Abstract
Context
Hospital-based palliative care consultation teams (PCCTs) are rapidly being disseminated throughout Japan. The roles of PCCTs have changed during the past decade, particularly with the introduction of a modified national cancer care act to promote early palliative care and integrated oncology and palliative care.
Objectives
This study aimed to develop a consultation team standard for hospital-based palliative care in Japan.
Methods
We developed a provisional standard based on literature review and used a modified questionnaire-based Delphi method. Our Delphi panel comprises 20 experts selected from all relevant disciplines.
Results
All experts selected responded to the surveys over all rounds, and 14 of the 20 participated in the panel meeting. In the first round, 79 of 109 statements were judged to be appropriate, and 30 of 109 statements led to disagreements. About 16 of those 30 statements underwent minor revision, 1 was divided into two statements, and 13 remained unchanged. We then added six statements based on a discussion among participants and authors. In addition, based on comments from an external reviewer, we revised the standard, resulting in four statements being combined into two for a new total of 114 statements. In the second round, 108 of 114 statements were judged to be appropriate, and in the third round, none of the six controversial statements were judged to be appropriate. The final version comprises 108 statements.
Conclusion
We developed a standard for PCCTs in Japanese cancer hospitals. This standard provides a useful guide for clinical activities and a tool to evaluate quality of palliative care.
Key Words
Introduction
In the 1990s, palliative care consultation teams (PCCTs) comprising a multidisciplinary group of health care providers were established in many Western countries, with the aim of maximizing quality of life (QOL) for patients and their families facing life-threatening illness. Since that time, the number of hospital-based PCCTs has increased markedly in various countries, including the U.K., the U.S., Canada, and Australia, and in all cases, these teams play important roles in the overall health care system.
1
, 2
, 3
, 4
Various systematic reviews,5
, 6
randomized controlled trials,7
, 8
and cohort studies9
, 10
have also reported on the efficacy and activity of PCCTs. Similar studies have also been undertaken in Japan,11
, 12
, 13
where PCCTs are expected to play an even more important role in the future.In 2007, the Cancer Control Act and the Basic Plan to Promote Cancer Control Programs were enacted in Japan, addressing palliative care as a major issue in improving cancer care. These programs required all designated cancer hospitals to establish PCCTs within their institutes (437 hospitals, as of April 2018).
14
In 2008, structural requirements for the recommended PCCTs were established as follows: 1) members of the PCCTs must include full-time palliative care physicians, psychiatrists, nurses, and pharmacists; 2) a palliative care outpatient clinic must be offered; 3) PCCT conferences must be held more than once a week; 4) information about the activity and availability of PCCTs must be provided to patients and their families; 5) discharge support must be provided to the hospitalized patients; and 6) palliative care consultations must be provided to community health care providers. Sasahara et al.Ministry of Health, Labour and Welfare. The list of regional cancer centers [in Japanese]. Available at: http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/kenkou/gan/gan_byoin.html. Accessed May 4, 2018.
15
developed a standard for PCCTs consisting of 37 statements in four areas to improve and standardize the quality and efficacy of care delivered by the teams. In 2014, the Basic Plan to Promote Cancer Control Programs was revised to promote early palliative care and integration of oncology and palliative care, including a requirement that PCCTs play additional roles in conducting distress screening and enforcement of the community-based consultation. Thus, the required activities and the role of PCCTs in designated cancer hospitals in Japan have formally changed. Furthermore, skills and knowledge in the area of basic palliative care have improved in the past 10 years largely because of more than 100,000 physicians having finished a two-day basic palliative care education program.16
, 17
This study therefore aimed to revise and develop a new standard for PCCTs that all designated cancer hospitals should achieve by 2020.Methods
A consensus method using the subjective opinions of several experts is an established approach for developing a clinical care standard with clear methodology. Accordingly, we adopted a modified Delphi method
18
to develop a standard for PCCTs in Japan. Previous efforts to develop a standard in palliative medicine similarly used a modified Delphi method that provides panelists with the opportunity to discuss their decisions and opinions face to face between the rating rounds.15
This method also facilitates the participants' understanding of each statement developed and the opportunity to make each objective more understandable and achievable.Development of a Provisional Standard
To develop a provisional standard for PCCTs, we adopted the following procedures. First, the authors discussed the basic assumption of this standard and decided that it should be established at the fundamental level, designed to show a new PCCT what they need to provide at the very least. The subject focus was cancer patients because current palliative care in Japan mostly targets such patients, and we have insufficient clinical experience of palliative care for noncancer patients. We applied the Donabedian model to develop the provisional standard. This conceptual model provides a framework for examining health services and evaluating quality of health care.
19
According to the model, information about quality of care can be drawn from three categories: structure, process, and outcomes. The standard can then also be used for evaluation, and the framework of the standard references existing standards and manuals on palliative care.15
, 20
, National Consensus Project. Clinical practice guidelines for quality palliative care. Available at: http://www.nationalconsensusproject.org/Guideline.pdf. Accessed May 4, 2018.
21
, A crosswalk of National Quality Forum preferred practices. Policies and tools for hospital palliative care programs. Available at: https://media.capc.org/filer_public/88/06/8806cedd-f78a-4d14-a90e-aca688147a18/nqfcrosswalk.pdf. Accessed May 4, 2018.
22
Second, one author (Y. K.) generated statements in line with the framework based on a literature review.Palliative Care Australia. Standards for providing quality palliative care for all Australians. Available at: https://ahsri.uow.edu.au/chsd/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow090570.pdf. Accessed May 4, 2018.
15
, 20
, National Consensus Project. Clinical practice guidelines for quality palliative care. Available at: http://www.nationalconsensusproject.org/Guideline.pdf. Accessed May 4, 2018.
21
, A crosswalk of National Quality Forum preferred practices. Policies and tools for hospital palliative care programs. Available at: https://media.capc.org/filer_public/88/06/8806cedd-f78a-4d14-a90e-aca688147a18/nqfcrosswalk.pdf. Accessed May 4, 2018.
22
, Palliative Care Australia. Standards for providing quality palliative care for all Australians. Available at: https://ahsri.uow.edu.au/chsd/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow090570.pdf. Accessed May 4, 2018.
23
, Ministry of Health, Labour and Welfare. Palliative Care Promotion Review Committee Secondary Interim Report [in Japanese]. Available at: http://www.mhlw.go.jp/file/05-Shingikai-10901000-Kenkoukyoku-Soumuka/0000022195.pdf. Accessed May 4, 2018.
24
Third, the authors discussed the appropriateness and coverage of the statements to reach a consensus regarding validity, before formulating a provisional standard. We classified all statements under the Donabedian triad of structure, processes, and outcomes, and categorized five domains (philosophies and policies, care delivery system, content of activities, evaluation and improvement of care quality, and activity evaluation) consisting of 109 statements.Ministry of Health, Labour and Welfare. The guideline for developing regional cancer centers [in Japanese]. Available at: http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000155799.pdf. Accessed May 4, 2018.
Expert Panel Selection
For this Delphi study, we aimed to create a multiprofessional panel of 20 experts based on the following criteria: 1) clinicians with adequate experience as part of a PCCT and 2) representatives of palliative care-related organizations. We contacted four such organizations (Japanese Society for Palliative Medicine, Japan Psycho-Oncology Society, Japanese Society of Cancer Nursing, and Japanese Society for Pharmaceutical Palliative Care and Sciences) by mail and asked them to participate in this study and recommend five panelists. As a condition to be a panelist, we proposed clinical experience with PCCTs of more than two years. All respondents confirmed that they met the eligibility criteria and expressed a willingness to participate in this Delphi study. The present study was conducted in accordance with the Declaration of Helsinki and ethical guidelines with regard to clinical research. This study was reviewed by the institutional review board at Hyogo Prefectural Kakogawa Medical Center.
Survey Process
The study was conducted from May 2015 to December 2015. Our Delphi study consisted of three rounds, each lasting four weeks and separated by four weeks. Nonrespondents were sent weekly electronic mail (e-mail) reminders. No financial incentives were provided.
First, each panelist was asked to review existing standards and manuals on palliative care twice by e-mail, so as to standardize their knowledge regarding the roles and activities of PCCTs.
Second, two months later, we implemented a first-round survey, mailing a questionnaire with the outline of a provisional standard to each panelist. Each member was asked to rate the appropriateness of each statement using a nine-point Likert-type scale (1–3, inappropriate; 4–6, intermediate; and 7–9, appropriate). In cases where panelists were unfamiliar with items because of their specialty, incapable of rating was also offered. As the statements to be adopted by all PCCTs in designated cancer hospitals by 2020, we defined that it was appropriate even if it became mandatory for all designated cancer hospitals. Panelists who rated a statement as less than six were asked to give the reason. A consensus in this study was defined a priori when agreement (7–9, appropriate) was provided by a minimum of 75% of the experts. We also collected basic demographic information from the experts, such as age, sex, type of clinical practice, and years of experience. A summary of the first-round survey was sent to each panelist and author, and disagreements were discussed by e-mail for two weeks. We then asked the panelists, especially those who would not be able to attend a panel meeting, to give their opinions.
