Hospice Elements And Device Models Manual Lawn

Published online 2014 Mar 26. doi: 10.1186/1472-6963-14-136

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2. Roku Device Models
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5. Hamburg Wheel Tracking Device Models

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Iv HSPICE® MOSFET Models Manual X-2005.09 Contents Equation Variables................... 32 Using the MOSFET. Elements of effective palliative care models: a rapid review. Contexts in which these were implemented and lack of detailed reporting meant that elements of models constituted a more meaningful unit of analysis than models themselves. Wilson SA, Noonan PE. The effects of hospice interventions on behaviors, discomfort, and physical.

Abstract

Background

Population ageing, changes to the profiles of life-limiting illnesses and evolving societal attitudes prompt a critical evaluation of models of palliative care. We set out to identify evidence-based models of palliative care to inform policy reform in Australia.

Method

A rapid review of electronic databases and the grey literature was undertaken over an eight week period in April-June 2012. We included policy documents and comparative studies from countries within the Organisation for Economic Co-operation and Development (OECD) published in English since 2001. Meta-analysis was planned where >1 study met criteria; otherwise, synthesis was narrative using methods described by Popay et al. (2006).

Results

Hospice Elements And Device Models Manual Lawn Tractor

Of 1,959 peer-reviewed articles, 23 reported systematic reviews, 9 additional RCTs and 34 non-randomised comparative studies. Variation in the content of models, contexts in which these were implemented and lack of detailed reporting meant that elements of models constituted a more meaningful unit of analysis than models themselves. Case management was the element most consistently reported in models for which comparative studies provided evidence for effectiveness. Essential attributes of population-based palliative care models identified by policy and addressed by more than one element were communication and coordination between providers (including primary care), skill enhancement, and capacity to respond rapidly to individuals’ changing needs and preferences over time.

Conclusion

Models of palliative care should integrate specialist expertise with primary and community care services and enable transitions across settings, including residential aged care. The increasing complexity of care needs, services, interventions and contextual drivers warrants future research aimed at elucidating the interactions between different components and the roles played by patient, provider and health system factors. The findings of this review are limited by its rapid methodology and focus on model elements relevant to Australia’s health system.

Keywords: Palliative care, Models of care, Rapid review, Case management, Home based care, Nursing homes, Specialist palliative care, Acute care, Emergency departments

Background

Access to appropriate care and support at the end of life is recognised by many as a basic human right []. However, ongoing changes in disease and society demand rethinking who should properly receive such care, and how, where and from whom they should receive it. The traditional focus on specialist palliative care (SPC) teams caring for people with cancer in a hospice or community setting has been expanded to include a wide range of life-limiting disease groups and care settings []. Changes in living and social circumstances mean that current generations can no longer expect the informal caregiving taken for granted by their forbearers, forcing people to look to formalised healthcare and social services. At the same time, individualistic, consumerist attitudes mean that people demand greater choice in determining and tailoring their healthcare, including the opportunity to be cared for and die in places of preference [].

Advances in detection and treatment mean that diseases such as cancer and HIV that previously killed people quickly are now chronic conditions that confer an increasing burden of symptoms and functional decline over many years [,]. Medical advances have also contributed to population ageing, facing health systems with an increasing number and proportion of frail people with multiple conditions. Despite the best of intentions, this population is often ‘crisis managed’ within the acute care system rather than being adequately supported in the community for as long as possible []. In most countries, access to healthcare varies according to socioeconomic and geographic variables, mandating efforts to decrease health disparities [,]. Given the increasing number and changing profile of people with life-limiting illness, it is neither feasible nor desirable that SPC services provide care for everyone; rather, these services should be reserved for patients with the most complex palliative care needs []. A population approach to planning is therefore required that takes a ‘birds-eye view’ across the health system to inform the development of models of palliative care that integrate SPC with other services according to need [,].

The current study set out to inform Australian palliative care policy reform by identifying and synthesising:

1) recommendations for population based palliative care from international policy, and

2) the evidence for improvements on patient, family and health system outcomes available for different population-based models of palliative care from studies of any design comparing one model with another or models to usual care.

