Background: Cancer pain has variable responses to different opioids. Opioid switching is recommended if a lack of effect or adverse effects are seen, and studies of opioid switching observe improved pain outcomes. We aimed to characterise patients with advanced cancer requiring an opioid switch, compared to a control group on stable opioid doses, and to report opioid doses after switch.

 

Methods: This prospective longitudinal study recruited consecutive adult patients from 5 Australian centres. Decision for opioid switch was based on palliative care physician decision. Paired data include pain characteristics, side effects, and treatment efficacy at baseline (T0) and 7 days (T1) using validated instruments. Wilcoxon signed-rank test was used. 

 

Results: 58 patients (24 control, 34 switch) were recruited. At baseline, the switch group experienced more severe pain than the control group (worst pain 8 vs 6/10). Opioid switch resulted in significantly improved average pain (pain 5->4, p.004), function (7->4.5, p.003), mood (7->5, p.05), and sleep (7->4, p.01) at T1 vs T0. Clinicians rated superior global improvement in switch group (mean efficacy index 2.22 vs 1.52; p<0.05).

 

To achieve final stable dose, median oral morphine equivalent daily dose (oMEDD) increased by more than two-fold for those switched to hydromorphone (2.2 fold) and morphine (2.1 fold), but reduced for oxycodone (0.9 fold) and fentanyl (0.8 fold). Patients switched to another opioid had a better improvement in pain than control patients. This was particularly true when different SR and IR opioids were used in combination post-switch.

 

Conclusions: Opioid switching significantly reduces cancer pain and associated symptoms. Final stable switched opioid dose in oMEDD varies between opioids. It is not known whether this reflects a variable effect from opioids or that opioid conversion tables are not accurate in chronic cancer pain.

Background

Mucositis can cause severe acute pain and may be opioid refractory. 

 

Aims 

To evaluate ketamine’s efficacy versus placebo in managing treatment-related oral and pharyngeal mucositis pain.

 

Mucositis patients with an average pain score of ≥ 4 (Brief Pain Inventory) received ketamine plus midazolam 5 mg or placebo plus midazolam 5 mg via subcutaneous infusion over 24 hours for 3 to 5 days. Ketamine dosage was escalated from 100 to 300 mg/24 hours in 100 mg increments. Clinical pain response indicated at least a 2-point reduction in average pain score from baseline without over four breakthrough analgesic doses in 24 hours. A linear mixed-effects model was used for repeated measures data and sample size calculation, requiring 18 patients to achieve 80% power. Fisher’s Exact test was used. Baseline data, pain scores, and medications were recorded. 

 

A preliminary analysis of 14 participants was performed. The pain response rate was 75 % (6 of 8) in the ketamine and 0% (0 of 6) in the placebo groups, with a significant difference (P=0.009). The mean average pain score significantly decreased from 6.25 to 2.00 (95%CI, 0.62 to 3.39) and 7.17 to 6.00 (95%CI, 4.87 to 7.13) in ketamine and placebo groups, respectively; P=0.019. The mean worst pain in ketamine group decreased from 8.13 to 3.20 (95%CI, 1.11 to 5.30) compared to 8.50 to 7.33 (95%CI, 6.69 to 7.98) in placebo group;P=0.031. The mean morphine daily dose was significantly lower in the ketamine group (P=0.027). Ketamine improved functional oral intake (P=0.031) and yielded a 50% improvement in dysphagia score versus placebo (P=0.085). All adverse effects were grade 1, with no difference between groups.

This is the first study investigating ketamine’s efficacy in mucositis patients. Preliminary results support the low-dose, subcutaneous ketamine infusion as effective analgesia for moderate to severe mucositis pain. 

 People with Post-Traumatic Stress Disorder (PTSD) experience dying differently. What is known is that people with a diagnosis of PTSD have a high burden of medical co-morbidities, including chronic pain. What isn’t known is how these impact on death. 

Objectives 
The aim of this integrative review is to investigate the following: 1) Is previous trauma identified in people who are dying and if so, how? 2) How is previous trauma associated with the experience of death/dying in people with or without cognitive impairment? and 3) What palliative care interventions are available to people with previous trauma at end of life?

 Method

An integrated review was conducted. Electronic databases were searched using key search terms and pre-defined eligibility criterion. This integrative review has been reported according to PRIMSA statement guidelines. Data extraction included phenomena of interest, setting, context, participation characteristics, study findings and illustrations. Thematic analysis was used.  

