized psychological support Psychiatric consultation 6 (5.4) Psychological consultation 4 (3.6) finding is consistent with previous studies, which demonstrated significant improvement of pain, nausea, vomiting, breathlessness, constipation, and insomnia after PCT consultation. 9,10 The potential interpretations of inadequate palliation of fatigue, appetite loss, somnolence, and delirium include: 1) palliative treatment provided by the PCT was insufficient, 2) symptoms did not improve due to progressive general conditions despite adequate treatment or lack of highly effective treatments for these symptoms, 3) the sensitivity of the symptom inventories is too low to detect clinical changes. The first interpretation is, we believe, unlikely, because a clinical review of treatments for patients with unpalliated symptoms revealed that medical teams had provided standard treatments for symptom palliation. Because these symptoms are highly influenced by the progression of underlying disease, 26,27 the second interpretation appears reasonable. In addition, as we roughly categorized the severity of delirium as none, mild, or moderate/ severe in this study, more detailed symptom evaluation might better identify treatment effects for delirium. 24,25 Of note was the significantly increased prevalence of depression reported at the second evaluation. We do not believe that depression was of new onset during this time period, because the observation period was short (one week). Our interpretation of this finding is that palliation of physical symptoms and establishment of a closer relationship between patients and PCT members enabled patients to disclose their emotions more openly, leading to higher detections of depression. This study also revealed that backgrounds of patients referred to the PCT were different from the PCU. That is, PCT patients were younger and had better performance but more serious symptoms, and physicians referred patients to the PCT with the primary aim

7 464 Morita et al. Vol. 29 No. 5 May 2005 of symptom palliation. On the other hand, PCU patients were older and had worse performance status and relatively less serious symptoms, and were referred with the primary aims of end-oflife care and transfer of care. These results suggest that the PCT and the PCU play different roles in our hospital, namely, symptom palliation for the PCT and end-of-life care and transfer of care for the PCU; therefore, both the PCT and the PCU are necessary to fulfill the various needs of patients and families. This study was an audit survey and has considerable limitations. First, measurement of symptom severity was based on observer ratings and might have an observer bias, although the reliability and validity of the instrument were well examined. Second, without a control group, we could not reach definite conclusions about the effects of PCT consultations on patient symptoms. Third, the outcomes and treatments investigated in this study were limited to symptoms and medical management, and other variables, such as patients insight about their conditions and nursing care, should be included in future studies. In conclusion, the PCT was successfully implemented in Seirei Mikatabara Hospital in the first year. The PCT may contribute to symptom improvement in cancer patients who are not admitted to PCU. Well-designed clinical trials are promising to further evaluate the impact of PCT referral on patient outcomes. References 1. World Health Organization. National cancer control programmes. Policies and managerial guidelines, 2nd ed. Geneva: WHO, Higginson IJ, Finlay I, Goodwin DM, et al. Do hospital-based palliative teams improve care for patients or families at the end of life? J Pain Symptom Manage 2002;23: Hanks GW, Robbins M, Sharp D, et al. The impact study: a randomized controlled trial to evaluate a hospital palliative care team. Br J Cancer 2002; 87: Rabow MW, Dibble SL, Pantilat SZ, McPhee SJ. The comprehensive care team. A controlled trial of outpatient palliative medicine consultation. Arch Intern Med 2004;164: Jacobs LG, Bonuck K, Burton W. Can palliative care reports improve end-of-life care for hospitalized patients? J Pain Symptom Manage 2002; 24: McQuillan R, Finlay I, Branch C, et al. Improving analgesic prescribing in a general teaching hospital. J Pain Symptom Manage 1996;11: McQuillan R, Finlay I, Roberts D, et al. The provision of a palliative care service in a teaching hospital and subsequent evaluation of that service. Palliat Med 1996;10: Bruera E, Brenneis C, Michaud M, MacDonald RN. Influence of the pain and symptom control team (PSCT) on the patterns of treatment of pain and other symptoms in a cancer center. J Pain Symptom Manage 1989;4: Abrahm JL, Callahan J, Rossetti K, Pierre L. The impact of a hospice consultation team on the care of veterans with advanced cancer. J Pain Symptom Manage 1996;12: Ellershaw JE, Peat SJ, Boys LC. Assessing the effectiveness of a hospital palliative care team. Palliat Med 1995;9: Kuin A, Courtens AM, Deliens L, et al. Palliative care consultation in The Netherlands: a nationwide evaluation study. J Pain Symptom Manage 2004;27: Homsi J, Walsh D, Nelson KA, et al. The impact of a palliative medicine consultation service in medical oncology. Support Care Cancer 2002;10: Manfredi PL, Morrison S, Morris J, et al. Palliative care consultations: how do they impact the care of hospitalized patients? J Pain Symptom Manage 2000;20: Carter H, McKinlay E, Scott I, et al. Impact of a hospital palliative care service: perspective of the hospital staff. J Palliat Care 2002;18: Low JA, Liu RK, Strutt R, Chye R. Specialist community palliative care services: a survey of general practitioners experience in eastern Sydney. Support Care Cancer 2001;9: Jack B, Hillier V, Williams A, Oldham J. Hospitalbased palliative care teams improve the insight of cancer patients into their disease. Palliat Med 2004; 18: Axelsson B, Christensen SB. Evaluation of a hospital-based palliative support service with particular regard to financial outcome measures. Palliat Med 1998;12: Morita T, Chihara S, Kashiwagi T. Family satisfaction with inpatient palliative care in Japan. Palliat Med 2002;16: Maeyama E, Kawa M, Miyashita M, et al. Multiprofessional team approach in palliative care units in Japan. Support Care Cancer 2003;11: Ida E, Miyachi M, Uemura M, et al. Current status of hospice cancer deaths both in-unit and at home ( ), and prospects of home care services in Japan. Palliat Med 2002;16: Carson MG, Fitch MI, Vachon ML. Measuring patient outcomes in palliative care: a reliability and

8 Vol. 29 No. 5 May 2005 Palliative Care Team 465 validity study of the support team assessment schedule. Palliat Med 2000;14: Miyashita M, Sasahara T, Kawa M, Shima Y. Introduction of Japanese version STAS (Support Team Assessment Schedule) and clinical audit in palliative care [in Japanese]. Jap J Hospice Palliat Care 2003;13: Akizuki N, Akechi T, Nakanishi T, et al. Development of a brief screening interview for adjustment disorders and major depression in patients with cancer. Cancer 2003;97: Breitbart W, Rosenfeld B, Roth A, et al. The Memorial Delirium Assessment Scale. J Pain Symptom Manage 1997;13: Matsuoka Y, Miyake Y, Arakaki H, et al. Clinical utility and validation of the Japanese version of the Memorial Delirium Assessment Scale in a psychogeriatric inpatient setting. Gen Hosp Psychiatry 2001; 23: Maltoni M, Nanni O, Pirovano M, et al. Successful validation of the palliative prognostic score in terminally ill cancer patients. J Pain Symptom Manage 1999;17: Morita T, Tsunoda J, Inoue S, Chihara S. The palliative prognostic index: a scoring system for survival prediction of terminally ill cancer patients. Support Care Cancer 1999;7: