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BACKGROUND: Despite global support, there remain gaps in the integration of early palliative care into cancer care. The methods of implementation whereby evidence of benefits of palliative care is translated into practice deserve attention.AIM: To identify implementation frameworks utilised in integrated palliative care in hospital-based oncology services and to describe the associated enablers and barriers to service integration.DESIGN: Systematic review with a narrative synthesis including qualitative, mixed methods, pre-post and quasi experimental designs following the guidance by the Centre for Reviews and Dissemination (PROSPERO registration CRD42021252092).DATA SOURCES: Six databases searched in 2021: EMBASE, EMCARE, APA PsycINFO, CINAHL, Cochrane Library and Ovid MEDLINE searched in 2023. Included were qualitative or quantitative studies, in English language, involving adults >18 years, and implementing hospital-based palliative care into cancer care. Critical appraisal tools were used to assess the quality and rigour.RESULTS: Seven of the 16 studies explicitly cited the use of frameworks including those based on RE-AIM, Medical Research Council evaluation of complex interventions and WHO constructs of health service evaluation. Enablers included an existing supportive culture, clear introduction to the programme across services, adequate funding, human resources and identification of advocates. Barriers included a lack of communication with the patients, caregivers, physicians and palliative care team about programme goals, stigma around the term 'palliative', a lack of robust training, or awareness of guidelines and undefined staff roles.CONCLUSIONS: Implementation science frameworks provide a method to underpin programme development and evaluation as palliative care is integrated within the oncology setting.

Primary care providers, including general practice teams (GPTs), are well positioned within the community to integrate cancer survivorship care into ongoing health management. However, roles of GPT members in delivery of cancer survivorship care have not been explored. The purpose of this study is to explore these roles from the perspectives of General Practitioners (GPs), Practice Nurses (PNs) and Practice Managers (PMs). An interpretive qualitative study using semi-structured in-depth telephone interviews with ten GPs, nine PNs and five PMs was conducted. Interviews were recorded, transcribed and analysed using grounded theory methods. Perspectives of roles in delivery of cancer survivorship care were highly variable. Variation was evident among perceptions of needs of cancer survivors, individual team members’ scopes of practice, and individual professional knowledge and skills. A lack of clarity in roles and responsibilities of GPT members was thought to contribute to a lack of consistency in survivorship care. Reducing variations in perceptions of survivorship care in the primary care setting should be a priority. Such efforts may include development of practical guidance to support GPT members to clarify scopes of practice within the team. In addition to accessible comprehensive education programs, other innovative, tailored individualised education approaches may be helpful. System-level support in clarifying and supporting the roles of the primary care team is needed to facilitate a survivorship delivery system at general practice level where those within GPT can ensure that individual patients’ needs are met in a timely and effective manner.

Background 40% of Parkinson's Disease (PD) sufferers experience insomnia, impacting health and quality of life for patients and family members, especially carers. There is little evidence that current treatments are effective. Objectives To determine the effectiveness of melatonin in reducing insomnia in 44 individuals with PD using N-of-1 trials. To aggregate group data to arrive at population estimates of effectiveness (measured by improvements in PDSS-2) and safety (measured by adverse events) of melatonin in improving insomnia in PD. To assess the feasibility of offering N-of-1 trials for insomnia in PD. Methodology Participants will receive either immediate-release melatonin or placebo in random order in 3 paired two-week treatment periods (12 weeks total). Based on their response in a two-week run-in period on 3 mg daily, they will trial either 3 mg or 6 mg. Patients will keep daily sleep diaries and wear a MotionWatch throughout. After the trial patients will discuss their individual report with their doctor, which provides direct feedback about effectiveness and safety of melatonin for them. Statistical methods We will analyse N-of-1 tests 1) individually: effects of melatonin on PDSS-2 and safety will be reported; and 2) aggregated across individual N-of-1 studies, combined using a Bayesian multilevel random effects model, which will account for repeated measures on individuals over time, and will return posterior estimates of overall treatment effect, and effect in each individual. Clinical Trial Registration number ACTRN12617001103358.