Results
A total of n= 1399 abstracts were identified, n= 243 duplicates removed, and n=1 record identified from alerting service, n=1156 records screened, 11 studies met the inclusion criteria.  Three themes were identified. Theme 1. PTSD- and its related symptoms are difficult to identify at EOL. Theme 2. Experiencing PTSD-Related symptoms at EOL is complicated by lack of understanding and trust. Theme 3. High symptom burden and increased pain and suffering at end of life.  

Conclusion
There is little evidence to say that previous trauma is identified in people who are dying and only one trauma informed palliative care approach identified in this review called the Stepwise Psychosocial Palliative Care model (SPPC). This is despite PTSD and its related symptoms causing increased pain and suffering at end of life. Education needs to be developed to support palliative care clinicians so that they have the skills and knowledge to identify, manage and treat PTSD and related symptoms at end of life to reduce further trauma and increase the quality of life and death for this population. 

Background: Voluntary Assisted Dying (VAD) is an additional end-of-life (EOL) option available to those meeting strict eligibility criteria. In Queensland, information about VAD can only be provided in combination with communication about all other EOL choices, including palliative care. Palliative care providers may choose to be involved in their patient’s VAD journey, which includes facilitating VAD substance supply. According to Queensland legislation, only pharmacists employed by the statewide pharmacy service (located in South East Queensland, SEQ) can supply VAD substances and are required to do so in an equitable manner across the state. 
  
  

Aim: To investigate if a patient’s location impacts delivery of the VAD substance by a centralised pharmacy service. 

 

Method: Substance delivery data collected by a centralised pharmacy service in Queensland between 1/01/23-15/03/23 was analysed to investigate the impact of location on VAD substance delivery timeframes. The time taken to provide VAD substances was determined by comparing patients’ preferred versus actual supply date. The patients’ location in relation to the SEQ region was then analysed in conjunction with delivery times. 

 

Results: The pharmacy service was able to deliver the substance to patients (n=111) within four days of their preferred supply date regardless of their geographical location. Most patients (98.2%) received the substance within two days of preferred supply date. Furthermore, the difference in delivery times between SEQ (n=65) and son-SEQ (n=46) was not statistically significant (p=0.1464), with delivery occurring on the requestor’s preferred date of supply in 78.5% (51) and 69.6% (32) of instances respectively.

 

Discussion: The findings suggest that patients living in rural and remote locations are not disadvantaged by a centralised VAD pharmacy service, allowing palliative care providers to facilitate timely access to VAD care for their patients. This contributes to services being able to provide equitable, dignified EOL care to patients wishing to access VAD. 

Background: Family caregivers take on much of the burden of end-of-life care for most patients. Provision of bereavement information and support is an expected function of specialist palliative care services. However, the impact of bereavement services is not well understood. Bereavement services are often described as providing universal interventions regardless of the need, though the assertion lacks evidence. 

Aim: A central aim of this research was to assess the preferences for, and impact of, service-initiated contact and subsequent use of support. Further, self-reported data were gathered on preparedness, impact of support, adjustment, and signs of problems moving forward. 

Method: Data were gathered from a consecutive sample of bereaved caregivers (224/1057) from an Australian specialist palliative site using a purpose-designed, self-administered questionnaire. Current adjustment was self-reported using the Prolonged Grief tool, PG-13. 

Results: Participants were bereaved between 20-55 months, ages ranged from 24 to 94 years, 71.0% had experienced the death of a partner, and 75.9% were female.  Thematic analysis showed that the provision of bereavement information and pathways to support provides a ‘safety net’. The decision to make use of bereavement services was related to self-assessed need and not simply because of contact. Most reported little difficulty in adjustment though 16.8% experienced regular heightened symptoms of grief. Multivariate analysis indicated the negative impact of poor preparedness, with 62.1% feeling under-prepared. Caregiver preparedness for an expected death was reported to be influenced by healthcare professionals' communication skills.  

Conclusions: These findings demonstrate that bereaved caregivers experience value in service-initiated delivery of grief information and pathways to support, which is experienced as safety net. Provision of information on pathways to support eases that burden upon the bereaved when seeking support. Significantly, service-initiated contact can be distinguished from counselling interventions. Use of support was not solely due to service-initiated contact. 

Background: The demand for community palliative care is increasing, with greater preference to stay at home. Effective communication between inpatient consult palliative care and community palliative care teams is vital to ensure effective transitions of care. Diversity, inconsistency and accessibility of information documented by the inpatient consult team at each consultation can negatively impact the quality of care provided in the community on discharge. The aim of this quality improvement (QI) project was to improve documentation for the consult team to improve care transitions to the community.

