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Categoria: Senza categoria ,. Lascia un commento Annulla risposta. Programma un Test Drive 19th and 24th in first. Miglior tempo. In contrast to this, other comments were stated, including, for example:. We only bring evidence-based medicine in palliative care forward by a chair, only a chair offers acquiring meaningful external funding, a chair is needed for setting up an own-research department.
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In July , the roundtable followed. One of the five controversial recommendations was dropped unanimously BP15 , because its content was included in another of these five controversial recommendations BP In conclusion, four resulting recommendations were provided for a third Delphi round. The third call took place in July and August During the third round, four of the five remaining recommendations were consented. One recommendation referring to participation in oncology decision-making processes, such as tumor boards or consultation hours BP18 , found no consensus for feasibility of implementing this recommendation In all three Delphi rounds, staff shortage was specified as the main reason for nonfeasibility.
The modified recommendation BP27 reached consensus by including a parenthesis. In this way, to enhance research and education, a structural concept that includes a chair for palliative care is recommended. There is agreement that inside the ED, medical and nursing staff must work with a palliative care based qualification and competence , which is acquired and regularly updated, to be able to recognize the needs for specialized palliative care BP The majority CCCs should function as institutions that have the highest possible performance standards caring for the most complex cancer patients.
Providing the best possible cancer care must certainly have an enormous impact on the provision of palliative care in these certified centers. The recommendations presented here can serve as guidance for future development in SPC in comprehensive cancer care in Germany and elsewhere. To date, the situation in many CCCs needs much improvement and investment to achieve the standard experts have agreed on, especially in CCCs not certificated by DKG as an oncologic center with its detailed recommendations for palliative care services [ 26 ].
Conclusions from the current status quo [ 4 ] and the future perspectives arising from the Delphi study emphasize an urgent need for better implementation of SPC into CCCs in Germany. The development of multiprofessional palliative care consultation teams, outpatient clinics, and the integration of SPC in consultation hours of other departments and research projects of CCCs are future goals for German CCCs.
The expert panel of the Delphi study easily found consensus on best practice recommendations for the presence and size of palliative care units. In contrast, international experts do not favor a dedicated number of palliative care beds in hospitals, [ 2 ] which is not yet widely established [ 3 ].
The main focus lies rather on an inpatient palliative care consultation service and an outpatient palliative care clinic, which were also recommended by German experts for a CCC. However, these are rarely available in Germany compared with availability in the U. Recommendations on day care, health care proxy and advance directives, pathways for dealing with dying patients, and research in a CCC achieved broad consensus quickly. On other issues, in particular concerning feasibility, the process for consensus finding was much more complex or even impossible.
The involvement of SPC in tumor boards, for example, has an educational character [ 4 ] and aims to detect patients with certain palliative care needs [ 27 ]; however, the best practice recommendation on the participation of SPC in tumor boards has not been consented. Whereas this recommendation was rated highly relevant and clearly stated, its feasibility was doubted until the last round.
This outcome points at the challenge that the constant participation of SPC in tumor boards as well as other oncology decision-making processes are currently perceived as unsustainable due to large efforts of time and staffing parallel to restricted financial resources of the SPC at CCCs [ 4 ]. Nevertheless, international experts stated that the routinely integration of the palliative care team in multidisciplinary tumor boards for patient case discussions is a minor quality indicator [ 2 ].
The need for the presence of a chair in palliative care at CCCs was discussed controversially throughout the Delphi process. More than half of experts favored the presence of a chair, similarly to international observations [ 2 ]. Experts in favor of chairs argue that the foundation of palliative care chairs is central and necessary for fundraising, performing research, and implementing education and that chairs might reinforce the institutional status within the CCCs.
This argumentation is supported by the fact that palliative care departments with a chair position have significantly more research grants than departments without a chair [ 4 ]. A second argument in favor of palliative care departments with a chair is that the presence of a chair may become a future feature for the approval as a CCC by the German Cancer Aid. Another argument against a chair for palliative care, which was named in status analysis, was to rely on that the subject develops mainly through interdisciplinary networking [ 4 ].
