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ObjectivesTo assess the degree of frailty in older people with different advanced diseases and its relationship with end-of-life illness trajectories and survival.MethodsProspective, observational study, including all patients admitted to the Acute Geriatric Unit of the University Hospital of Vic (Spain) during 12 consecutive months (2014–2015), followed for up to 2 years. Participants were identified as end-of-life people (EOLp) using the NECPAL (NECesidades PALiativas, palliative care needs) tool and were classified according to their dominant illness trajectory. The Frail-VIG index (Valoración Integral Geriátrica, Comprehensive Geriatric Assessment) was used to quantify frailty degree, to calculate the relationship between frailty and mortality (Receiver Operating Characteristic (ROC) curves), and to assess the combined effect of frailty degree and illness trajectories on survival (Cox proportional hazards model). Survival curves were plotted using the Kaplan-Meier estimator with participants classified into four groups (ie, no frailty, mild frailty, moderate frailty and advanced frailty) and were compared using the log-rank test.ResultsOf the 590 persons with a mean (SD) age of 86.4 (5.6) years recruited, 260 (44.1%) were identified as EOLp, distributed into cancer (n=31, 11.9%), organ failure (n=79, 30.4%), dementia (n=86, 33.1%) and multimorbidity (n=64, 24.6%) trajectories. All 260 EOLp had some degree of frailty, mostly advanced frailty (n=184, 70.8%), regardless of the illness trajectory, and 220 (84.6%) died within 2 years. The area under the ROC curve (95% CI) after 2 years of follow-up for EOLp was 0.87 (0.84 to 0.92) with different patterns of survival decline in the different end-of-life trajectories (pConclusionsAll older people towards the end-of-life in this study were frail, mostly with advanced frailty. The degree of frailty is related to survival across the different illness trajectories despite the differing survival patterns among trajectories. Frailty indexes may be useful to assess end-of-life older people, regardless of their trajectory.

ObjectivesTo analyse patterns of use and costs of unscheduled National Health Service (NHS) services for people in the last year of life.DesignRetrospective cohort analysis of national datasets with application of standard UK costings.Participants and settingAll people who died in Scotland in 2016 aged 18 or older (N=56 407).Main outcome measuresFrequency of use of the five unscheduled NHS services in the last 12 months of life by underlying cause of death, patient demographics, Continuous Unscheduled Pathways (CUPs) followed by patients during each care episode, total NHS and per-patient costs.Results53 509 patients (94.9%) had at least one contact with an unscheduled care service during their last year of life (472 360 contacts), with 34.2% in the last month of life. By linking patient contacts during each episode of care, we identified 206 841 CUPs, with 133 980 (64.8%) starting out-of-hours. People with cancer were more likely to contact the NHS telephone advice line (63%) (χ2 (4)=1004, p2 (4)=1924,p2 (4)=2644, p2 (4)=584, pConclusionsOver 90% of people used NHS unscheduled care in their last year of life. Different underlying causes of death and demographic factors impacted on initial access and subsequent pathways of care. Managing more unscheduled care episodes in the community has the potential to reduce hospital admissions and overall costs.

Background: The International Association for Hospice and Palliative Care (IAHPC) developed a consensus-based definition of palliative care (PC) that focuses on the relief of serious health related suffering, a concept put forward by the Lancet Commission Global Access to Palliative Care and Pain Relief. Aim: The objective of this paper is to present the research behind the new definition. Methods: The three-phased consensus process involved health care workers from countries in all income levels. In phase one, 38 PC experts evaluated the components of the World Health Organization (WHO) definition and suggested new/revised ones. In phase two, 412 IAHPC members in 88 countries expressed their level of agreement with the suggested components. In phase three, using results from phase two, the expert panel developed the definition. Results: The consensus-based definition is “Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers.” The definition includes a number of bullet points with additional details as well as recommendations for governments to reduce barriers to palliative care. Conclusions: Participants had significantly different perceptions and interpretations of PC. The greatest challenge faced by the core group was trying to find a middle ground between those who think that PC is the relief of all suffering, and those who believe that PC describes the care of those with a very limited remaining life span.