Methods

A rapid review of the palliative care literature was undertaken over an eight week period in April 2012. Rapid review methodology utilises similar processes to a full systematic review but generates a more timely synthesis of the evidence by limiting scope (e.g. search terms and inclusion criteria ) and various aspects of synthesis (e.g. data extraction and bias assessment) [,]. In deciding which efficiency measures to introduce, researchers undertaking rapid reviews need to carefully weigh up advantages in time/resource saving against disadvantages in the form of decreased coverage and increased risk of bias; given an appropriate balance, a rapid review can generate adequate advice for the majority of clinical and policy decision when a pre-defined methodology is followed []. Decisions made in the current rapid review and associated limitations are summarised in relevant parts of the Methods and Discussion. A protocol was developed and discussed prior to commencement but was not made available publically.

Eligibility criteria

Two kinds of document were deemed informative. First, we were interested to identify how various models of palliative care had been defined in the literature and which of these have been supported by evidence. We also sought international policy documents/reports with most applicability to Australia’s universal health care system and federal/state structure of funding. To be included, documents of both kinds needed to come from an Organisation for Economic Co-operation and Development (OECD) country and have been made publically available in English since 2001. We limited to more recent publications to maximise relevance to contemporary populations and healthcare contexts. Documents had to be concerned with facilitating the delivery of palliative care to people with progressive life-limiting illness in any setting.

Inclusion criteria relating to palliative care were based on the World Health Organisation (WHO) definition on the basis of being the most widely used internationally [14]. Models of care were defined as those providing a framework or system for the organisation of care for people with a progressive life-threatening illness and/or their family, carers or close friends []. Eligible care activities included those consistent with the aims of palliative care as defined by WHO (e.g. advance care planning and self-management) as well as meeting the care needs of the patient population (e.g. symptom management and care-giver support). In accordance with the WHO definition, inclusion criteria did not relate to the degree of training and/or experience of those providing care, but rather the nature of care provided. Indeed, as indicated in the Introduction, we were especially interested to identify evidence-based models of care involving generalist or primary palliative care providers as well as specialist services.

Studies were considered eligible for inclusion if they provided data on effectiveness and/or cost-effectiveness based on comparison either between two alternative models of palliative care or between a model of palliative care and usual care. Usual care was assumed to include routine community and hospital services other than SPC models (including private). Comparisons could be concurrent or historical. Studies providing level 1 and 2 evidence (systematic reviews and randomised controlled trials [RCTs]) were prioritised, with studies using other, less rigorous designs (e.g. multiple time series) being treated as secondary sources of information [15].

We were also interested to see which models of palliative care had been recommended by current international policy. Policy document were defined as any publically available statement of position, standards or recommendations officially put forward by a government. Eligible document types included reports by health services and peak bodies as well as peer-reviewed journal articles and books/book sections.

Information sources

Electronic searches

We searched Medline, AMED, CINAHL, the Cochrane Database of Systematic Reviews, Health Technology Assessment Database and CENTRAL from their earliest records. We also searched the grey literature via internet search engines (Google and Google Scholar), the online Australian palliative care knowledge network, CareSearch, and other relevant online clearinghouses (e.g. Americans for Better Care of the Dying). Deep web searching using Mednar was considered useful for the targeting of scientific material unavailable to search engines like Google [16]. Documents listed in CareSearch’s Review Collection relating to “Service/Systems Issues” (http://www.caresearch.com.au/caresearch/tabid/501/Default.aspx) were also reviewed for inclusion.

Other sources

The reference lists of all included reviews were searched manually for further relevant articles.

Search terms

Searches for literature reporting on palliative care were conducted simultaneously with those aimed at meeting secondary aims of identifying service planning tools and research on the palliative care needs of Australians (not reported in this paper). Database searches used Medical Subject Headings (MeSH) terms or equivalent as well as keywords relating to palliative and end of life care + service models (see Table 1 for an example). Search terms were based on those for PubMed developed by CareSearch.

