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Urban and rural differences in geographical accessibility to inpatient palliative and end-of-life (PEoLC) facilities and place of death: a national population-based study in England, UK
Background
Little is known about the role of geographic access to inpatient palliative and end of life care (PEoLC) facilities in place of death and how geographic access varies by settlement (urban and rural). This study aims to fill this evidence gap.
Methods
Individual-level death data in 2014 (N = 430,467, aged 25 +) were extracted from the Office for National Statistics (ONS) death registry and linked to the ONS postcode directory file to derive settlement of the deceased. Drive times from patients’ place of residence to nearest inpatient PEoLC facilities were used as a proxy estimate of geographic access. A modified Poisson regression was used to examine the association between geographic access to PEoLC facilities and place of death, adjusting for patients’ socio-demographic and clinical characteristics. Two models were developed to evaluate the association between geographic access to inpatient PEoLC facilities and place of death. Model 1 compared access to hospice, for hospice deaths versus home deaths, and Model 2 compared access to hospitals, for hospital deaths versus home deaths. The magnitude of association was measured using adjusted prevalence ratios (APRs).
Results
We found an inverse association between drive time to hospice and hospice deaths (Model 1), with a dose–response relationship. Patients who lived more than 10 min away from inpatient PEoLC facilities in rural areas (Model 1: APR range 0.49–0.80; Model 2: APR range 0.79–0.98) and urban areas (Model 1: APR range 0.50–0.83; Model 2: APR range 0.98–0.99) were less likely to die there, compared to those who lived closer (i.e. ≤ 10 min drive time). The effects were larger in rural areas compared to urban areas.
Conclusion
Geographic access to inpatient PEoLC facilities is associated with where people die, with a stronger association seen for patients who lived in rural areas. The findings highlight the need for the formulation of end of life care policies/strategies that consider differences in settlements types. Findings should feed into local end of life policies and strategies of both developed and developing countries to improve equity in health care delivery for those approaching the end of life.
Journal Article
Regional variations in geographic access to inpatient hospices and Place of death: A Population-based study in England, UK
There is much variation in hospice use with respect to geographic factors such as area-based deprivation, location of patient's residence and proximity to services location. However, little is known about how the association between geographic access to inpatient hospice and hospice deaths varies by patients' region of settlement.
To examine regional differences in the association between geographic access to inpatient hospice and hospice deaths.
A regional population-based observational study in England, UK. Records of patients aged ≥ 25 years (n = 123088) who died from non-accidental causes in 2014, were extracted from the Office for National Statistics (ONS) death registry. Our cohort comprised of patients who died at home and in inpatient hospice. Decedents were allocated to each of the nine government office regions of England (London, East Midlands, West Midlands, East, Yorkshire and The Humber, South West, South East, North West and North East) through record linkage with their postcode of usual residence. We defined geographic access as a measure of drive times from patients' residential location to the nearest inpatient hospice. A modified Poisson regression estimated the association between geographic access to hospice, comparing hospice deaths (1) versus home deaths (0). We developed nine regional specific models and adjusted for regional differences in patient's clinical & socio-demographic characteristics. The strength of the association was estimated with adjusted Proportional Ratios (aPRs).
The percentage of deaths varied across regions (home: 86.7% in the North East to 73.0% in the South East; hospice: 13.3% in the North East to 27.0% in the South East). We found wide differences in geographic access to inpatient hospices across regions. Median drive times to hospice varied from 4.6 minutes in London to 25.9 minutes in the North East. We found a dose-response association in the East: (aPRs: 0.22-0.78); East Midlands: (aPRs: 0.33-0.63); North East (aPRs: 0.19-0.87); North West (aPRs: 0.69-0.88); South West (aPRs: 0.56-0.89) and West Midlands (aPRs: 0.28-0.92) indicating that decedents who lived further away from hospices locations (≥ 10 minutes) were less likely to die in a hospice.
The clear dose-response associations in six regions underscore the importance of regional specific initiatives to improve and optimise access to hospices. Commissioners and policymakers need to do more to ensure that home death is not due to limited geographic access to inpatient hospice care.
Journal Article
A scoping review of initiatives to reduce inappropriate or non-beneficial hospital admissions and bed days in people nearing the end of their life: much innovation, but limited supporting evidence
Background
Hospitalisation during the last weeks of life when there is no medical need or desire to be there is distressing and expensive. This study sought palliative care initiatives which may avoid or shorten hospital stay at the end of life and analysed their success in terms reducing bed days.
Methods
Part 1 included a search of literature in PubMed and Google Scholar between 2013 and 2018, an examination of governmental and organisational publications plus discussions with external and co-author experts regarding other sources. This initial sweep sought to identify and categorise relevant palliative care initiatives. In Part 2, we looked for publications providing data on hospital admissions and bed days for each category.
Results
A total of 1252 abstracts were reviewed, resulting in ten broad classes being identified. Further screening revealed 50 relevant publications describing a range of multi-component initiatives. Studies were generally small and retrospective. Most researchers claim their service delivered benefits. In descending frequency, benefits identified were support in the community, integrated care, out-of-hours telephone advice, care home education and telemedicine. Nurses and hospices were central to many initiatives. Barriers and factors underpinning success were rarely addressed.
