Identified Palliative Care Approach Needs with SPICT in Family Practice: A Preliminary Observational Study

Abstract

Background:

Identifying patients who require palliative care approach is challenging for family physicians, even though several identification tools have been developed for this purpose.

Objective:

To explore the prevalence and characteristics of family practice patients who need palliative care approach as determined using Supportive and Palliative Care Indicators Tool (SPICT™, April 2015) in Japan.

Design:

Single-center cross-sectional study.

Setting/Subjects:

We enrolled all patients ≥65 years of age who visited the chief researcher's outpatient clinic in October 2016.

Measurements:

We used Japanese version of SPICT (SPICT-J) to identify patients who need palliative care approach. We assessed patients' backgrounds and whether they had undergone advance care planning with their family physicians.

Results:

This study included 87 patients (61 females) with a mean age of 79.0 ± 7.4 years. Eight patients (9.2%) were identified as needing palliative care approach. The mean age of patients who needed this approach was 82.3 ± 8.3 years and main underlying conditions were heart/vascular disease (37.5%), dementia/frailty (25.0%), and respiratory disease (12.5%). Only two of eight patients identified as needing palliative care approach had discussed advance care planning with their family physicians.

Conclusions:

In family practice, 9.2% of outpatients ≥65 years of age were identified as needing palliative care approach. Family physicians should carefully evaluate whether outpatients need palliative care approach.

Introduction

Palliative care approach focuses on the needs of patients with life-threatening illness as well as those of their families. It emphasizes the timely recognition of these needs, which may be physical, psychological, social, or existential in nature.^1–3

Timely identification of patients who need palliative care approach was shown to promote the discussion of advance care planning between patients and their physicians.⁴ Such planning enables providers to clarify treatment preferences and goals of care, improves symptom control and the quality of end-of-life care, reduces distress, allows for less aggressive care, lowers medical costs, and may even lengthen survival.⁵ Thus, it is essential to conduct high-quality end-of-life care,^6,7 although family physicians have reported difficulties with the prompt identification of patients who need palliative care approach.^8,9

A recent study revealed that a systematic method or tool could facilitate the timely identification of patients who need palliative care approach.¹⁰ Several such tools have been developed for use in the family practice setting, such as the Gold Standards Framework Prognostic Indicator Guidance (PIG),¹¹ Supportive and Palliative Care Indicators Tool (SPICT™),¹² the Palliative Necessities CCOMS-ICO (NECPAL),⁷ and the RADboud indicators for PAlliative Care Needs (RADPAC).¹³

One recent retrospective study analyzed the predictive value of SPICT in terms of one-year mortality at the single acute geriatric ward in Belgium, and revealed a sensitivity of 0.841 and a specificity of 0.579.¹⁴ This high sensitivity indicates the usefulness of SPICT for identifying geriatric patients who will survive for at least one year, although the low specificity means it is difficult to assess which patients will die within one year. Although one study explored the prevalence and characteristics of patients in acute hospital settings in Scotland who required palliative care approach as determined by SPICT,¹² this issue has not been well examined in family practice patients in Japan.

The aim of this preliminary observational study was to explore the prevalence and characteristics of family practice patients in Japan who needed palliative care approach as determined by SPICT, with the hope that clarifying these issues will improve timely conversation between patients and physicians regarding treatment preferences, goals of care, and other end-of-life issues.

Materials and Methods

In this single-center cross-sectional study, eligible patients were enrolled consecutively as they visited the chief researcher's office in the Yamato Clinic from October 1 to 30, 2016. The Yamato Clinic, which employs five physicians who specialize in family practice, provides ambulatory care, and home visiting services for community residents. The Yamato Clinic is located in a rural area of Japan. It serves ∼30 outpatients every day, about 80% of whom are ≧65 years of age. In Japan, specialized palliative care is provided mainly in hospital wards for cancer patients. Only a limited number of family physicians actively care for patients in each community who are dying from conditions other than cancer. Therefore, the availability of specialized and generalist palliative care services vary among communities.

We enrolled all patients ≥65 years of age who visited the chief researcher's outpatient clinic in October 2016. We used Japanese version of SPICT, April 2015 (SPICT-J) to identify patients who needed palliative care approach (Appendix Table A1: original version of SPICT, April 2015).

Development of SPICT-J

Japanese version of SPICT, April 2015 (SPICT-J) was developed according to a standard international translation and back-translation procedure.¹⁵ The English language items were initially translated by two native Japanese speakers with experience in community palliative care who were familiar with how words and phrases would be understood by family physicians in Japan. The final version of SPICT-J was developed based on comments from expert panel members.

