The development and evaluation of a palliative care admission assessment tool.

351 Pages·2015·2.98 MB·English

The development and evaluation of a
palliative care admission assessment
tool.
By
Martina O Reilly (BSc.)
Submitted in partial fulfilment of the requirements for the degree
of Doctor of Philosophy
at

University of Limerick
Supervisor: Professor David Meagher

Submitted to the University of Limerick, October 2014
TABLE OF CONTENTS

Abstract i
Declaration ii
Acknowledgements iii
List of Tables iv
List of Figures v
List of Appendices vi
List of Abbreviations vii
Chapter 1 Introduction 1
Chapter 2 Methodology 15
Chapter 3 Literature Review 55
Chapter 4 Results 133
Chapter 5 Discussion 198
References 239
“Life is pleasant. Death is peaceful. It's the transition that's
troublesome.”

Isaac Asimov
Abstract
Effective palliative care intervention is contingent upon a comprehensive
multidimensional assessment of the patient’s experience of illness. Assessment in
palliative care settings must be focused, sensitive, specific and effective in order to
minimise discomfort to vulnerable and often highly morbid patients. Optimal
assessment can be facilitated by careful choice of tools that allow systematic
standardised assessment, are feasible within clinical practice and acceptable to patients.
The aim of this research was the development and testing of evidence based,
multidisciplinary, specialist palliative care assessment; accompanying guidelines and
training package (the intervention). The tools included in the admission assessment
were chosen further to extensive literature review. Mixed methods were utilised to
facilitate a comprehensive evaluation pre and post-intervention to test the effectiveness,
feasibility and acceptability of the intervention in a busy clinical environment.
Results demonstrated an increase in evidence of assessment across the palliative care
domains and in particular in relation to assessment of the patient’s psychosocial distress
and assessment of carer’s needs. Post-intervention increased concordance of outcome
of clinical assessment with the patients self-rating of pain, nausea, breathlessness and
distress is evident in comparison to pre-intervention. Referrals to other disciplines
occurred earlier in the admission post-intervention. Staff reported that there was an
increase in the assessment of palliative care domains, less need for training and an
increased likelihood of assessment of carers needs.
Significant improvement with regard to assessment of patient needs were reported. The
admission assessment should be tested in other clinical environments to determine the
degree to which the results can be replicated and to investigate concordance with the
finding presented here. An adapted version of the assessment should also be developed
for the home care and day care services.
Declaration

I hereby certify that this material, which I now submit for assessment on the programme
of study leading to the award of PhD is my own work. I have exercised reasonable care
to ensure that the work is original and does not to the best of knowledge breach any law
of copyright, and has not been taken from the work of others save and to the extent that
such work has been cited and acknowledged within the text of my work.

Signature: ________________________

ID No. : _________________________

Date: _________________________
Acknowledgements

I would like to thank my supervisors, Professor David Meagher, Professor Philip Larkin
and Dr Marion Conroy for their guidance and advice in the conduction of this work. I
owe a huge debt of gratitude to the members of steering committee who worked
tirelessly to choose the most appropriate tools for inclusion in the MPCAT and in its
implementation.

This research was part funded by the Irish Hospice Foundation and by Milford Care
Centre and I wish thank them and to recognise their support in the completion of the
work.

