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Background: Delirium is a complex condition, stressful for all involved. Although highly prevalent in palliative care settings, it remains underdiagnosed and associated with poor outcomes. Guideline-adherent delirium care may improve its detection, assessment and management. Aim: To inform a future definitive study that tests whether an implementation strategy designed to improve guideline-adherent delirium care in palliative care settings improves patient outcomes (reduced proportion of in-patient days with delirium). Design: With Patient Involvement members, we conducted a feasibility study to assess the acceptability of and engagement with the implementation strategy by hospice staff (intervention), and whether clinical record data collection of process (e.g. guideline-adherent delirium care) and clinical outcomes (evidence of delirium using a validated chart-based instrument;) pre- and 12-weeks post-implementation of the intervention would be possible. Setting/participants: In-patient admissions in three English hospices. Results: Between June 2021 and December 2022, clinical record data were extracted from 300 consecutive admissions. Despite data collection during COVID-19, target clinical record data collection (n = 300) was achieved. Approximately two-thirds of patients had a delirium episode during in-patient stay at both timepoints. A 6% absolute reduction in proportion of delirium days in those with a delirium episode was observed. Post-implementation improvements in guideline-adherent metrics include: clinical delirium diagnosis 15%–28%; delirium risk assessment 0%–16%; screening on admission 7%–35%. Conclusions: Collection of data on delirium outcomes and guideline-adherence from clinical records is feasible. The signal of patient benefit supports formal evaluation in a large-scale study. [ABSTRACT FROM AUTHOR]

Background: Delirium is common and distressing for patients receiving palliative care. Interventions targetting modifiable risk factors in other settings have been shown to prevent delirium. Research on delirium risk factors in palliative care can inform context-specific risk-reduction interventions. Aim: To investigate risk factors for the development of delirium in adult patients receiving specialist palliative care. Design: Systematic review and meta-analysis (PROSPERO CRD42019157168). Data sources: CINAHL, Cochrane Database of Systematic Reviews, Embase, MEDLINE and PsycINFO (1980-2021) were searched for studies reporting the association of risk factors with delirium incidence/prevalence for patients receiving specialist palliative care. Study risk of bias and certainty of evidence for each risk factor were assessed. Results: Of 28 included studies, 16 conducted only univariate analysis, 12 conducted multivariate analysis. The evidence for delirium risk factors was limited with low to very low certainty. Potentially modifiable risk factors: Opioids and lower performance status were positively associated with delirium, with some evidence also for dehydration, hypoxaemia, sleep disturbance, liver dysfunction and infection. Mixed, or very limited, evidence was found for some factors targetted in multicomponent prevention interventions: sensory impairments, mobility, catheter use, polypharmacy (single study), pain, constipation, nutrition (mixed evidence). Non-modifiable risk factors: Older age, male sex, primary brain cancer or brain metastases and lung cancer were positively associated with delirium. Conclusions: Findings may usefully inform interventions to reduce delirium risk but more high quality prospective cohort studies are required to enable greater certainty about associations of different risk factors with delirium during specialist palliative care. [ABSTRACT FROM AUTHOR]

Background: Trials of interventions for delirium in various patient populations report disparate outcomes and measures but little is known about those used in palliative care trials. A core outcome set promotes consistency of outcome selection and measurement. Aim: To inform core outcome set development by examining outcomes, their definitions, measures and time-points in published palliative care studies of delirium prevention or treatment delirium interventions. Design: Prospectively registered systematic review adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Data sources: We searched six electronic databases (1980–November 2020) for original studies, three for relevant reviews and the International Clinical Trials Registry Platform for unpublished studies and ongoing trials. We included randomised, quasi-randomised and non-randomised intervention studies of pharmacological and non-pharmacological delirium prevention and/or treatment interventions. Results: From 13/3244 studies (2863 adult participants), we identified 9 delirium-specific and 13 non-delirium specific outcome domains within eight Core Outcome Measures in Effectiveness Trials (COMET) taxonomy categories. There were multiple and varied outcomes and time points in each domain. The commonest delirium specific outcome was delirium severity (n = 7), commonly using the Memorial Delirium Assessment Scale (6/8 studies, 75%). Four studies reported delirium incidence. Non-delirium specific outcomes included mortality, agitation, adverse events, other symptoms and quality of life. Conclusion: The review identified few delirium interventions with heterogeneity in outcomes, their definition and measurement, highlighting the need for a uniform approach. Findings will inform the next stage to develop consensus for a core outcome set to inform delirium interventional palliative care research. [ABSTRACT FROM AUTHOR]

Background: Despite evidence demonstrating the utility of using Person-Centred Outcome Measures within palliative care settings, implementing them into routine practice is challenging. Most research has described barriers to, without explaining the causal mechanisms underpinning, implementation. Implementation theories explain how, why, and in which contexts specific relationships between barriers/enablers might improve implementation effectiveness but have rarely been used in palliative care outcomes research. Aim: To use Normalisation Process Theory to understand and explain the causal mechanisms that underpin successful implementation of Person-Centred Outcome Measures within palliative care. Design: Exploratory qualitative study. Data collected through semi-structured interviews and analysed using a Framework approach. Setting/participants: 63 healthcare professionals, across 11 specialist palliative care services, were purposefully sampled by role, experience, seniority, and settings (inpatient, outpatient/day therapy, home-based/community). Results: Seven main themes were developed, representing the causal mechanisms and relationships underpinning successful implementation of outcome measures into routine practice. Themes were: Subjectivity of measures; Frequency and version of Integrated Palliative care Outcome Scale; Training, education, and peer support; Building and sustaining community engagement; Electronic system readiness; The art of communication; Reinforcing use through demonstrating value. Conclusions: Relationships influencing implementation resided at individual and organisational levels. Addressing these factors is key to driving the implementation of outcome measures into routine practice so that those using palliative care services can benefit from the systematic identification, management, and measurement of their symptoms and concerns. We provide key questions that are essential for those implementing and using outcome measures to consider in order to facilitate the integration of outcome measures into routine palliative care practice. [ABSTRACT FROM AUTHOR]