Data collection

The chief researcher recorded patients' demographic and clinical characteristics, specifically age, sex, main underlying disease, use of care services, level of care needed,¹⁶ and living situation, and subsequently assessed patients with SPICT-J. In addition, the chief researcher reviewed electronic medical records to determine if any of three types of advance care planning had been recorded: (1) advance care planning for medical treatment, (2) durable power of attorney, and (3) advance directives for cardiopulmonary resuscitation.

Statistical analysis

Patients were identified as SPICT-J positive if two or more general indicators were present or one or more clinical indicators were present. We used descriptive statistics as continuous variables and categorical variables. Analyses were conducted with SPSS-J software (version 22.0; IBM, Tokyo, Japan).

Results

A total of 87 patients were included in this study. Patient characteristics are summarized in Table 1. The mean age was 79.0 ± 7.4 years. Hypertension (44.8%) was the most common main underlying disease, followed by dementia/frailty (18.4%), and cancer (9.2%). Eight patients (9.2%) were identified as SPICT-J positive. The mean ages of SPICT-J-positive and SPICT-J-negative patients were 82.3 ± 8.3 and 78.6 ± 7.3 years, respectively (Table 2). The main underlying diseases in SPICT-J-positive patients were heart/vascular disease (37.5%) and dementia/frailty (25.0%), whereas that in SPICT-J-negative patients was hypertension (48.1%). The prevalence of general indicators for deteriorating health among SPICT-J-positive patients is shown in Table 3; all patients with heart/vascular disease asked for supportive and palliative care or treatment withdrawal.

Table 1.

Patient Characteristics (n = 87)

	n	%
Age (mean ± standard deviation)	79.0 ± 7.4
Sex
Male	26	29.9
Female	61	70.1
Main underlying disease
Cancer	8	9.2
Dementia/frailty	16	18.4
Neurological disease	7	8
Heart/vascular disease	5	5.7
Respiratory disease	3	3.4
Kidney disease	1	1.1
Liver disease	0	0
Hypertension	39	44.8
Diabetes mellitus	1	1.1
Osteoarthritis	1	1.1
Other	6	6.9
Care services utilized
Home visit nursing	2	2.3
Home care services	0	0
Home visit pharmacist	0	0
Day care services	12	13.8
Specialized palliative care services	0	0
Level of care needed^a
No certified care needs	70	80.5
Support need level 1	0	0
Support need level 2	4	4.6
Care-need level 1	5	5.7
Care-need level 2	6	6.9
Care-need level 3	2	2.3
Care-need level 4	0	0
Care-need level 5	0	0
Living situation
Living with family	83	95.4
Living alone	4	4.6
SPICT™ general indicators for deteriorating health
KPS ≤50% with limited reversibility	3	3.4
Dependent on others for most care needs due to physical or mental health problems	1	1.1
Two or more unplanned hospital admissions in the past six months	0	0
Significant weight loss (5–10%) over the past three to six months or low body mass index	1	1.1
Persistent troublesome symptoms despite optimal treatment of underlying condition	2	2.3
Patient asks for supportive and palliative care or treatment withdrawal^b	21	24.1
Advanced care planning for medical treatment	6	6.9
Durable power of attorney	8	9.2
Advanced directive	1	1.1
Any advanced care planning	11	12.6
SPICT positive	8	10.3

Level of care needed: the number given for care-need level is higher with greater care needs, such as bed confinement or dementia. Generally, many people with care-need level 5 are bedridden.

Chief researcher measured “patients asks for supportive and palliative care or treatment withdrawal” when patient spontaneous mentioned or part of a discussion between GP and patient.

Home care services, formal professional carer provide personal caring at home; ^bHome visit pharmacist, pharmacist provide the instruction on the use of drugs at home; KPS: Karnofsky Performance Status; SPICT™, Supportive and Palliative Care Indicators Tool; SPICT positive: ≥2 general indicators or ≥1 clinical indicators.

Table 2.

Characteristics of SPICT-J-Positive and Negative Patient (n = 87)

	SPICT-J positive		SPICT-J negative
	n	%	n	%
Age (mean ± standard deviation)	82.3 ± 8.3		78.6 ± 7.3
Sex
Male (n = 26)	3	37.5	23	29.1
Female (n = 61)	5	62.5	56	70.9
Main underlying disease
Cancer (n = 8)	0	0	8	10.1
Dementia/frailty (n = 16)	2	25.0	14	17.7
Neurological disease (n = 7)	0	0	7	8.9
Heart/vascular disease (n = 5)	3	37.5	2	2.5
Respiratory disease (n = 3)	1	12.5	2	2.5
Kidney disease (n = 1)	0	0	1	1.3
Hypertension (n = 39)	1	12.5	38	48.1
Diabetes mellitus (n = 1)	1	12.5	0	0
Osteoarthritis (n = 1)	0	0	1	1.1
Level of care needed
No certified care needs	4	50.0	66	83.5
Support need level 2	1	12.5	3	3.8
Care-need level 1	1	12.5	4	5.1
Care-need level 2	1	12.5	5	6.3
Care-need level 3	1	12.5	1	1.3
Living situation
Living with family (n = 83)	8	100	75	94.9
Living alone (n = 4)	0	0	4	5.1

SPICT positive, ≥2 general indicators or ≥1 clinical indicators.