I would like to thank all of the patients, who participated in the study. Their time was
precious and they gave it generously. I would like to thank all of the staff in the
inpatient unit in Milford Care Centre who took part in their study and for sharing their
insights with regard to the assessment process and palliative care.
To my husband and my beautiful boys, James and Michael, who have patiently
supported me every step of this journey, thank you!
I dedicate this thesis to my parents Bernard and Mary O Reilly, to whom I owe
everything.
Figures
Chapter 1
None
Chapter 2
Figure 2.4.1 Methodologies used for each phase
Chapter 3
Figure 3.1.1 Systematic literature review results
Chapter 4
Figure 4.3.1 Evidence of completion of the pain assessment tool pre and post-
intervention.
Figure 4.6.1 Resuscitation status and communication around resuscitation decision
making.
Figure 4.7.1 Documentation of psychological impact in the notes completed by
doctors prior to the intervention
Figure 4.8.1 Documentation of spiritual needs in the medical notes pre- intervention
Figure 4.8.2 Documentation of spiritual issues by nurses pre-intervention
Figure 4.10.1 Referrals to members of the multidisciplinary team occurring in the first
24 hours of admission
Figure 4.10.2 Frequency of referrals to other members of the Multidisciplinary team,
before and after the intervention
Figure 4.11.1 Documented evidence of the completion of a genogram and assessment
of other practical domestic issues
Figure 4.13.1 Frequency of controls documented to reduce risk of falls documented
when a patient was at risk of falls
Figure 4.14.1 Documented evidence of patient’s and families’ awareness of
diagnosis and prognosis
Figure 4.19.1 Comparison of patient severity ratings and clinician assessment of pain
Figure 4.19.2 Patient self-rating and clinician assessment of fatigue
Figure 4.19.3 Patient self-rating and clinician assessment of nausea
Figure 4.19.4 Patient self-rating and clinician assessment of shortness of breath
Figure 4.19.5 Patient self -rating and clinician assessment of disturbed sleep
Figure 4.19.6 Patient self-rating and clinician assessment of lack of appetite
Figure 4.19.7 Patient self-rating clinician assessment of dry mouth
Figure 4.21.1 Patient self-rating and clinician assessment of spirituality
Figure 4.22.1 Frequency of patient reported priority symptoms and
issues identified in the care plan summary
Figure 4.26.1 Respondents years of experience pre and post-intervention
Figure 4.26.2 Respondents views of need for additional training
Figure 4.26.3 Respondents views of the assessment of all domains of
patient need
Figure 4.26.4 Respondent’s views of the need to incorporate additional
evidence-based assessment tools
Figure 4.26.5 Clinicians perspective concerning assessment of carer’s need

Chapter 5
None
Tables
Chapter 1
None
Chapter 2
None
Chapter 3
Table 3.1.2 Inclusion and exclusion criteria for the literature review
Table 3.3.1 Pain domains, in order of their importance in respect of the assessment of
pain in palliative pain
Table 3.3.2 Illustrating the question areas in the pain assessment questionnaire for a
patient with advanced disease
Table 3.3.3 Pain assessment tools validated for use in Palliative Care Settings
Table 3.4.1 Studies describing symptoms clusters experienced by palliative care
patients with advanced cancer
Table 3.4.2 Physical symptom assessment tools identified
Table 3.5.1 Prognostic and functional assessment tools identified
Table 3.6.1 Tools to screen for cognitive impairment and delirium
Table 3.7.3.1 Instruments for obtaining a spiritual history
Table 3.7.3.2 Spirituality assessment tools validated in a palliative care population
Table 3.8.1 Psychological tools identified that have been validated in a palliative
care population
Table 3.9.1 Summary of tools which assess needs of caregivers of palliative care
patients
Chapter 4
Table 4.1.1 Demographics of patients who agreed to be interviewed and whose
charts were audited.
Table 4.4.1 Frequency of documented percentage evidence of assessment for
common physical symptoms
Table 4.5.1 The frequency of documented evidence of cognition and delirium
Table 4.7.1 Assessment of psychosocial needs
Table 4.9.1 Documentation of assessment of carer needs
Table 4.10.1 Frequency of referrals to members of the multidisciplinary team within
the first twenty four hours of admission
Table 4.12.1 Documented evidence assessment of activities of daily living
Table 4.16.1 The completion, median severity and interquartile range of patient
ratings.
Table 4.23.1 Total score and median factor scores of the FAMCARE 2 pre and post-
intervention
Table 4.23.2 Median scores of additional questions asked of carers
Table 4.24.1 Change in confidence and competence median scores of NCHD’s to
conduct psychosocial assessment
Table 4.24.2 Change in confidence and competence median scores of non consultant
hospital doctor’s to conduct psychosocial assessment between Time 1
and Time 2.
Table 4.24.3 Change in confidence and competence median scores of non consultant
hospital doctor’s to conduct psychosocial Assessment between Time 2
and Time 3.
Table 4.25.1 Comparison of the pre-intervention and the MPCAT with other inpatient
admission assessments
Chapter 5
None