Conclusions
A wide range of initiatives have been introduced to improve end-of-life experiences. Formal evidence supporting their effectiveness in reducing inappropriate/non-beneficial hospital bed days was generally limited or absent.
Trial registration
N/A
Journal Article
Willpower : discover it, use it and get what you want
\"Be a master of self-control. It's been proven that strong willpower is a better predictor of success than a high IQ. Having firm, unshakable self-control is the secret to bashing through barriers and hitting your life goals. Willpower is the heartbeat of a successful, fulfilling work and personal life. But you either have willpower or you don't --right? Learn the science. Develop the habits. Globally acclaimed psychology and executive coach Ros Taylor is here to show us how willpower can be learned and developed. You don't need to be born with innate self-control--you can follow Ros's steps and learn to master you will. Ros distills a powerful step-by-step model, with actionable self-assessments and strategies, which will ensure you establish the proper habits of self-control to overcome the challenges holding you back. Regardless of what you want to achieve and where you're starting from, Willpower shows you how to: practice the scientifically-proven skillset for enhancing you willpower; make progress immediately and have new, positive habits in just three weeks; use this repeatable process to break through barriers in every area of your life; live with the stress-free confidence that comes with being in control. The difference between those who get what they want and those who don't comes down to self-control--Willpower is the way you master it and use it for personal and professional success.\"--Back cover.
Book
4 Advances in palliative care
Palliative care is at a pivotal point in its trajectory. For the last 50 years there has been a focus on service development for the new specialty, the safer use of opioids and obtaining the evidence that palliative care makes a difference, the earlier the better.However the next 50 years will be a massive challenge, but also an opportunity. There will be a shortage of all physicians, not just palliative physicians and this is a perfect storm with our increased longevity, frailty and comorbidities.The lecture will focus on potential solutions, drawing on global innovation and imagination. Having braver conversations about the future is all very well but we also need practical options to improve the care of dying people in all settings not just five-star hospices, and we need to be less risk-averse about supporting patient and family goals of care in a culture dominated by compliance rather than comfort and care!
Journal Article
P-97 HPAL – a unique web-based clinical decision tool, combined with a place-based service directory, to support hospice coordination hubs
AimTo provide a web-based clinical decision tool, aligned to national and local ICS guidelines and services, to support the frontline triage staff in the new Hillingdon Palliative Coordination Hub. BackgroundRecent national guidance has emphasised the need for less fragmented care, coordination of support, together with more accessible palliative information for clinicians and family carers. HPAL (https://hpal.medindex.co.uk) was initially developed as an innovative clinical information tool for the London Borough of Hillingdon and has now expanded to support the eight boroughs in the North West London Integrated Care System (ICS). It is a unique website, providing trusted curated clinical expertise (2 minute read time) linked to a place-based service directory for each borough.Method157 local palliative care services, including hospice teams, pharmacies stocking palliative medicines, carers and bereavement organisations have now been linked to relevant clinical topics.Clinical topics have been chosen based on analysis of common advice questions from clinicians and patients and all clinical guidance is aligned with local ICS guidelines. The Coordination Hub is being launched imminently with trained Band 4 compassionate communicators who will use HPAL as a clinical decision tool with intelligent access to relevant local services.ResultsHPAL has been extremely well received by patients, families and clinicians. It is seen as accessible, easy to navigate and has become a one-stop site for our community palliative teams and is embedded in the service specification for the new Hillingdon Coordination Hub.Next steps and conclusionsContinually develop the Coordination Hub interface with the website. Feedback and analytics will constantly enhance the site. An Out Of Hours chat function will be added. HPAL will underpin two further Coordination Hubs planned for North West London, supporting a population of 2.5 million. Its uniqueness lies in its clinical content linked to a local place-based service directory – it can be easily scaled to any area in the UK.
Journal Article
Report of the Lancet Commission on the Value of Death: bringing death back into life
Climate change, the COVID-19 pandemic, environmental destruction, and attitudes to death in high-income countries have similar roots—our delusion that we are in control of, and not part of, nature. Palliative care can provide better outcomes for patients and carers at the end of life, leading to improved quality of life, often at a lower cost, but attempts to influence mainstream health-care services have had limited success and palliative care broadly remains a service-based response to this social concern. Income, education, gender, race, ethnicity, sexual orientation, and other factors influence how much people suffer in death systems and the capacity they possess to change them. The five principles are: the social determinants of death, dying, and grieving are tackled; dying is understood to be a relational and spiritual process rather than simply a physiological event; networks of care lead support for people dying, caring, and grieving; conversations and stories about everyday death, dying, and grief become common; and death is recognised as having value. The five principles are: the social determinants of death, dying, and grieving are tackled; dying is understood to be a relational and spiritual process rather than simply a physiological event; networks of care lead support for people dying, caring, and grieving; conversations and stories about everyday death, dying, and grief become common; and death is recognised as having value.
Journal Article