Table 3.

Prevalence of Positive General Indicators for Deteriorating Health Among SPICT-J-Positive Patients (n = 8)

	Dementia/frailty (n = 2)^a	Heart/vascular disease (n = 3)^a	Respiratory disease (n = 1)^a	Hypertension (n = 1)^a	Diabetes mellitus (n = 1)^a
KPS ≤50% and reversibility is limited	1	1	0	0	1
Dependent on others for most care needs due to physical or mental health problems	1	0	0	0	0
Two or more unplanned hospital admissions in the past six months	0	0	0	0	0
Significant weight loss (5%) over the past six months or low body mass index	0	1	0	0	0
Persistent troublesome symptoms despite optimal treatment of underlying condition	0	1	0	1	0
Patient asks for supportive and palliative care or treatment withdrawal	0	3	1	1	1

Each patient allowed to check multiple answers.

Prevalence of general indicators of poor health in SPICT-J-positive patients

Table 3 shows the prevalence of general indicators of deteriorating health in SPICT-J-positive patients.

Prevalence of advance care planning in SPICT-J-positive patients

Two of eight SPICT-J-positive patients had implemented at least one form of advance care planning. Only one patient had documented advance care planning for both medical treatment and advance directives.

Discussion

This is the first study to explore the prevalence and characteristics of patients in family practice who needed palliative care approach as identified by SPICT-J.

One of the most important findings of this study is that 9.2% of family practice outpatients ≥65 years of age were SPICT-J positive, indicating that almost 1 in every 10 patients needs palliative care approach. This result is consistent with a previous population study in which 8.0% of patients ≥65 years of age were identified by the NECPAL as having palliative care needs.¹⁷ A recent qualitative interview study revealed that palliative care needs in different domains arose during different stages of illness and varied by illness type and duration.¹⁸ Thus, our results indicate that family physicians might not recognize patients' needs for palliative care approach because such needs are not common in outpatients ≥65 years of age. Then, multidisciplinary assessment is likely to be more accurately performed in outpatient clinics, although several studies showed that physicians found the SPICT to be convenient and feasible in inpatient settings.^12,19,20

Another important finding is that only 25% of SPICT-J-positive patients had implemented at least one form of advance care planning. No previous research has explored the relationship between the use of an identification tool and implementation of advance care planning. One possible reason for fewer SPICT-J-positive patient to have advance care planning in this study is that the chief researcher would initiate advance care planning based on his or her subjective standards, which may not coincide with the timing suggested by SPICT-J. Thus, our finding that only 12.6% of family practice outpatients ≥65 years of age and two of eight SPICT-J-positive patients had advance care planning suggests that the use of SPICT-J might facilitate timely advance care planning in outpatient family practice clinics. Further research is needed to explore this issue.

It is noteworthy that 5 of 16 patients with dementia or frailty asked for supportive and palliative care or treatment withdrawal, although all 5 patients were SPICT-J negative (Appendix Table A2). In addition, these five patients were KPS ≧60% and were independent from others for most care needs due to physical or mental health problems. This suggests that SPICT-J, which identifies the need for a palliative care approach if two or more general indicators or one or more clinical indicators are present, might not have adequate sensitivity in patients with dementia or frailty. Thus, physicians should be aware of the potential need for the palliative care approach in family practice outpatients with these conditions, regardless of performance status and physical care needs.

Strengths and limitations

One strength of this study is that it is the first to reveal the prevalence and characteristics of family practice patients who need palliative care approach as identified by SPICT-J. In addition, this is the first study to validate the use of SPICT-J in an outpatient setting. The limitations of this study are its single-institution design and small sample size. Therefore, caution is needed when interpreting the results. It is important to study the need for palliative care approach in many different family practice settings to generalize the prevalence and characteristics of patients who need palliative care approach.

Conclusion

Among outpatients ≥65 years of age in family practice, 9.2% required palliative care. A low proportion had discussed advance care planning with their family physician. Family physicians should carefully evaluate the need for palliative care in the outpatient clinic setting.

Footnotes

Acknowledgments

This project received funding from the Japan Hospice/Palliative Care Foundation. The funder had no role in the design and conduct of the study; the collection, management, analysis, and interpretation of data; the preparation, review, or approval of the article; or the decision to submit the article for publication. The authors thank Scott Murray from the University of Edinburgh for permitting the use of SPICT™ in this project.