ObjectiveTo estimate the capacity of European countries to integrate palliative care (PC) into their health systems through PC service provision for patients of all ages, with different care needs and diseases, in various settings and by a range of providers.MethodsSecondary analysis of survey data from 51 countries with 22 indicators explored the integration of available PC resources for children, for patients of all ages, at the primary care level, for oncology and cardiac patients, and in long-term care facilities. We also measured volunteer participation. Results were quantified, converted into weighted subscores by area and combined into a single ‘Integration Capacity Score (ICS)’ for each country.ResultsThirty-eight countries reported 543 specialised paediatric PC services. One-third of all surveyed countries reported 20% or more of patients with PC needs at the primary care level. Twenty-four countries have a total of 155 designated centres that integrate oncology and PC. Eight countries were pioneering cardiology services that integrate PC. Eight reported a volunteer workforce of over 1000 and 12 had policies regulating PC provision and interventions in long-term care facilities. Across all indicators, 39 countries (76%) score from low to very low integration capacity, 8 (16%) score at an intermediate level, and 4 (8%; the Netherlands, UK, Germany and Switzerland) report a high-level integration of PC into their health systems.ConclusionVariable progress according to these indicators shows that most European countries are still in the process of integrating PC into their health systems.

Background ECCO Essential Requirements for Quality Cancer Care (ERQCC) are checklists and explanations of organisation and actions that are necessary to give high-quality care to cancer patients. They are written by European experts representing all disciplines involved in cancer care. This paper concerns the integration of primary care into care for all cancers in Europe. Primary care integration: • Primary care professionals play major roles in the diagnosis of cancer and care of cancer patients • There are many opportunities for extending care at the primary level to cope with the increasing cancer burden and its nature as a chronic disease, but there are also significant barriers to progress towards high-quality patient-centred care • To meet European aspirations for comprehensive cancer control, healthcare organisations must consider the requirements in this paper to include primary and community care in patient-centred pathways from diagnosis to treatment and survivorship.

Much has been achieved in advancing palliative care on the global health agenda, but there is more to do. The 2014 World Health Assembly (WHA) committed countries to integrating palliative care into their health systems and WHO was tasked with monitoring progress. By 2017, WHO had updated the definition of universal health coverage (UHC)—Sustainable Development Goal 3.8—to include palliation along with promotion, prevention, treatment, and rehabilitation. A Lancet Commission in 2017 highlighted the global need to take action when 61 million people are living with serious health-related suffering due to uncontrolled pain and without access to an affordable essential package for palliative care.

Our two recent editorials on whether palliative care should be rebranded and the urgent need to pay attention to primary palliative care stimulated debate and two polls on bmj.com.12 In the first poll, only 50% of readers thought that palliative care should be “rebranded” but in the second, a month later, 89% called for primary care staff to have …

ObjectiveTo estimate future palliative care need and complexity of need in Scotland, and to identify priorities for future service delivery.DesignWe estimated the prevalence of palliative care need by analysing the proportion of deaths from defined chronic progressive illnesses. We described linear projections up to 2040 using national death registry data and official mortality forecasts. An expert consultation and subsequent online consensus survey generated recommendations on meeting future palliative care need.SettingScotland, population of 5.4 million.ParticipantsAll decedents in Scotland over 11 years (2007 to 2017). The consultation had 34 participants; 24 completed the consensus survey.Primary and secondary outcomesEstimates of past and future palliative care need in Scotland from 2007 up to 2040. Multimorbidity was operationalised as two or more registered causes of death from different disease groups (cancer, organ failure, dementia, other). Consultation and survey data were analysed descriptively.ResultsWe project that by 2040, the number of people requiring palliative care will increase by at least 14%; and by 20% if we factor in multimorbidity. The number of people dying from multiple diseases associated with different disease groups is projected to increase from 27% of all deaths in 2017 to 43% by 2040. To address increased need and complexity, experts prioritised sustained investment in a national digital platform, roll-out of integrated electronic health and social care records; and approaches that remain person-centred.ConclusionsBy 2040 more people in Scotland are projected to die with palliative care needs, and the complexity of need will increase markedly. Service delivery models must adapt to serve growing demand and complexity associated with dying from multiple diseases from different disease groups. We need sustained investment in secure, accessible, integrated and person-centred health and social care digital systems, to improve care coordination and optimise palliative care for people across care settings.