Method: This QI was conducted within a metropolitan hospital in NSW Australia as part of the Sydney Partnership for Health, Education, Research & Enterprise Palliative Care Clinical Academic Group collaborative with Stanford Medicine (USA). QI methodology was adapted from the Realizing Improvement through Team Empowerment (RITE) and Clinical Excellence Leadership Training (CELT).  The A3 problem solving process guided the multidisciplinary interventions to increase documentation using the ISBAR principles in the initial and final consult of the inpatient palliative care team.  Patient electronic medical records (eMR) were retrospectively reviewed for content and identification of the ISBAR principles from April – November 2022, to identify gaps in the content, develop a specific audit tool and deliver education material.

Results: The percentage of patients who had documentation following the ISBAR principles across the initial and final consultation entry in eMR increased from 50% prior to the QI project to 80% at project completion.  

Conclusion: The project demonstrated the potential to instigate impactful and meaningful change within healthcare in a short period of time, with limited resources through simple and low-cost interventions. It achieved Palliative Care specific content within documentation and standardisation of location for timely access to written communication when there is transfer of care from inpatient to community to ensure ongoing person centred and safe care.

Background: Community Palliative Care Services (CPCS) in Victoria mostly operate during business hours, Monday to Friday 0800-1700hrs, with some provide evening and/or after-hours short visits. However, care at the end-of-life can be complex and occurs across 24 hours of the day and night. Symptom management and care needs often become more intensified. When home is the preferred site of death is home, the carer role puts extra strain on carers and subjects them to learning new skills at a stressful time and providing 24-hour care, resulting in exhaustion and sleep deprivation. Escalated carer stress can influence the place of choice and inadvertent hospital admissions at the end of life. In the bereavement phase, many carers state that they regret the last hospital admission and would have kept the client at home had they known that the client would die within the next hours or few days.

Objectives:

· To evaluate the effect of overnight nursing respite in preventing hospital transfer at the terminal phase of life.

· To identify resources available to facilitate overnight respite at end-of-life period.

· To identify the challenges for the CPCS to provide overnight nursing respite.

· To provide cost analysis of a Model of Care for end-of-life-care at home that includes provisioning of overnight nursing respite by CPCS.

Method: Retrospective Qualitative research. Data will be collected from CPCS Overnight Respite reports from 2019-2022. With an approval from the Ethics Committee, 100 carers will be randomly selected from the Overnight respite reports and be contacted by CPCS staff. With their consent, carers will be interviewed using a set of questionnaires. The data will be analysed and presented in a report.

Expected outcomes:

· Evidence to support ongoing fundings for overnight nursing respite to clients in their terminal phase of life

· Development of a CSPC Model of Care for end-of-life-care at home that includes provisioning of overnight nursing respite

Introduction 

Care coordination of palliative care clients in the community setting is complex. Clinicians must have a broad range of skills in assessment, recognising deteriorating clients, complex symptom management, leading difficult conversations with clients and carers. Nursing teams have a broad skill mix from experienced community nurses, to beginning career nurses. 

Aims 

The aim of the project was to test if structured and standardised approach to orientating new staff to palliative care in the community enhanced their skills and confidence in providing care.

Methods

A Palliative Care Skills self-assessment tool was developed incorporating core skills required to provide palliative care nursing in a community setting. Skills were assessed using ‘Benners Stages of Clinical Competence’ prior to commencing the Palliative Care Pathway (the pathway). 

An orientation guide with a set of skills  across clinical and non-clinical domains was developed by the Clinical Nurse Consultant (CNC). The Registered Nurses (RN) were provided with a booklet outlining skills to achieve with support of the palliative care nursing .The CNC met individually with each staff member to discuss their initial self-assessment and provided them with a list or resources specific to palliative care. A follow up self-assessment was performed at the end of 6 months on the pathway. 

Participating RNs were interviewed after 6 months. The interviews were informal and exploring the process of following the structured orientation pathway.

Conclusion

The pilot project made a difference to the nursing staff as they felt supported by having a structured process to develop their skills.  The specialist palliative care nursing team was able to assess the development of nurses skills using a standardised process with a structure directing their learning. The Pathway is now embedded in the standard orientation of new Registered Nursing staff in the community nursing team.