Ethical Approval

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki and the ethical guidelines for epidemiological research issued by the Ministry of Health, Labor, and Welfare of Japan. The Institutional Review Board of the University of Tsukuba approved this study (No. 1089).

Author Disclosure Statement

No competing financial interests exist.

Appendix Table A1.

Supportive and Palliative Care Indicators Tool (SPICT), April 2015

Look for two or more general indicators of deteriorating health

• Performance status is poor or deteriorating (in bed or a chair for ≥50% of the day); reversibility is limited

• Dependent on others for most care needs due to physical or mental health problems

• Two or more unplanned hospital admissions in the past six months

• Significant weight loss (5–10%) over the past three to six months or a low body mass index

• Persistent, troublesome symptoms despite optimal treatment of underlying condition(s)

• Patient asks for supportive and palliative care or treatment withdrawal

•Liver transplant is contraindicated.

Look for any clinical indicators of one or more advanced conditions

Cancer

• Functional ability deteriorating due to progressive metastatic cancer

• Too frail for oncology treatment or treatment is for symptom control

Dementia/frailty

• Unable to dress, walk, or eat without help

• Eating and drinking less or swallowing difficulties

• Urinary and fecal incontinence

• No longer able to communicate using verbal language or little social interaction

• Femur fracture or multiple falls

• Recurrent febrile episodes or infections, or aspiration pneumonia

Neurological diseases

• Progressive deterioration in physical or cognitive function despite optimal therapy

• Speech problems with increasing difficulty communicating or progressive swallowing difficulties

• Recurrent aspiration pneumonia, breathlessness, or respiratory failure

Heart/vascular disease

• NYHA Class III/IV heart failure or extensive untreatable coronary artery disease with breathlessness or chest pain at rest or on minimal exertion

• Severe inoperable peripheral vascular disease

Respiratory disease

• Severe chronic lung disease with breathlessness at rest or on minimal exertion between exacerbations

• Needs long-term oxygen therapy

• Has needed ventilation for respiratory failure or ventilation is contraindicated

Kidney disease

• Stage 4 or 5 chronic kidney disease (eGFR <30 mL/min) with deteriorating health

• Kidney failure complicating other life-limiting conditions or treatments

• Discontinuation of dialysis

Liver disease

• Advanced cirrhosis with one or more complications in the past year:

Diuretic-resistant ascites

Hepatic encephalopathy

Hepatorenal syndrome

Bacterial peritonitis

Recurrent variceal bleeding

eGFR, estimated glomerular filtration rate; NYHA, New York Heart Association.

Appendix Table A2.

Characteristics of Dementia/Frailty Patient (n = 16)

	SPICT™-J positive (n = 2)		SPICT-J negative (n = 14)
	N	%	n	%
Age (mean ± standard deviation)	76.0 ± 8.5		84.7 ± 4.0
Sex
Male (n = 5)	2	100	3	21.4
Female (n = 11)	0	0	11	78.6
Level of care needed
No certified care needs	1	50.0	7	50.0
Support need level 2	0	0	2	14.3
Care-need level 1	1	50.0	2	14.3
Care-need level 2	0	0	3	21.4
Care-need level 3	0	0	0	0
Living situation
Living with family (n = 83)	2	100	13	92.9
Living alone (n = 4)	0	0	1	7.1
SPICT general indicators for deteriorating health
KPS ≤50% with limited reversibility	1	50.0	0	0
Dependent on others for most care needs due to physical or mental health problems	1	50.0	0	0
Two or more unplanned hospital admissions in the past six months	0	0	0	0
Significant weight loss (5–10%) over the past three to six months or low body mass index	0	0	0	0
Persistent troublesome symptoms despite optimal treatment of underlying condition	0	0	0	0
Patient asks for supportive and palliative care or treatment withdrawal^a	0	0	5	35.7
SPICT clinical indicators of Dementia/Frail
Unable to dress, walk, or eat without help	0	0	0	0
Eating and drinking less or swallowing difficulties	0	0	0	0
Urinary and fecal incontinence	0	0	0	0
No longer able to communicate using verbal language or little social interaction	2	100	0	0
Femur fracture or multiple falls	0	0	0	0
Recurrent febrile episodes or infections, or aspiration pneumonia	0	0	0	0
Advanced care planning for medical treatment	0	0	2	14.3
Durable power of attorney	1	50.0	5	35.7
Advanced directive	0	0	0	0
Any advanced care planning	1	50.0	5	35.7

Chief researcher measured “patients asks for supportive and palliative care or treatment withdrawal” when patient spontaneously mentioned or part of a discussion between GP and patient.

KPS, Karnofsky Performance Status; SPICT, Supportive and Palliative Care Indicators Tool; SPICT-J positive, ≥2 general indicators, or ≥1 clinical indicators.

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