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OBJECTIVE This study attempted to determine: (1) if degree of dental malocclusion assigned prior to dental treatment was associated with equine rideability, assessed using a standardized score and (2) if performance dentistry improved this score. ANIMALS Thirty-eight Franches-Montagnes stallions. METHODS All horses were examined and assigned a dental malocclusion score by a veterinary dentist and randomized into two groups: sham treatment (Group S) and performance dentistry including occlusal equilibration (Group D). The horses were ridden twice before and three times after treatment by a professional dressage rider (unaware of treatment allocation). The horses were assigned a rideability score using a 27-point scale. The malocclusion score was compared to the average of the first two rideability scores using Spearman's coefficient of rank. Change in rideability scores over time was assessed by repeated measures ANOVA. Statistical significance was set at P < 0.05. RESULTS There was no correlation between dental score and rideability score prior to treatment (rs = 0.06, P = 0.73). In addition, there were no differences in the rideability score between treatment groups or as an interaction of treatment group and time (P = 0.93, P = 0.83, respectively). CONCLUSIONS In conclusion, we were unable to show that performance dentistry improved equine rideability assessed by rider scoring. The addition of more objective measurement tools and a longer assessment period may help to scientifically prove what is anecdotally believed.

International audience; The number of people in their last years of life with advanced chronic conditions, palliative care needs, and limited life prognosis due to different causes including multi-morbidity, organ failure, frailty, dementia, and cancer is rising. Such people represent more than 1% of the population. They are present in all care settings, cause around 75% of mortality, and may account for up to one-third of total national health system spend. The response to their needs is usually late and largely based around institutional palliative care focused on cancer. There is a great need to identify these patients and integrate an early palliative approach according to their individual needs in all settings, as suggested by the World Health Organization. Several tools have recently been developed in different European regions to identify patients with chronic conditions who might benefit from palliative care. Similarly, several models of integrated palliative care have been developed, some with a public health approach to promote access to all in need. We describe the characteristics of these initiatives and suggest how to develop a comprehensive and integrated palliative approach in primary and hospital care and to design public health and community-oriented practices to assess and respond to the needs in the whole population. Additionally, we report ethical challenges and prognostic issues raised and emphasize the need for research to test the various tools and models to generate evidence about the benefits of these approaches to patients, their families, and to the health system. (C) 2016 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

We were delighted to read Spencer and colleagues’ excellent review of palliative radiotherapy aimed at general practitioners.1 But its last learning point, that “holistic palliative care may be more appropriate” in the final weeks of life, may mislead readers that they must choose one or the …

The massive cultural shift that Lakhani calls for has to occur at various levels in health systems.1 In France, for example, after several national strategies to develop palliative care (lastly in 2008-12), access to specialist palliative care remains poor. A recent report by the French Court of Audit highlights that …

Background: A multidisciplinary European Association of Palliative Care Taskforce was established to scope the extent of and learn what facilitates and hinders the development of palliative care in the community across Europe. Aim: To document the barriers and facilitators for palliative care in the community and to produce a resource toolkit that palliative care specialists, primary care health professionals or policymakers, service developers, educationalists and national groups more generally could use to facilitate the development of palliative care in their own country. Design: (1) A survey instrument was sent to general practitioners with knowledge of palliative care services in the community in a diverse sample of European countries. We also conducted an international systematic review of tools used to identify people for palliative care in the community. (2) A draft toolkit was then constructed suggesting how individual countries might best address these issues, and an online survey was then set up for general practitioners and specialists to make comments. Iterations of the toolkit were then presented at international palliative care and primary care conferences. Results: Being unable to identify appropriate patients for palliative care in the community was a major barrier internationally. The systematic review identified tools that might be used to help address this. Various facilitators such as national strategies were identified. A primary palliative care toolkit has been produced and refined, together with associated guidance. Conclusion: Many barriers and facilitators were identified. The primary palliative care toolkit can help community-based palliative care services to be established nationally.

