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. 2016 Sep 19;6(9):e012340.
doi: 10.1136/bmjopen-2016-012340.

Identifying patients with advanced chronic conditions for a progressive palliative care approach: a cross-sectional study of prognostic indicators related to end-of-life trajectories

Affiliations

Identifying patients with advanced chronic conditions for a progressive palliative care approach: a cross-sectional study of prognostic indicators related to end-of-life trajectories

J Amblàs-Novellas et al. BMJ Open. .

Abstract

Objectives: 2 innovative concepts have lately been developed to radically improve the care of patients with advanced chronic conditions (PACC): early identification of palliative care (PC) needs and the 3 end-of-life trajectories in chronic illnesses (acute, intermittent and gradual dwindling). It is not clear (1) what indicators work best for this early identification and (2) if specific clinical indicators exist for each of these trajectories. The objectives of this study are to explore these 2 issues.

Setting: 3 primary care services, an acute care hospital, an intermediate care centre and 4 nursing homes in a mixed urban-rural district in Barcelona, Spain.

Participants: 782 patients (61.5% women) with a positive NECPAL CCOMS-ICO test, indicating they might benefit from a PC approach.

Outcome measures: The characteristics and distribution of the indicators of the NECPAL CCOMS-ICO tool are analysed with respect to the 3 trajectories and have been arranged by domain (functional, nutritional and cognitive status, emotional problems, geriatric syndromes, social vulnerability and others) and according to their static (severity) and dynamic (progression) properties.

Results: The common indicators associated with early end-of-life identification are functional (44.3%) and nutritional (30.7%) progression, emotional distress (21.9%) and geriatric syndromes (15.7% delirium, 11.2% falls). The rest of the indicators showed differences in the associations per illness trajectories (p<0.05). 48.2% of the total cohort was identified as advanced frailty patients with no advanced disease criteria.

Conclusions: Dynamic indicators are present in the 3 trajectories and are especially useful to identify PACC for a progressive PC approach purpose. Most of the other indicators are typically associated with a specific trajectory. These findings can help clinicians improve the identification of patients for a palliative approach.

Keywords: Advanced Frailty; Advanced chronic conditions; End-of-life trajectories; Health Status Indicators; Prognosis.

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Figures

Figure 1
Figure 1
Key transitions and the three end-of-life trajectories. Early identification of palliative care needs becomes the starting point for transition 1. Situational diagnosis refers to the evaluation and assessment of patients that allows healthcare professionals determine patients’ health degree (A, B, C, D or E) and identify entrance to transition 2 (D) or last days–hours situation, instead (E); this situational diagnosis is indispensable to establish the objectives of care in this progressive care model in a decision-making process shared by professionals, patients and their families.

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