Third, after discussion by e-mail, an expert panel meeting was convened on September 6, 2015, in Tokyo to discuss face to face those statements causing disagreement. At the meeting, a summary of the first-round survey and e-mail discussions was distributed. After the panel meeting, a summary of the meeting and a revised version of the standard were sent to all panelists to confirm corrections and determine whether there were additional opinions.
Fourth, in October 2015, we mailed all 200 representatives of the Japanese Society for Palliative Medicine the provisional standard, summary of first-round survey, and description of each panelist to request their opinion about the revised version of the standard as an external reviewer. We collected opinions from an external reviewer by e-mail and then shared the opinions among all panelists by e-mail. We then revised the standard based on e-mail discussions among the panelists based on the external review.
Fifth, we implemented a second-round survey using the same method as in the first-round survey as well as a revised version of the standard based on the expert panel meeting. For statements considered inappropriate, the relevant panelists were contacted by e-mail individually, and we tried to reach a compromise.
Sixth, we conducted a third-round survey using the same method as in the first-round survey but only for the statements that were not subject to compromise in the second-round survey. We deleted any statements for which consensus agreement could not be attained.
Statistical Analysis
All statistical analyses were carried out using the SAS, version 9.1, statistical package (SAS Institute, Inc., Cary, NC).
Results
Participant Characteristics
Table 1 summarizes the participant characteristics. All participants had experience working in a PCCT, and 14 (70%) participants had more than eight years of clinical experience in palliative care. Among 20 experts surveyed, 20 (100%) responded over all rounds, and 14 (70%) participated in a panel meeting.
Table 1Characteristics of Panelists (n = 20)
| n | Percentage of Total (%) | |
|---|---|---|
| Sex | ||
| Male | 9 | 45 |
| Female | 11 | 55 |
| Age (yrs) | ||
| 0–39 | 3 | 15 |
| 40–49 | 14 | 70 |
| 50–59 | 3 | 15 |
| Specialty | ||
| Physician | 5 | 20 |
| Psychiatrist | 5 | 20 |
| Nurse | 5 | 20 |
| Pharmacologist | 5 | 20 |
| Clinical experience (yrs) | ||
| 5–9 | 1 | 5 |
| 10–19 | 11 | 55 |
| 20–29 | 8 | 40 |
| ≥30 | 0 | 0 |
| Clinical experience in palliative care (yrs) | ||
| <2 | 0 | 0 |
| 2–4 | 1 | 5 |
| 4–6 | 1 | 5 |
| 6–8 | 4 | 20 |
| 8–10 | 6 | 30 |
| ≥10 | 8 | 40 |
First Delphi Round
In the first-round survey, 79 of 109 (72.5%) statements were judged to be appropriate by more than 75% of respondents, and 30 of 109 (27.5%) statements led to disagreements. In the panel meeting, all statements were examined carefully. We analyzed the reasons for the 30 disagreements and found that the minimum goal envisaged for PCCTs was different among the members. We also ascertained that the range of PCCT activities set out in the statements was not sufficiently clear with respect to whether they applied to hospital inpatients or patients in the community. During the discussions by e-mail and in the panel meeting, the following resolutions were agreed: 1) the standard should be established by 2020, taking into account the wide-ranging skills of teams rather than the minimal or lowest acceptable practices; 2) the standard should be applied to cancer patients first and then expanded to other diseases in the future; and, 3) the standard should focus on consultation activities within a hospital. According to the results of the first-round survey and discussion at the panel meeting, the 30 statements that produced disagreement were dealt with as follows: 13 statements were unmodified, 16 statements underwent minor revision, and one statement was divided into two statements for clarity. Moreover, we added six statements based on a separate discussion among participants and authors. After the panel meeting, a summary of the outcomes and a revised version of the standard were sent to all panelists to confirm corrections or determine whether there were additional opinions. We then made final revisions of the standard based on a discussion among authors. Consequently, the statements numbered 116 across five domains.
In October 2015, we sent the revised version of a provisional standard, summary of the first-round survey, and a description of each panelist to 200 representatives of the Japanese Society for Palliative Medicine for their opinions as external reviewers. We received back 19 opinions from four external reviewers. Of note, the external reviewer feedback highlighted the lack of a clear pathway for integrating the PCCT activities and role with the existing palliative and oncology care. We revised the standard accordingly, resulting in four statements being combined into two to give a new total of 114 statements across five domains and then conducted the second Delphi round.
Second Delphi Round
In the second-round survey, all panelists responded, and 108 of 114 (94.7%) statements were judged to be appropriate by more than 75% of respondents, 6 of 114 (5.3%) statements led to disagreements, leading to the third Delphi round to consider only those six statements.