Background There is increasing recognition of the clinical need for timely and coordinated supportive and palliative care for those with terminal organ failure. Objective To describe symptoms, quality of life and supportive care needs in the anticipated 12‐month period prior to death in adults with chronic kidney disease (CKD) stages 4 or 5. Method An observational, prospective, longitudinal design was used to follow 19 patients. The measures used were the Chronic Kidney Disease‐Symptom Burden Index (CKD‐SBI), the Australian Karnofsky Performance Scale (AKPS), the Functional Assessment of Chronic illness Therapy Palliative‐14 (FACIT PAL‐14), the Assessment of Quality of Life 6 Dimensions (AQoL‐6D) and the Sheffield Profile for Assessment and Referral for Care (SPARC). Data were collected at study entry and three monthly until death or study end. Results Patients’ median age was 78 years (range 42–90), most were male (63%), 10 were receiving dialysis and seven died during the study. The most prevalent symptoms reported differed from those that were most troublesome. The median AKPS score did not change over time (60). Quality of life remained steady over time [FACIT‐PAL median range: 43.5‐46; AQoL‐6D means range: 0.66 (SD 0.19) to 0.75 (SD 0.2)]. Supportive care needs were few. Conclusion We found a substantial symptom burden and slow functional decline in this group of patients. Regular assessment of both symptoms and QOL is warranted particularly if clinical experience indicates that the person is likely to be in their last year of life. Integrated supportive care programmes could assist with easing symptom burden during this time.

Background Chronic kidney disease (CKD) is a growing global problem affecting around 10% of many countries’ populations. Providing appropriate palliative care services (PCS) to those with advanced kidney disease is becoming paramount. Palliative/supportive care alongside usual CKD clinical treatment is gaining acceptance in nephrology services although the collaboration with and use of PCS is not consistent. Methods The goal of this study was to track and quantify the health service utilisation of people with CKD stages 3-5 over the last 12 months of life. Patients were recruited from a kidney health service (Queensland, Australia) for this prospective, longitudinal study. Data were collected for 12 months (or until death, whichever was sooner) during 2015-17 from administrative health sources. Emergency department presentations (EDP) and inpatient admissions (IPA) (collectively referred to as critical events) were reviewed by two Nephrologists to gauge if the events were avoidable. Results Participants (n=19) with a median age of 78 years (range 42-90), were mostly male (63%), 79% had CKD stage 5, and were heavy users of health services during the study period. Fifteen patients (79%) collectively recorded 44 EDP; 61% occurred after-hours, 91% were triaged as imminently and potentially life-threatening and 73% were admitted. Seventy-four IPA were collectively recorded across 16 patients (84%); 14% occurred on weekends or public holidays. Median length of stay was 3 days (range 1-29). The median number of EDP and IPA per patient was 1 and 2 (range 0-12 and 0-20) respectively. The most common trigger to both EDP (30%) and IPA (15%) was respiratory distress. By study end 37% of patients died, 63% were known to PCS and 11% rejected a referral to a PCS. All critical events were deemed unavoidable. Conclusions Few patients avoided using acute health care services in a 12 month period, highlighting the high service needs of this cohort throughou

Background Providing end of life care in rural areas is challenging. We evaluated in a pilot whether nurse practitioner (NP)-led care, including clinical care plans negotiated with involved health professionals including the general practitioner(GP), ± patient and/or carer, through a single multidisciplinary case conference (SMCC), could influence patient and health system outcomes. Methods Setting – Australian rural district 50 kilometers from the nearest specialist palliative care service. Participants: Adults nearing the end of life from any cause, life expectancy several months. Intervention- NP led assessment, then SMCC as soon as possible after referral. A clinical care plan recorded management plans for current and anticipated problems and who was responsible for each action. Eligible patients had baseline, 1 and 3 month patient-reported assessment of function, quality of life, depression and carer stress, and a clinical record audit. Interviews with key service providers assessed the utility and feasibility of the service. Results Sixty-two patients were referred to the service, forty from the specialist service. Many patients required immediate treatment, prior to both the planned baseline assessment and the planned SMCC (therefore ineligible for enrollment). Only six patients were assessed per protocol, so we amended the protocol. There were 23 case conferences. Reasons for not conducting the case conference included the patient approaching death, or assessed as not having immediate problems. Pain (25 %) and depression (23 %) were the most common symptoms discussed in the case conferences. Ten new advance care plans were initiated, with most patients already having one. The NP or RN made 101 follow-up visits, 169 phone calls, and made 17 referrals to other health professionals. The NP prescribed 24 new medications and altered the dose in nine. There were 14 hospitalisations in the time frame of the project. Participants were sat

Introduction and Aims: Long-term use of benzodiazepines remains common, and conveys significant risk. Providing psychological intervention in association with gradual dose reduction increases cessation rates above dose reduction alone, but appropriate psychological support is difficult to obtain. This study was undertaken to assess the outcomes of an uncontrolled case series of an internet-based cognitive-behaviour therapy (I-CBT) for benzodiazepine cessation. Design and Method: Users of benzodiazepines for > 3 months who wanted to reduce or cease benzodiazepines participated in the trial. They completed online assessments and accessed 13 newsletters on managing withdrawal symptoms and developing alternate ways to cope with life events. Therapist assistance was provided by email. Follow-up was at 3 and 6 months and feedback was obtained via comments and emails. Results: Program ratings and emailed comments of the program were positive. Thirty-two people registered for the program and 14 (44%) completed a 6-month follow-up. Of these, 8 (57%) reduced weekly intake by at least half, including 5 (36%) who ceased use. Shorter duration of use and birth outside Australia predicted greater percentage reductions at 3 months, while being partnered and in paid employment predicted reductions at 6 months. Discussion and Conclusion: While results were encouraging, controlled research is required to confirm the efficacy of the program, and engagement of both users and prescribers needs further attention.