Backed by a state government commitment to improve palliative care for all South Australians, a mobile telehealth project was developed for regional Local Health Networks (rLHNs) to: enable access to specialist medical palliative care consultation with metropolitan services in between scheduled face-to-face medical specialist visits; broaden the availability and reach of home-based effective and timely palliative care for regional patients;  strengthen collaboration/partnerships between metropolitan and regional palliative care services and regional GPs to improve coordination and continuity of care; and keep patients in the comfort of their home longer, improving complex symptom and medication management, reducing travel and minimising pressure on hospital systems.

A small project team supported implementation of the project into the six rLHNS including evaluation of project outcomes. Data collection included number of patients seen and telehealth (video) consultations undertaken, and patient and clinician feedback which will be the focus of this presentation.

Feedback highlighted appreciation for the mobile telehealth services in maximising patient care: enabling access to medical specialists when most needed; enabling the inclusion of several clinical/medical practitioners in a consult, making care more holistic and coordinated, and improving effective collaboration and efficiency (particularly with metropolitan-based clinicians) in giving the right care at the right time; enabling the participation of geographically dispersed family members to contribute to care decision making; and the significant reduction in physically and mentally taxing travel afforded by home-based/bed-side consultations.

 

Overall, the mobile telehealth service has greatly improved the end-of-life experience for patients and a wider group of patients now have access to specialist consultation when they require it, “not only the extreme cases”. The advent of COVID-19 had an impact on the project and lessons learned, providing both barriers and enablers to successful implementation.

Background
Cultural humility is vital in building cultural awareness and respect; and in working towards equality in healthcare. It is key in advocacy and improving the quality of care provided to children and their families; particularly in Paediatric Palliative Care (PPC), an area that requires sensitivity and individualised care. 

With Australia’s multicultural and multi-ethnic diversity, the Queensland Children’s Hospital PPC team recognises the importance in being culturally sensitive and are keen to continually learn more.

Aim
We aim to improve our cultural awareness; to better appreciate how culture may impact decision making, and patient and family experiences of healthcare. Through shared stories, we hope to discuss factors that facilitate provision of holistic and individualised patient care.

Methods
We conducted a literature review and reflective exercise to identify current capabilities, gaps, and areas that can be optimised. 

Results
Many of us have encountered challenging situations in PPC, where an understanding of one’s cultural background was essential in breaking barriers to facilitate improved communication and understanding. Some of these complexities including collusion, misconceptions on opioids, fears surrounding death and dying, requests for palliative sedation, are often influenced by cultural factors. Cultural factors though may be perceived as barriers but are in fact opportunities for enhanced personalised care and human connection. In seeking to understand our patients and families to a deeper level, where we can respect not only the values and beliefs that we share, but also our differences, this facilitates trust, fosters the patient-healthcare-professional relationship and enhances meaning making for all. 

Conclusion/Lessons
Cultural humility is a life-long learning process.  There are benefits of a multicultural and inclusive workforce, yet we also acknowledge there is heterogeneity even within same cultures and religions. The key is for openness and humility to listen, learn and seek to understand ourselves, our colleagues, patients and families.

Background:

NSW Health has developed a patient flow system to identify barriers that delay patient discharges from hospitals.  The Sacred Heart Supportive & Palliative Care inpatient unit is part of St Vincent’s Hospital, Sydney, and participates in this system.  The trajectory, reasons why a patient is in the hospital, and barriers to a patient's discharge in a palliative care unit will likely differ from that of an acute hospital patient.  However, what palliative care inpatients are waiting for has not been explored.

Aim:

To identify what patients are waiting for during their inpatient stay, and the common barriers that delay patient discharges from an inpatient palliative care unit.

Method:

The reasons why a palliative care patient is in a palliative care unit, what patients are waiting for during their inpatient stay, and the barriers that delay patient discharge from a metropolitan teaching inpatient palliative care unit will be prospectively identified by the palliative care team (doctors and nurses) each working day over 3 months. 

In addition to the barriers identified by NSW Health, our team has identified additional reasons and barriers listed below. The prevalence of these barriers will be presented. 

Results:

This data is currently being collected. The most common factors, how each factor affects a palliative care inpatient’s trajectory, and comparisons to the acute hospital will be discussed.  These findings will assist clinicians, and hospital administrators to understand the trajectory of palliative care patients, and to identifying strategies to minimise the barriers, reduce the length of expensive hospital stays, reduce hospital costs, and improve patients’ quality of care.

Background: A metropolitan Local Health District (LHD) commissioned a research study to understand the experience of people bereaved following a death in the LHD, with focus on informing service improvement.

Aim: To understand the experience of people bereaved in the LHD, including the influence of care and communication pre-death, Advance Care Planning, Trauma Informed Care, and experience of bereavement supports.