Third Delphi Round
In the third-round survey, all panelists responded with 0 of 6 (94.7%) statements judged to be appropriate by more than 75% of respondents, resulting in them being deleted from the standard. The final version of the standard (Appendix) consists of 108 statements across five domains.
Discussion
We developed a PCCT standard using a clear methodology in the modified Delphi method and a multidisciplinary panel of experts. The findings of this study could provide guidelines for new and existing PCCTs and help them evaluate ongoing activities based on this standard, all of which contributes to improving the quality of palliative care for patients and their families. As the next step, we have started peer review and benchmarking of PCCTs for quality improvement using checklists from this standard.
Of prime importance, we established innovative processes to develop the standard. First, based on the modified Delphi method, we used e-mail discussion and panel meetings between the first and the second rounds of our study, wherein the participants discussed their ratings of each statement and shared their reasoning process and opinions with each other, with the aim of making the statements more adequate and achievable. Second, we selected expert panelists to create a multiprofessional group, allowing us to create standards that reflect more specialized perspectives, but across several relevant professions and activities. Third, incorporating external reviewers enabled us to access perspectives from other disciplines directly, leading to a wider range of specialist opinions regarding the standard.
Another important finding from this study was the addition of new and broader perspectives into the standard including the integration of oncology and palliative care, early palliative care, community-based palliative care, and evaluation and improvement of care quality.
15
Consequently, the new standard comprises 108 statements compared with 37 in the existing version. In particular, we limited the description of how PCCTs would contribute to the integration of oncology and palliative care, based on literature review.10
, 25
, 26
, 27
Although many organizations support such integration, it remains an abstract and complex concept that is poorly defined. The European Society for Medical Oncology (ESMO) has put forth 13 criteria for the incentive program of “ESMO designated centers of integrated oncology and palliative care”;28
however, a global consensus on indicators for integration is currently lacking. To better understand what integration entails, Hui et al.29
conducted a systematic review to identify the clinical, educational, research, and administrative indicators of integration in the published literature. These indicators would help us to better understand the concept of integration and could allow clinicians, patients, researchers, hospital administrators, and policy makers to better assess the level of integration of oncology and palliative care.This new Japanese standard for PCCT has two major differences compared with the standard described previously in the U.S. and Australia.
20
, National Consensus Project. Clinical practice guidelines for quality palliative care. Available at: http://www.nationalconsensusproject.org/Guideline.pdf. Accessed May 4, 2018.
21
, A crosswalk of National Quality Forum preferred practices. Policies and tools for hospital palliative care programs. Available at: https://media.capc.org/filer_public/88/06/8806cedd-f78a-4d14-a90e-aca688147a18/nqfcrosswalk.pdf. Accessed May 4, 2018.
22
First, descriptions about spiritual care are scarce throughout the standard. Even in Japan, patients and their families suffer from spiritual pain, but they have not received adequate spiritual care,Palliative Care Australia. Standards for providing quality palliative care for all Australians. Available at: https://ahsri.uow.edu.au/chsd/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow090570.pdf. Accessed May 4, 2018.
30
possibly because health care providers do not see spiritual care as part of their job, and patients and their families may feel that it is difficult to receive spiritual care. This cultural difference is clearly present between Japan and Western countries.31
In addition, health care providers specializing in spiritual care are not recognized with national qualifications and therefore are not available in designated cancer hospitals in Japan. In addition, most of the designated cancer hospitals in Japan do not provide religious care, and only a few chaplains are included in PCCTs.32
For these reasons, spiritual care was not adopted as part of the standard that all designated cancer hospitals should achieve in 2020. Second, the finished standard did not sufficiently consider bereavement as a component of care. In Japan, although bereavement care is relatively well provided in palliative care wards,The Japanese Society for Palliative Medicine: ‘Registration for palliative care team’ [in Japanese]. Available at: http://www.jspm.ne.jp/pct/report_jspmpct2016.pdf. Accessed July 31, 2018.
33
sufficient resources and systems for bereavement care are not being developed in designated cancer hospitals.34
, 35
This situation is consistent with a previous report36
that bereaved families did not receive specialized bereavement care and did not expect such support from physicians and nurses in Japan. In the future, we need to develop a system that can provide sufficient bereavement care within designated cancer hospitals.Ministry of Health, Labour and Welfare. A Nationwide Survey about current status of end-of-life care [in Japanese]. Available at: https://www.mizuho-ir.co.jp/case/research/pdf/mhlw_kaigo2018_09.pdf. Accessed August 12, 2018.
