Optimization of complex palliative care at home by means of expert consultation via telemedicine.

Objective:

The aging population in Western society is a great challenge for palliative care. Many people, particularly elderly, eventually dying of cancer or non-oncological diseases prefer to die at home. However, 30-40% of palliative patients in Belgium and the Netherlands is being transferred to a hospital or health care institution in the last week of life. Good palliative care at home is necessary to guarantee quality of dying. Telemedicine has the potential to deliver high quality of palliative care at home and therefore possibly decreases the symptom burden of the patient. The primary goal of this study is to evaluate the effectiveness of telemedicine in reducing the symptom burden of the palliative patient at home.



Subjects:

Dutch-speaking adult patients, with a progressive oncological disease in an advanced stage, that have a life expectancy of 3 months or less will participate in a cluster randomized controlled clinical trial (n=100).



Primary outcome measure:

The symptom burden of palliative patients at home, measured at baseline and then weekly (ESAS; HADS).



Methods:

Patients will be included via the GP. GP’s in the area of Nijmegen will be invited to participate in this study. A telemedicine device will be installed in the homes of the patients in the intervention group. Besides the usual care, these patients have a weekly teleconsultation with a member of the palliative consultation team. The GP will join the consult when medical decision-making is on the agenda. During this study, the GP continues to be the coordinator of medical care of the patient. The nurse practitioner, in cooperation with the palliative care specialist of the palliative consultation team, will advise the GP. The control group will receive care as usual, and will not make use of the telemedicine device.



Hypotheses:

Teleconsultation will decrease the symptom burden of the patient and the burden of the family caregiver. Besides, teleconsultation will lead to less hospital admissions and improves the continuity of care. It is also hypothesized that the patient, GP and the members of the palliative consultation team are satisfied with the teleconsultations.

Palliative care is a growing need in Western society. The improved quality of healthcare makes people live longer and chronic diseases are increasing. Evidence shows that many elderly, eventually dying of cancer or non-oncological diseases, prefer to die at home. However, 30-40% of palliative patients in Belgium and the Netherlands is being transferred to a hospital or health care institution in the last week of life. The transfer of the patient is an immense burden for patient and family caregiver and leads to increased health care costs. Early recognition and anticipation at the patient’s worsening situation is necessary to prevent this heavy burden and can subsequently decrease the number of hospital admissions.



The delivery of palliative care at home is necessary to enable patients to die at their preferred place of death and to improve the quality of the last phase of life.

Teleconsultation has the potential to support good palliative care at home and is therefore hypothesized to decrease the symptom burden of the patient and the burden of the family caregiver. Besides, it will be considered whether telemedicine will decrease the number of hospital admissions and will lead to improved continuity of care.

1. Primary outcome: At baseline and after every week;

2. Secondary outcomes: At baseline and after every 4 weeks. Exceptions: The burden of care of the informal caregiver (every two weeks) and the satisfaction with the teleconsultations (just after the first two consultations).

The intervention consists of a weekly teleconsultation palliative care. A telemedicine computer will be installed at the patient’s home. The first teleconsultation will be between the patient and a Nurse Practitioner of the palliative consultation team. During this first consult, the NP checks for problems in palliative care (e.g. physical problems, social problems, coordination of care). Next, there will be a weekly teleconsultation between the patient and a member of the palliative consultation team. The GP will join the consult when medical decision-making is on the agenda. During this study, the GP continues to be the coordinator of medical care of the patient. The nurse practitioner, in cooperation with the palliative care specialist of the palliative consultation team, will advise the GP on treatment policy of the patient.



The control group will receive care as usual, and will not make use of the telemedicine device.