Background: Recognising dying is a key clinical skill for doctors, yet there is little training. Aim: To assess the effectiveness of an online training resource designed to enhance medical students' ability to recognise dying. Design: Online multicentre double-blind randomised controlled trial (NCT03360812). The training resource for the intervention group was developed from a group of expert palliative care doctors' weightings of various signs/symptoms to recognise dying. The control group received no training. Setting/participants: Participants were senior UK medical students. They reviewed 92 patient summaries and provided a probability of death within 72 hours (0% certain survival – 100% certain death) pre, post, and 2 weeks after the training. Primary outcome : (1) Mean Absolute Difference (MAD) score between participants' and the experts' scores, immediately post intervention. Secondary outcomes : (2) weight attributed to each factor, (3) learning effect and (4) level of expertise (Cochran–Weiss–Shanteau (CWS)). Results: Out of 168 participants, 135 completed the trial (80%); 66 received the intervention (49%). After using the training resource, the intervention group had better agreement with the experts in their survival estimates (δ MAD = −3.43, 95% CI −0.11 to −0.34, p = <0.001) and weighting of clinical factors. There was no learning effect of the MAD scores at the 2-week time point (δ MAD = 1.50, 95% CI −0.87 to 3.86, p = 0.21). At the 2-week time point, the intervention group was statistically more expert in their decision-making versus controls (intervention CWS = 146.04 (SD 140.21), control CWS = 110.75 (SD 104.05); p = 0.01). Conclusion: The online training resource proved effective in altering the decision-making of medical students to agree more with expert decision-making. [ABSTRACT FROM AUTHOR]

Background: Performance status, a predictor of cancer survival, and ability to maintain independent living deteriorate in advanced disease. Understanding predictors of performance status trajectory could help identify those at risk of functional deterioration, target support for independent living and reduce service costs. The relationship between symptoms, analgesics and performance status is poorly delineated. Aim: The aim of this study is to determine whether demographics, analgesics, disease characteristics, quality-of-life domains and C-reactive protein predict the trajectory of Karnofsky Performance Status (KPS) in patients with advanced cancer. Design: The study design is the secondary data analysis of the international prospective, longitudinal European Palliative Care Cancer Symptom study (ClinicalTrials.gov: NCT01362816). A multivariable regression model was built for KPS area under the curve per day (AUC). Setting and participants: This included adults with advanced, incurable cancer receiving palliative care, without severe cognitive impairment and who were not imminently dying (n = 1739). Results: The mean daily KPS AUC (n = 1052) was 41.1 (standard deviation = 14.1). Opioids (p < 0.001), co-analgesics (p = 0.023), poorer physical functioning (p < 0.001) and appetite loss (p = 0.009) at baseline were explanatory factors for lower KPS AUC. A subgroup analysis of participants with C-reactive protein data (n = 240) showed that only C-reactive protein (p = 0.040) and physical function (p < 0.001) were associated with lower KPS AUC. Conclusion: This study is novel in determining explanatory factors for subsequent functional trajectories in an international dataset and identifying systemic inflammation as a candidate therapeutic target to improve functional performance. The effect of interventions targeting physical function, appetite and inflammation, such as those used for cachexia management, on maintaining functional status in patients with advanced cancer needs to be investigated. [ABSTRACT FROM AUTHOR]

Background: Red blood cell transfusions are commonly used in palliative care to treat anaemia or symptoms caused by anaemia. In patients with advanced disease, there is little evidence of benefit to guide treatment decisions in the face of increased risk of harms. Aim: To determine national transfusion practice in hospices and compare this against National Institute for Health and Care Excellence and British Society of Haematology guidelines to develop recommendations to improve practice. Design and Setting: Prospective data collection on red blood cell transfusion practice in UK adult hospices over a 3-month census period. Results: A total of 121/210 (58%) hospices participated. A total of 465 transfusion episodes occurred in 83 hospices. Patients had a mean age of 71 years, and 96% had cancer. Mean pre-transfusion haemoglobin was 75 g/L (standard deviation = 11.15). Anaemia of chronic disease was the largest cause of anaemia (176; 38%); potentially amenable to alternative treatments. Haematinics were not checked in 70% of patients. Alternative treatments such as B12, folate and iron were rarely used. Despite transfusion-associated circulatory overload risk, 85% of patients were not weighed, and 84% had two or more units transfused. Only 83 (18%) patients had an improvement maintained at 30 days; 142 (31%) had <14 day improvement, and 50 (11%) had no improvement. A total of 150 patients (32%) were dead at 30 days. Conclusion: More rigorous investigation of anaemia, increased use of alternative therapies and more restrictive approach to red cell transfusions are recommended. Clinicians should discuss the limited benefit versus potentially higher risks with patients in hospice services to inform treatment decisions. [ABSTRACT FROM AUTHOR]

Background: Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety. Aim: To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness. Design: Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909. Data sources: Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools. Results: From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance. Conclusion: This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed. [ABSTRACT FROM AUTHOR]