Our study had several limitations. First, this standard focused on consultation activities within a hospital, and thus, we did not include sufficient consideration of community-based palliative care. Second, although our panel of experts comprises diverse professionals, the number of palliative care specialists was large compared with other professions. Therefore, this standard might not sufficiently reflect the experience and opinion of oncologists and PCCT users, that is, patients. Third, this standard was revised mainly for PCCTs working in government-designated regional cancer hospitals and thus might not be transferable to PCCTs for noncancer patients, nonregional cancer centers, and other settings. Fourth, we clarified and changed our aims of the standard slightly in the panel meeting that influenced the reliability of the first Delphi round. We should have discussion about the aims of the standard in detail before the first Delphi round.
Conclusion
We developed a standard for PCCTs in designated cancer hospitals using a clear and established methodology. This standard comprises 108 statements across five domains and might provide both the teams and institutions with a useful guide for clinical activities and a tool to evaluate quality of palliative care.
Disclosures and Acknowledgments
This study was conducted with the Japan Hospice Palliative Care Foundation. The authors thank all participants and participating institutions for taking part in this study. The authors declare no conflicts of interest.
Appendix
Hospital-Based Palliative Care Consultation Team Standard 2015
- •All palliative care consultation teams in designated cancer hospitals should adopt this standard by 2020. These statements are the ones that are “appropriate even if they are specified in the designated requirements of designated cancer hospitals and their achievements are obligatory at all designated cancer hospitals.”
- •Palliative care is intended for all patients facing life-threatening illnesses and their families; however, in light of the current situation in Japan, this standard was predominantly created with regard to patients with cancer. This should not necessarily exclude care teams who provide palliative care from applying this standard to noncancer patients and their families. Furthermore, although this standard was created for the treatment of adult patients, this is also applicable for the treatment of pediatric patients.
- •Although the integration of palliative care with oncology is recommended by the American Society of Clinical Oncology, the ESMO, and other medical societies, such integration is not clearly defined. Using the literature as a guide, we strove to describe in concrete terms the ideal approaches of palliative care consultation teams (PCCTs) that are likely to contribute to integration the two areas of care.
Structure
I. Philosophies and Basic Policies
- 1.Philosophies
- a.PCCTs carry out consultation activities with hospitals and regional health care providers using specialist clinical knowledge and skills in palliative care to improve the QOL of patients and their families.
- b.PCCTs carry out educational and awareness-raising activities on the topic of palliative care targeted at medical and health care providers, patients and their families, and residents to improve the QOL of patients and their families.
- a.
- 2.Basic policies
- a.Carry out consultation activities (advice and support) targeted at hospitals and regional health care providers.
- b.Coordinate hospital resources, identify the multifaceted pains and needs of patients and their families, and provide necessary treatment and care.
- c.Conduct comprehensive assessments of patients and their families on an interdisciplinary basis and share these with requesting health care providers.
- d.Discuss, decide, and share objectives and policies related to care for patients and their families within palliative care teams as well as with requesting health care providers.
- e.Provide direct care to patients and their families whenever needed with the consent of the requesting health care providers.
- f.Provide palliative care to patients along with treatment to improve the course of disease (disease-modifying treatment) as needed from early diagnosis.
- g.Carry out activities in accordance with the palliative care needs of patients and their families as well as in accordance with hospital and regional characteristics and health care providers' needs regarding palliative care.
- h.Ensure that seamless palliative care can be provided in hospitals, outpatient settings, and communities based on the needs of patients and their families.
- i.Carry out educational and awareness-raising activities targeted at health care providers in hospitals on the topic of palliative care.
- j.Carry out educational and awareness-raising activities targeted at health care providers in the region on the topic of palliative care independently or in collaboration with other resources.
- k.Carry out educational and awareness-raising activities targeted at local residents on the topic of palliative care independently or in collaboration with other resources.
- a.
II. Care Delivery System
- 1.Professionals comprising and cooperating with teams
- A. A system is adopted in which teams either include or can cooperate as needed with the following professionals (cooperating professionals are preferably retained by hospitals but can also be external resources who can be consulted at any time; e.g., a hospital does not have a dentist but has one available for consultation).
- a.Physicians skilled in the alleviation of physical symptoms.
- b.Physicians skilled in the alleviation of psychiatric symptoms.
- c.Nurses with expertise/certification in the field of palliative care.
- d.Pharmacists skilled in palliative care.
- e.Medical social workers.
- f.Individuals involved in medical psychology (such as psychologists).
- g.Health care providers involved in rehabilitation (e.g., physical therapists, occupational therapists, speech-language-hearing therapists).
- h.Registered dietitians.
- i.Dentists and dental hygienists.
- j.Liaison staff involved in palliative care (health care providers responsible for or supervising palliative care in a hospital department, such as an outpatient clinic, hospital ward, or clinical department).