Table 1

Medline search terms used to identify relevant articles on palliative care models, service planning tools and palliative care needs of Australians in searches conducted on 4^th April 2012

1.	exp advance care planning/OR exp attitude to death/OR exp bereavement/OR exp terminal care/OR exp hospices/OR exp life support care/OR exp palliative care/OR exp terminally ill/OR death/OR palliate$.mp OR hospice$.mp OR terminal care.mp
2.	(dying.mp OR death.mp OR end of life.mp) AND (imminen$.mp OR nearing.mp OR last day$.mp OR last week.mp OR last hour$.mp OR final day$.mp OR final week.mp OR final hour$.mp OR critical pathway$.mp)
3.	1 OR 2
4.	exp delivery of health care/AND (exp models, theoretical/OR exp models, economic/)
5.	exp Community Health Planning/OR exp health care reform/OR exp decision making, organizational/OR exp planning techniques/OR exp Health Services Needs and Demand/OR exp healthcare disparities/
6.	(exp Australia/OR Australia$.mp) AND (exp attitude/OR attitude$.mp OR belief$.mp OR knowledge.mp or “unmet need$”.mp)
7.	4 OR 5 OR 6
8.	3 AND 7 (limit publication date to 2001-current)

Only results relating to palliative care models are reported in this paper.

Study selection

Articles returned from searches of electronic databases were imported into Endnote (version X4) and coded by a single researcher against inclusion criteria for evaluative studies using a standardised proforma.

Data collection process and data items

Given the rapid nature of our review, we extracted detailed data only from those original studies not contributing to the findings of an included systematic review and data extraction was undertaken by one researcher only. Data on each model of palliative care were extracted using an electronic proforma according to a recently published disease management taxonomy which considered: patient population, intervention recipient; intervention content, delivery personnel, method of communication, intensity and complexity, environment and clinical outcomes []. Variables relating to study design, comparator, outcomes and findings were also extracted. Study authors were contacted via email to ask for more information as required.

Assessment of bias

Systematic reviews were quality rated by a single reviewer using the AMSTAR checklist []. Any RCTs we identified that were not included in one or more systematic reviews were rated for quality by a single reviewer using criteria set by the US Agency for Healthcare Research and Quality (AHRQ) [19].

Synthesis

Models of care were classified according to definitions provided by a range of sources identified by Medline and Google searches; wherever possible, definitions were taken from Australian sources to ensure relevance to the Australian healthcare system [20-33]. Classification was carried out by one reviewer, seeking input from the team as necessary where classification was not straight-forward. Meta-analysis was planned where two or more studies evaluating models of care met criteria set out in the Cochrane Handbook of Systematic Reviews [19]. Where meta-analysis was not possible, synthesis took a narrative approach using techniques described by Popay and colleagues, namely: tabulation, textual descriptions, grouping and clustering, transformation of data to construct a common rubric, vote counting, and translation of data through thematic and content analysis [34-36]. Initial synthesis was undertaken by one author, with each allocated to consider findings in a particular settings (community, hospital, aged care, paediatric and regional/rural). Iterative discussion was used to distil models and elements thereof. In the absence of studies directly comparing different models of palliative care, inference was made from results comparing models with usual care as to which had most evidence for efficacy and cost-effectiveness. No formal methods were used to examine bias across studies.

Results

Table 2 includes definitions of models of palliative care identified in the literature.

Table 2

Definitions of various models or components thereof for palliative care delivery found in the literature