In contrast, political and personal weight or visibility must be in place having power on its own. Consideration to offer palliative care to patients with incurable cancer early in the course of disease is internationally recognized and discussed [ 28 ].
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Although diverse concepts on early integration are proposed, sufficiently establishment still does not exist in clinical practice. In this study, there was a high acceptance of the wording and relevance of a recommendation on early palliative care from the first Delphi round, but consensus regarding feasibility of early palliative care was lacking until the second round. The approved recommendation underlines mandatory early integration of palliative care but leaves open how this goal can be achieved. With regard to the Delphi findings reported here, the minimal education requirements for all professionals in general palliative care in Germany were set to 40 hours of a basic palliative care course in the second round of the presented Delphi process.
This lack of palliative care education underpins international reports that indicate that many oncology fellows or nurses are still insufficiently prepared to provide palliative care to their patients [ 29 — 34 ].
EDs are part of the steering system for patients with urgent needs. Many patients with advanced chronical diseases or malignancies and their family members could benefit from SPC resources and referrals in EDs [ 35 , 36 ]. Benefits have been seen in improved patient outcomes [ 37 ], patient and family satisfaction [ 38 ], and cost savings [ 39 ]. In the first two Delphi rounds there were substantial concerns about how SPC could be implemented in the ED practice and routine. Some experts proposed to guarantee SPC consultation around the clock versus basic palliative care qualification for medical and nursing ED staff.
Finally, the inclusion of emergency physicians and emergency medical staff into the continuing basic palliative care education was discussed and approved. Despite this debate it is obvious that intercommunication with ED is of special significance for offering adequate cancer and palliative care in a CCC. The Delphi technique is an adequate consensus method to improve decision-making in health care [ 40 ].
However, it can be argued how powerful the generated recommendations are [ 20 ] in terms of implementation into practice. Although more than two thirds of the participants responded during the whole Delphi process, a minor portion from all clinical settings dropped out during the study period, which leads to missing expert opinions.
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Structural and personal differences between the sites, especially for research and teaching, restrict collecting opinions of different perspectives in relation to the practice settings. Unequal distribution of professional backgrounds might have led to diverging conclusions with regard to the given recommendations. The greatest proportion of physicians is justified by its special comprehensive look to clinical processes, research, and education.
However, the high participation in all practical settings and high degree of consensus indicate a representation for recommendations. The German CCC network connects the cancer centers of excellence that have a leading role in clinical care, education, and research in Germany. Members of the palliative care working group have reached a broad consensus on 29 recommendations of a national best practice for integrating palliative care.
These recommendations will be used to optimize the implementation of palliative care into the clinical oncology routine and to strengthen research and teaching activities. Possibly, the consideration of the best practice recommendations and the National Guideline Palliative Care for patients with noncurable cancer into the certification process for Oncologic Centers will compensate for existing gaps in higher-level institutions such as German CCCs funded by the German Cancer Aid. Transfer of positive effects of anchored palliative care into the clinical practice of other national cancer centers is desired.
Simon, Peter Stachura, Christoph Ostgathe. The funding organization had no influence on design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation of the manuscript.
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The present work was performed in partial fulfillment of the requirements for obtaining the academic degree Dr. User Name Password Sign In. Telephone: ; E-Mail: julia. Accepted May 17, Published online before print July 20, Disclosures of potential conflicts of interest may be found at the end of this article. Materials and Methods. Implications for Practice: General and specialized palliative care SPC is an integral part of comprehensive cancer care. Previous Section Next Section. Participants Members of the multidisciplinary palliative care expert panel for this Delphi study [ 14 , 20 — 22 ] were defined as individuals with activity related to clinical care, teaching, or research within SPC in a German CCC.
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