- k.Physicians, nurses, and pharmacists skilled in cancer treatment and associated adverse events.
- l.Supervisors of discharge support and coordination departments.
- m.Medical administrators.
- a.
- 2.Activity system developments
- a.Clearly position hospital PCCTs within the organization.
- b.Disclose the philosophies and basic policies of PCCTs in hospitals.
- c.Raise awareness of the scope of roles and responsibilities of PCCTs in hospitals and the community.
- d.Set annual targets for PCCTs.
- e.Raise awareness of PCCT systems (positioning in hospitals, constituent members, duration and content of activities, etc.) among patients, their families, and health care providers in hospitals.
- f.Raise awareness within hospitals on the methods for requesting PCCTs (health care providers who can be requested, procedures, etc.).
- g.Consult health care providers from different fields in addition to physicians.
- h.Develop a system wherein PCCTs can be used in parallel with treatment regardless of the disease stage and raise awareness of this system among patients, their families, and their health care providers.
- i.Develop an outpatient palliative care service and raise awareness of this service among patients, their families, and their health care providers.
- j.Screen for pain in cooperation with related departments and identify the distress of patients and their families.
- k.Clearly demonstrate the standards (criteria) according to individual pain screening results to consult with PCCTs.
- l.Develop a system in which requests elicit a rapid response.
- m.Develop procedures for publicizing the availability of palliative care to residents (e.g., Web sites and public relation brochures).
- n.Develop a system* by which the appropriate health care providers in the region can be consulted and raise awareness of this system among patients, their families, and their health professionals. (*Various methods exist depending on the circumstances of the region and hospital [telephone consultations, consultations using e-mail, accompanying patients to appointments, etc.]).
- o.Cooperate with related departments to provide information as needed to patients and their families on patient associations, patient salons, patient support groups, and bereavement associations.
- a.
Process
III. Content of Activities
- 1.Clinical activities
- A. Care for patients and families includes the following support:
- a.Alleviation of pain.
- b.Alleviation of physical symptoms other than pain.
- c.Alleviation of psychiatric symptoms (anxiety, depression, delirium, insomnia, etc.).
- d.Treatment and care for adverse events of treatment for disease.
- e.Psychiatric support.
- f.Support for financial problems associated with treatment and care.
- g.Support for decision making related to treatment and care.
- h.Support for adapting to treatment and care environments.
- i.Support for families and bereavement.
- j.Support for the distress of health professionals involved in care.
- a.
- B. Care for various end-of-life problems: The following support is provided:
- a.End-of-life care.
- b.Determining and implementing appropriate sedation.
- c.Withholding and discontinuing treatment.
- dCare for grief.
- a.
- C. Consultation activity procedures
- a.Comprehensively assess patients and families based on data, including information from health care providers, patient appointments, interviews with family members, medical records, and various test results, and provide recommendations or direct care accordingly.
- b.Conduct assessments using standardized tools.
- c.Provide recommendations or direct care based on treatment guidelines and other criteria depending on each patient and their family.
- d.Discuss assessments/recommendations with requesting medical and health care providers.
- e.List the content of assessments/recommendations/direct care in medical records and other documentation.
- f.Follow-up and review the results of recommendations/direct care.
- g.Obtain approval from the attending physician before providing medical consultation or direct care to patients.
- h.Explain and obtain patient and family consent for the content of any direct care.
- i.Provide explanations and information on medical conditions, symptoms, subsequent course, how to spend time, and other matters as needed to patients and their families.
- j.Hold conferences with requesting health care providers as needed.
- k.Hold routine conferences within PCCTs to standardize treatment and care policies.
- l.Participate in conferences attended by other specialists such as cancer boards and use expert knowledge on palliative care to participate in decision surrounding patient treatment policy.
- a.
- D. Coordination and adaptation of care
- a.Cooperate with liaison staff in hospitals to improve the quality of basic palliative care in wards and departments.
- b.Refer patients and their families to hospital or regional specialists as needed.
- a.
- E. Regional cooperation
- a.Plan for palliative care to continue as needed when a patient's place of treatment and care changes.
- b.Perceive the resources that provide palliative care in any given region (institutions and individuals) and provide information to patients, their families, and health care providers as needed.
- a.
- 2.Coordination, cooperation, and application of resources
- A.Coordination and cooperation with hospital resources
- Applies to care provided in coordination and cooperation with the following hospital professionals and resources:
- a.Physicians and nurses with other expertise.
- b.Interdisciplinary teams with other expertise.
- c.Consultation and support department supervisors.
- d.Cancer nurse consultation and outpatient services.
- a.
- B. Coordination and cooperation with regional resources
- Applies to care provided in coordination and cooperation with the following regional facilities:
- a.Hospitals.