In response to our recent analysis,1 Wise calls for palliative care doctors to be included in treatment decisions when palliative oncology or radiotherapy is being considered.2 He states that both patients and oncologists are frequently overoptimistic about treatment outcomes, and suggests that if a palliative medicine specialist were present, “best supportive care ” alone might then be a more …

Mapping the territory of human suffering with only clinical tools, diagnostic tests, and biomedical concepts is difficult, if not impossible.1 Or to say it differently, it doesn’t seem easy, or reasonable, to answer the questions of how …

Esta pesquisa trata sobre a expansão da soja na região amazônica por meio dos grandes produtores de soja. Teve como objetivo descrever a organização do espaço geográfico regional por meio da identificação dos elementos básicos da geopolítica da soja propostos por Becker (2007) : abertura de fronteiras, como a disponibilidade de terra barata e mercados, favorecendo a instalação de atividades produtivas com rapidez, em grande escala e a baixos custos ; a logística caracterizada pelas redes técnicas que viabilizam a integração produtiva-mercantil-financeira ; a integração política que corresponde a alianças estratégicas estabelecidas pelos produtores ; as relações de trabalho do grande produtor com seus funcionários ; e a ciência e tecnologia, responsável pela movimentação de toda a base produtiva. O estudo permitiu entender a evolução dos territórios da soja definida em quatro fases a partir da década de 1980. Estas fases baseiam-se acerca de uma idéia comum de melhoria da situação econômica da soja ; de uma ruptura na maneira de pensar o desenvolvimento da agricultura no estado do Mato Grosso e questionamentos sobre o impacto desta ruptura.Cette recherche traite de l'expansion du soja en Amazonie par les grands producteurs de soja. L'objectif est de décrire l’organisation de l'espace géographique régional par l'identification des éléments de base de la géopolitique du soja proposés par Becker (2007) : l’ouverture de frontières, comme la disponibilité de terres bon marché et de marchés favorisant l'installation rapide d'activités productives, à grande échelle et à bas coût ; la logistique caractérisée par les réseaux techniques qui rendent viable l'intégration productive-marchande-financière ; l'intégration politique qui correspond aux alliances stratégiques établies par les producteurs ; les relations de travail entre les grands producteurs et leurs salariés ; et les sciences et technologies, responsables du mouvement de la base productive entière. L'étude permet de comprendre l'évolution des territoires du soja définie en quatre phases à partir du début des années 1980. La compréhension de ces phases s’appuie sur une idée commune d'amélioration de la situation économique du soja, de rupture dans la manière de penser le développement de l'agriculture dans l'état du Mato Grosso et de questionnement de l'impact de cette rupture.

We agree with Pollock that a preoccupation with dying at home as an indicator of a good death deflects attention from improving the quality of care elsewhere.1 Because people die in all settings, and will continue to do so, we should seek to optimise …

Au vu des tendances démographiques actuelles il semble urgent de former les médecins généralistes afin de les sensibiliser vis-à-vis des soins palliatifs. C'est dans ce cadre que nous nous sommes intéressé à définir quelles compétences fondamentales du curriculum de médecine générale sont identifiées pour la mise en œuvre de soins palliatifs par les médecins généralistes exerçant dans le contexte des soins primaires. Il s'agissait d'une revue intégrative de la littérature, concernant la littérature scientifique publiée et disponible via les bases de données électroniques et la littérature grise. Étaient recherchés et étudiés tous les articles scientifiques, les rapports et curricula retrouvés dont nous avions accès au résumé et/ou à l'article en son entier, écrits en langue française ou anglaise, de 1980 jusqu'à la date de début de recherche (16/01/2020). Quarante-neuf études et documents ont été inclus. L'analyse de l'ensemble de ceux-ci a permis d'identifier 39 compétences fondamentales pour la mise en œuvre des soins palliatifs par les médecins généralistes, classées en 3 grands groupes : cognitives, psychomotrices et affectives. La synthèse de l'ensemble de ces documents a permis de mettre en évidence l'importance d'une formation plus vaste des médecins généralistes, d'une idée centrale des soins primaires, afin d'obtenir une prise en charge globale et précoce de ces patients nécessitant des soins palliatifs. Cette revue a contribué au développement de l'enseignement futur des médecins généralistes en ce qui concerne leur formation aux besoins de soins palliatifs dans le cadre des soins primaires.