Background: Palliative care should be provided according to the individual needs of the patient, caregiver and family, so that the type and level of care provided, as well as the setting in which it is delivered, are dependent on the complexity and severity of individual needs, rather than prognosis or diagnosis. This paper presents a study designed to assess the feasibility and efficacy of an intervention to assist in the allocation of palliative care resources according to need, within the context of a population of people with advanced cancer. ---------- Methods/design: People with advanced cancer and their caregivers completed bi-monthly telephone interviews over a period of up to 18 months to assess unmet needs, anxiety and depression, quality of life, satisfaction with care and service utilisation. The intervention, introduced after at least two baseline phone interviews, involved a) training medical, nursing and allied health professionals at each recruitment site on the use of the Palliative Care Needs Assessment Guidelines and the Needs Assessment Tool: Progressive Disease - Cancer (NAT: PD-C); b) health professionals completing the NAT: PD-C with participating patients approximately monthly for the rest of the study period. Changes in outcomes will be compared pre-and post-intervention.---------- Discussion: The study will determine whether the routine, systematic and regular use of the Guidelines and NAT: PD-C in a range of clinical settings is a feasible and effective strategy for facilitating the timely provision of needs based care.

Background: We wished to explore the ways in which palliative care is included in undergraduate health services curricula in Australia and the barriers to, and opportunities for, such inclusion. Methods: A scoping study of current Australian undergraduate health care curricula, using an email survey of deans (or equivalent) of health faculties was designed utilising all Australian undergraduate courses that prepare medicine, nursing and allied health professionals for entry to practice. Participants were deans or faculty heads from health and related faculties which offered courses relevant to the project, identified from the Australian Government Department of Education, Science and Training website. Sixty-two deans (or equivalent) from 41 Australian universities were surveyed. A total of 42 completed surveys were returned (68% of deans). Main outcome measures were total hours, content, teaching and learning strategies and resources for palliative care education in undergraduate curricula; perceived gaps, barriers, and opportunities to support the inclusion of palliative care education in undergraduate curricula. Results: Forty-five percent of respondents reported the content of current curricula reflected the palliative approach to a large degree. More than half of the respondents reported that their course had palliative care components integrated to a minor degree and a further third to a moderate degree. The number of hours dedicated to palliative care and teaching and learning strategies varied across all respondents, although there was a high degree of commonality in content areas taught. Conclusion: Current Australian undergraduate courses vary widely in the nature and extent to which they provide education in palliative care.

Needs assessment strategies can facilitate prioritisation of resources. To develop a needs assessment tool for use with advanced cancer patients and caregivers, to prompt early intervation. A convenience sample of 103 health professionals viewed three videotaped consultations involving a simulated patient, his/her caregiver and a health professional, completed the Palliative Care Needs Assessment Tool (PC-NAT) and provided feedback on clarity, content and acceptability of the PC-NAT. Face and content validity, acceptability and feasibility of the PC-NAT were confirmed. Kappa scores indicated adequate inter-rater reliability for the majority of domains; the patient spirituality domain and the caregiver physical and family and relationship domains had low reliability. The PC-NAT can be used by health professionals with a range of clinical expertise to identify individuals' needs, thereby enabling early intervention. Further psychometric testing and an evaluation to assess the impact of the systematic use of the PC-NAT on quality of life, unmet needs and service utilisation of patients and caregivers are underway.

A number of government reports have advocated the importance of healthy ageing and the need to develop multiple strategies to increase the physical activity levels of older Australians. One approach recommended is to use social support strategies to increase exercise adherence as well as improving health related outcomes. This study recruited a number of volunteer leaders (who were known by the acronym 'PAM' that stood for 'Physical Activity Motivator'). These volunteer leaders assisted and supported participants aged 65 years and older to participate in a community-based physical leisure activity. This activity was chosen by the older participant from an inventory of existing physical activity programs in the community. This paper reports on the effectiveness of strategies used to recruit volunteer leaders to help provide social support for older participants. In addition, it explores the volunteer leaders’ perceptions of the training program and the contribution volunteer leaders made in helping to achieve long term exercise adherence for older participants.