- b.Clinics.
- c.Home-visit nursing stations.
- d.Health insurance pharmacies.
- e.Palliative care wards.
- f.PCCTs of other hospitals.
- g.Comprehensive community support centers.
- h.Care and welfare offices.
- a.
- C. Application of resources
- a.Support liaison staff activities.
- b.Carry out consultation activities on new requests from inpatients every weekday.
- c.Carry out consultation activities on new requests from outpatients every weekday.
- d.Visit wards and outpatient clinics regularly to verify hidden needs of symptom relief and such and offer advice as needed.
- e.Assess information from inpatients under the care of team members every weekday.
- f.Provide support for the unbearable distress of inpatients as needed even at night and during holidays.
- g.Resolve consultations by patient families and bereaved families regarding palliative care.
- h.Develop and apply standardized evaluation methods and a palliative care manual that can be readily available within the hospital.
- i.Cooperate with health care providers and institutions* that provide other specialized palliative care to build a network of specialists to oversee the entirety of palliative care in the region. (*These specifically include hospitals, clinics, home-visit nursing stations, health insurance pharmacies, palliative care wards, PCCTs of other hospitals, comprehensive community support centers, care and welfare offices, patient associations, and patient support groups).
- a.
- A.
- 3.Educational and awareness-raising activities
- a.Provide education on basic and specialized palliative care to liaison staff regarding matters often encountered in routine treatment and care.
- b.Provide education and raise awareness of palliative care among hospital and regional health care providers through daily clinical activities.
- c.Hold routine seminars, lectures, and other events on palliative care for hospital and regional health care providers.
- d.Provide education and raise awareness of the end-of-life process to hospital and regional health care providers, including end-of-life care, appropriate sedation, withholding and discontinuing treatment, family and bereavement care, and support for staff.
- e.Provide education and raise awareness of palliative care to inpatients, outpatients, and their families.
- f.Provide education and raise awareness of palliative care to residents independently or in collaboration with other resources.
- g.Disseminate information on palliative care to residents independently or in collaboration with other resources.
- a.
IV. Evaluation and Improvement of Care Quality
- 1.Evaluation and improvement of care quality
- a.Conduct routine case studies and conferences within PCCTs to evaluate and improve activities targeted at requested patients.
- b.Exchange information about PCCTs activities with other regional PCCTs to improve knowledge and skills.
- c.Learn proactively about the newest forms of palliative care.
- d.Present the content of PCCTs activities in clinical, educational, and research fields through conference presentations, workshops, and article submissions.
- a.
Outcomes
V. Activity Evaluation
- 1.Self-evaluation and publication of activities
- a.Collect and analyze information on entrusted patients and PCCTs activities (disease names, reason for requests, number of requests, etc.) for evaluation purposes.
- b.Publicize and announce palliative care team activities in hospitals and regions.
- c.Assess and publicize annual care outcomes of PCCTs.
- d.Assess and analyze hospital use of drugs, medical equipment, medical tools, and other resources related to palliative care.
- a.
- 2.Mutual and other-party evaluation of activities
- a.Benchmark domestic PCCT members and other active individuals and create opportunities to review team activities.
- a.
References
- The impact on community palliative care services of a hospital palliative care team.Palliat Med. 1994; 8: 237-244
- Hospital based palliative care teams improve the symptoms of cancer patients.Palliat Med. 2003; 17: 498-502
- The benefits of a hospital-based inpatient palliative care consultation service: preliminary outcome data.J Palliat Med. 2005; 8: 1033-1039
- How prevalent are hospital-based palliative care programs? Status report and future directions.J Palliat Med. 2001; 4: 315-324
- Do hospital-based palliative teams improve care for patients or families at the end of life?.J Pain Symptom Manage. 2002; 23: 96-106
- What are the views of hospital-based generalist palliative care professionals on what facilitates or hinders collaboration with in-patient specialist palliative care teams? A systematically constructed narrative synthesis.Palliat Med. 2016; 30: 240-256
- The imPaCT study: a randomized controlled trial to evaluate a hospital palliative care team.Br J Cancer. 2002; 87: 733-739
- The comprehensive care team: a controlled trial of outpatient palliative medicine consultation.Arch Intern Med. 2004; 164: 83-91
- Cost analysis of a prospective multi-site cohort study of palliative care consultation teams for adults with advanced cancer: where do cost-savings come from?.Palliat Med. 2017; 31: 378-386
- Integration and activity of hospital-based palliative care consultation teams: the INSIGHT multicentric cohort study.BMC Palliat Care. 2017; 16: 36
- Palliative care team: the first year audit in Japan.J Pain Symptom Manage. 2005; 29: 458-465
- Preliminary statistical assessment of intervention by a palliative care team working in a Japanese general inpatient unit.Am J Hosp Palliat Care. 2007; 24: 29-35
- Assessment of reasons for referral and activities of hospital palliative care teams using a standard format: a multicenter 1000 case description.J Pain Symptom Manage. 2014; 47: 579-587.e6
Ministry of Health, Labour and Welfare. The list of regional cancer centers [in Japanese]. Available at: http://www.mhlw.go.jp/stf/seisakunitsuite/bunya/kenkou_iryou/kenkou/gan/gan_byoin.html. Accessed May 4, 2018.
