Latest Australian research

White NM, Barnett AG, Lee XJ, Farrington A, Carter H, McPhail SM, et al.

Objectives: To investigate if a prospective feedback loop that flags older patients at risk of death can reduce non-beneficial treatment at end of life. 

Design: Prospective stepped-wedge cluster randomised trial with usual care and intervention phases. 

Participants: 14 clinical teams were recruited across the three hospitals. Teams were recruited based on a consistent history of admitting patients aged 75+ years, and needed a nominated lead specialist consultant. Under the care of these teams, there were 4,268 patients (median age 84 years) who were potentially near the end of life and flagged at risk of non-beneficial treatment. 

Intervention: The intervention notified clinicians of patients under their care determined as at-risk of non-beneficial treatment. There were two notification flags: a real-time notification and an email sent to clinicians about the at-risk patients at the end of each screening day. The nudge intervention ran for 16-35 weeks across the three hospitals. 

Main outcome measures: The primary outcome was the proportion of patients with one or more intensive care unit (ICU) admissions. The secondary outcomes examined times from patients being flagged at-risk.

Results: There was no improvement in the primary outcome of reduced ICU admissions (mean probability difference [intervention minus usual care] = -0.01, 95% confidence interval -0.08 to 0.01). There were no differences for the times to death, discharge, or medical emergency call. There was a reduction in the probability of re-admission to hospital during the intervention phase (mean probability difference -0.08, 95% confidence interval -0.13 to -0.03).

Conclusions: This nudge intervention was not sufficient to reduce the trial's non-beneficial treatment outcomes in older hospital patients.

Trial Registration: Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).

 © The Author(s) 2024. Published by Oxford University Press on behalf of the British Geriatrics Society.

McDonald J, Ross L, Wicks C, Philip J.

Abstract: Systemic sclerosis is a complex, multi-organ disease which causes substantial and progressive symptoms and impairs quality of life. International guidelines recommend early, integrated palliative care for patients with advanced cardiopulmonary disease such as heart failure, and interstitial lung disease, as this care can improve patient, caregiver and health care outcomes. In this article, we examine the potential need and role for palliative care in systemic sclerosis. We propose early, integrated palliative care could improve symptom control and quality of life, and recommend a research agenda for palliative care in systemic sclerosis, to address the lack of evidence in this area. 

Humphrey GB, Inacio MC, Lang C, Churches OF, Sluggett JK, Williams H, et al.

Objective: Population-based data on the required needs for palliative care in residential aged care have been highlighted as a key information gap. This study aimed to provide a comprehensive estimate of palliative care needs among Australia's residential aged care population using a validated algorithm based on causes of death.

Methods: A population-based retrospective cohort study was conducted using data from the Registry of Senior Australians of non-Indigenous residents of residential aged care services in New South Wales, Victoria, and South Australia aged older than 65 years, who died between 2016 and 2017 (n = 71,677). An internationally validated algorithm was used to estimate and characterise potential palliative care needs based on causes of death. This estimate was compared to palliative care needs identified from funding-based care needs assessment data.

Results: Ninety two per cent (n = 65,949) were estimated to have had potential palliative care needs prior to their death. Of these, 19% (n = 12,467) were assigned an end-of-life trajectory related to cancer, 61% (n = 40,511) to organ failure and 20% (n = 12,971) to frailty and dementia. By comparison, only 6% (n = 4430) of residents were assessed as needing palliative care by the funding-based care needs assessment.

Conclusions: Over 90% of individuals dying in residential aged care may have benefited from a palliative approach to care. This need is substantially underestimated by the funding-based care needs assessment, which utilises a narrow definition of palliative care when death is imminent. There is a clear imperative to distinguish between palliative and end-of-life care needs within residential aged care to ensure appropriate and equitable access to palliative care.

© 2024 The Author(s). Australasian Journal on Ageing published by John Wiley & Sons Australia, Ltd on behalf of AJA Inc’.

Lion KM, Jamieson A, Billin A, Jones S, Pinkham MB, Ownsworth T.

Background: Family caregivers of people with high-grade glioma often report high rates of psychological distress, which has been attributed to the unique aspects of the disease and onerous care demands. Clinical practice guidelines advocate for caregiver support from diagnosis through to end-of-life and bereavement. Yet, research has identified that caregivers' support needs are often overlooked.

Aim: To explore caregivers' experiences of psychological support and perceptions of what constitutes optimal psychological support for caregivers in the context of high-grade glioma.

Design: Qualitative study involving semi-structured interviews with data analysed using reflexive thematic analysis.

Setting/participants: Eighteen current (n = 11) and bereaved (n = 7) family caregivers (73% female, aged 33-69 years) of adults with high-grade glioma participated. Interviews explored caregivers' perceptions of psychological support. 

Results: Two major themes were generated. The first theme, 'It was never about me', reflected caregivers prioritise for people with high-grade glioma to be well supported despite experiencing their own unmet psychological support needs. The second theme, 'Continuous, coordinated and personalised support', highlighted the importance of timely and tailored interventions addressing caregivers' practical, educational and emotional support needs throughout the illness journey.

Conclusions: Caregivers commonly prioritise the support needs of people with high-grade gliomas; yet, have their own distinct needs that vary throughout the illness. Primary care providers have a potential role in facilitating timely access to palliative care, practical support and brain tumour-specific psychological support to meet caregivers' diverse needs across the care continuum in the context of high-grade glioma.

Wong AKY, Wang D, Gordon I, Alexander M, Siew B, Yap N, et al.

Objectives: Early opioid initiation is recommended for advanced cancer pain, however the timing of opioid commencement in relation to diagnosis has not been described, and the role of palliative care prescribers is unclear. This study aims to determine the timing of opioid initiation by prescriber and cancer type in relation to key timepoints in the cancer illness course (diagnosis, palliative care referral and death).

Methods: This retrospective cohort study included patients at a quaternary cancer centre with incurable advanced cancer of five different subtype groups. Demographics, clinical characteristics, health service use and details of first slow and immediate release opioid prescription are reported. 

Results: Among 200 patients, median time to first immediate release opioid prescription was 23 days (IQR 1-82) and to slow release opioid prescription was 47 days (IQR 14-155). Most patients (95%, (n=190) were referred to palliative care (median time to referral 54 days (IQR 18-190)). Non-palliative care prescribers initiated slow release opioids for half the cohort (49%, n=97) prior to referral. Patients with pancreatic cancer had the shortest time to slow/immediate release opioid prescription (median 10 days (IQR 0-39) and 26 days (IQR 1-43) respectively) and shortest survival (median 136 days (IQR 82-214)). 

Conclusions: Median time to opioid commencement was approximately 3 weeks after diagnosis. Despite early palliative care involvement, opioid initiation by non-palliative care clinicians was common and remains important. Timely palliative care referral for those with pancreatic cancer may include consideration of earlier complex pain presentations and shorter prognosis.

© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.