Methods:  The multi method protocol comprised an online survey and qualitative interviews. The survey was designed by a multidisciplinary team (MDT), including consumer co-investigator. Invitations were mailed to the Next of Kin of adult patients who died in the LHD in the preceding 2-15 months. On completion of the survey online, participants could enter contact details offering to undertake an interview. Interviews were recorded and transcribed. A thematic analysis approach was employed. Transcripts were analysed by two investigators, using NVivo software, with the coding approach reviewed by the MDT. Survey results were analysed using descriptive statistics.


Results: Among other findings, of interest were the information needs expressed by bereaved people. These needs incorporated both pre and post death considerations. While only 18% of people reported having had a pre-death discussion regarding grief, of those 86% reported having found the discussion helpful. Interviews elicited a range of responses regarding information needs, including knowledge of the dying process, the practical tasks of early bereavement, grief and available supports. Participants shared ways these information needs were met through the shared experiences of friends and family, their own previous bereavement experiences, and from healthcare professionals. Often informal networks provided information that was not offered by healthcare professionals.


Conclusions: Findings highlight the need for systems to ensure consistent provision of information pre-death and in early bereavement. This study is guides the development of policy, bereavement resources and staff education.

Background:

Children with brain cancer and their families have complex care needs throughout diagnosis, active treatment, long-term survivorship and the palliative phase of illness. This study aimed to explore the perspectives of Australian specialist clinicians on barriers and facilitators to healthcare for children with brain cancer and their families.

Methods:

A qualitative approach was taken using semi-structured interviews. Eligible participants were clinicians of any discipline providing care to children with brain cancer and their families in Australia. Interviews were conducted by telephone and asked about perceived strengths and weaknesses in healthcare and available resources for this population. Content analysis used a directed approach with inductive refinement.

Results:

Eleven clinicians participated, 5 of whom were medical, 3 nursing, and 3 allied health. The over-arching theme was that the rarity and diversity of brain tumours in children confers challenges to care that lead to variation in practice. Participants reported having to adapt care from guidelines and patient/family resources designed for adults with brain cancer and children with other cancers, and rely on clinical and research networks. Specialist comprehensive cancer care was generally perceived to offer the best model for accommodating the unique needs of each child/family, but barriers to access were highlighted for children in remote Australia, and long-term follow-up was perceived to be inadequate regardless of where children lived.

Discussion:

Future research should focus on developing and evaluating guidelines and other resources specific to children with brain cancer, as well as informing suitable models for long-term follow-up care for survivors.

Background 

Delirium is a distressing acute neurocognitive condition experienced by around one-third of patients in inpatient palliative care units (PCUs). Proactive systems for evidence-based delirium care are missing and innovation is needed. 

 

Aim  

To develop a patient-centred delirium monitoring system in PCUs to improve delirium prevention, detection, root cause treatment, and clinical responses to patients’ distress by integrating Palliative Care Outcomes Collaboration (PCOC) and the Delirium Clinical Care Standard. 

 

Methods 

The ‘MODEL-PC study’ is an exploratory sequential mixed methods project (2022-23). Through consultation with patients, family carers, staff of four Australian PCUs and other stakeholders, a new delirium monitoring system will be developed (stage 1) and then piloted (stage 2). Data collection is via process mapping, clinical audits, semi-structured interviews, and case report forms aligned with PCOC methods. Quantitative, qualitative, and mixed methods analyses will determine a range of implementation, process, and patient outcomes, including the systemic utility (overall feasibility, acceptability, and appropriateness) of the new system for wider testing.

 Results

At abstract submission, preliminary stage 1 results include 111 baseline audits of discharged patients’ medical records (40 (36%) female, mean (±SD) age 76.2 (±13.8) years, 18.9% preferred language not English). Three-quarters (74.8%) died during admission and 31.5% experienced delirium. Of the eight Delirium Standard quality statements, only standard 1 (screening for cognitive impairment on admission, 71.2%) and 6 (risk assessment for hospital complications, 68.6%) were achieved. Preventive strategies, patient-centred information and support, and avoidance of both antipsychotics and benzodiazepines for delirium were rarely demonstrated (7.2%, 20% and 14%, respectively). 

 

Preliminary results confirm the need for quality improvement in delirium care in PCUs and the importance of obtaining patients’ perspectives about care. Full stage 1 results (including the new delirium monitoring system to be piloted) of the MODEL-PC study will be presented at the OPCC conference.