- Development of a standard for hospital-based palliative care consultation teams using a modified Delphi method.J Pain Symptom Manage. 2009; 38: 496-504
- Outcome evaluation of the Palliative Care Emphasis Program on symptom management and Assessment for Continuous Medical Education: nationwide physician education project for primary palliative care in Japan.J Palliat Med. 2015; 18: 45-49
- Improved knowledge of and difficulties in palliative care among physicians during 2008 and 2015 in Japan: association with a nationwide palliative care education program.Cancer. 2018; 124: 626-635
- The RAND/UCLA appropriateness method user's manual.RAND, Santa Monica, CA2001: 109
- The quality of care. How can it be assessed?.JAMA. 1988; 260: 1743-1748
National Consensus Project. Clinical practice guidelines for quality palliative care. Available at: http://www.nationalconsensusproject.org/Guideline.pdf. Accessed May 4, 2018.
A crosswalk of National Quality Forum preferred practices. Policies and tools for hospital palliative care programs. Available at: https://media.capc.org/filer_public/88/06/8806cedd-f78a-4d14-a90e-aca688147a18/nqfcrosswalk.pdf. Accessed May 4, 2018.
Palliative Care Australia. Standards for providing quality palliative care for all Australians. Available at: https://ahsri.uow.edu.au/chsd/content/groups/public/@web/@chsd/@pcoc/documents/doc/uow090570.pdf. Accessed May 4, 2018.
Ministry of Health, Labour and Welfare. Palliative Care Promotion Review Committee Secondary Interim Report [in Japanese]. Available at: http://www.mhlw.go.jp/file/05-Shingikai-10901000-Kenkoukyoku-Soumuka/0000022195.pdf. Accessed May 4, 2018.
Ministry of Health, Labour and Welfare. The guideline for developing regional cancer centers [in Japanese]. Available at: http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000155799.pdf. Accessed May 4, 2018.
- Indicators of integration of oncology and palliative care programs: an international consensus.Ann Oncol. 2015; 26: 1953-1959
- Integrated palliative care in Europe: a qualitative systematic literature review of empirically-tested models in cancer and chronic disease.BMC Palliat Care. 2016; 15: 56
- Integration of oncology and palliative care: setting a benchmark.Support Care Cancer. 2017; 25: 3253-3259
- European Society for Medical Oncology (ESMO) program for the integration of oncology and palliative care: a 5-year review of the designated centers' incentive program.Ann Oncol. 2010; 21: 362-369
- Integration of oncology and palliative care: a systematic review.Oncologist. 2015; 20: 77-83
- Value of religious care for relief of psycho-existential suffering in Japanese terminally ill cancer patients: the perspective of bereaved family members.Psychooncology. 2010; 19: 750-755
- International comparison study on the primary concerns of terminally ill cancer patients in Short-Term Life Review Interviews among Japanese, Koreans and Americans.Palliat Support Care. 2009; 7: 1-7
The Japanese Society for Palliative Medicine: ‘Registration for palliative care team’ [in Japanese]. Available at: http://www.jspm.ne.jp/pct/report_jspmpct2016.pdf. Accessed July 31, 2018.
- Japanese bereaved family members' perspectives of palliative care units and palliative care: J-HOPE study results.Am J Hosp Palliat Care. 2016; 33: 425-430
- Psychiatric disorders and background characteristics of cancer patients' family members referred to psychiatric consultation service at National Cancer Center Hospitals in Japan.Palliat Support Care. 2008; 6: 225-230
- Psychological distress of the bereaved seeking medical counseling at a cancer center.Jpn J Clin Oncol. 2012; 42: 506-512
Ministry of Health, Labour and Welfare. A Nationwide Survey about current status of end-of-life care [in Japanese]. Available at: https://www.mizuho-ir.co.jp/case/research/pdf/mhlw_kaigo2018_09.pdf. Accessed August 12, 2018.
Article info
Publication history
Published online: August 23, 2018
Accepted:
August 16,
2018
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© 2018 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc.
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