Model/component	Definition(s)
Case management	Case management is a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual’s holistic needs through communication and available resources to promote quality cost effective outcomes. The definition of case management notes the focus upon the meeting of a client’s health needs. Case management can be placed within a social model of health, within which improvement in health and well-being are achieved by directing efforts towards addressing the social and environmental determinants of health, in tandem with biological and medical factors [31].
Consultation model	An approach to care by which specialist advice is provided on assessment and treatment of symptoms, communication about goals of care and support for complex medical decision-making, provision of practical and psychosocial support, care coordination and continuity, and bereavement services when appropriate [37]. Advice is provided without necessarily assuming primary responsibility for care, although there is negotiation of the level of palliative care involvement.
Health or clinical networks	Health networks are formed when three or more health care agencies (services, organisations or health districts) formally come together to better meet the needs of patients in their service area. These agencies often include hospitals, community health centres, critical access hospitals, physician practices, mental health providers, rural health clinics and other for-profit and not-for-profit health care organizations. These health or clinical networks work to increase access to quality healthcare for local patients and streamline the cost of that care, as well [38].
Integrated care	Integrated care is a concept bringing together inputs, delivery, management and organisation of services relating to diagnosis, treatment, care, rehabilitation and health promotion. Integration is a means to improve the services in relation to access, quality, user selection and offering care [39].
Liaison model	The liaison model combines the education of patients after discharge with educational outreach and clinical support for primary care clinicians. This model may be particularly appropriate in deprived areas, where general practices vary in their capacity to manage chronic illness [40].
Managed clinical networks (MCNs)	Clinical networks are linked groups of health professionals and organisations from primary, secondary, and tertiary care working in a coordinated manner, unconstrained by existing professional and [organisational] boundaries to ensure equitable provision of high quality effective services [21]. MCNs address many of the problems that have been identified in the traditional delivery of health services, including: poor coordination and collaboration between health services; changing roles for health professionals; and the need for greater efficiencies, improved access, more equitable service provision, better use of limited resources and quality patient-centred care. More specifically, MCNs aim to develop locally delivered, quality assured care, through the managed integration of, and cooperation between, formerly separate clinical services. Their major focus is on actively involving patients in service design and building seamless services around the patient’s journey to ensure the best treatment gets to the right patient, at the right time, in the most appropriate place and is delivered by the most qualified and skilled professional with the greatest resources [22].
Pop-up model	Often palliative needs in rural areas may be intermittent or needs specific. Developing a permanent infrastructure would not be appropriate in these circumstances. Looking at available local resources and gaps would provide a basis for developing a ‘pop-up’ palliative service model that optimises how local resources and services can be used to respond to a specific palliative need [24].
Shared care model	A review [28] suggests that three definitions of shared care have been offered:
	1. An approach to care which uses the skills and knowledge of a range of health professionals who share joint responsibility in relation to an individual’s care. This also implies monitoring and exchanging patient data and sharing skills and knowledge between disciplines.
	2. A narrower approach concerned with joint participation of general practitioners and specialists in the planned delivery of care for patients with a chronic condition, informed by an enhanced information exchange, over and above the routine discharge and referral letters.
	3. Especially in mental health, shared care can be divided into systematic cooperation about how systems agree to work together and operational cooperation at local levels between different groups of clinicians.

A total of 1,959 articles returned from electronic databases were screened for inclusion as evaluative studies, of which 23 reported systematic reviews, 9 RCTs and 34 non-randomised comparative studies. Systematic reviews included an average of 18 studies (range 2–43) and varied as to whether they defined their focus by setting (day care [,], hospital [], hospice [], community [45-], aged care [], across settings [-]), patient group (transitioning to adult [], HIV/AIDS [], dementia []) or type of intervention (telehealth [], caregiver-focused [61], case conferencing [], UK Gold Standards Framework []). Only two of these systematic reviews limited inclusion criteria to RCTs [,], although all but three included RCTs alongside other designs. In total, the reviews included 126 RCTs, 29 of which were included in more than one review. Of the 9 RCTs we identified that had not been included in a review, three tested models using case management [-] and five SPC consultation [-].

See Figure 1 for a flowchart of inclusion/exclusion of peer-reviewed articles and Tables 3 and ​and44 for details of systematic reviews and RCTs respectively.

Flowchart for inclusion of articles reporting evaluative studies identified through searches of electronic databases.

Table 3

Systematic reviews evaluating the efficacy of palliative models of care

Review	Review question	Studies	Participants	Setting	Interventions	Quality *	Synthesis	Summary of results
[44]	To identify the current evidence on (1) the effectiveness, including cost-effectiveness, of hospices, and hospice care in a patient’s home and in nursing homes and (2) the experiences of those who use and of those who provide such services	Search date: 2003-2009	People dying from any LLI or their family	Inpatient, RAC, community	EOL care service provided by multidisciplinary team not part of general healthcare	Medium	Narrative	Hospice services are highly valued by patients and their families, reduce general health service use and costs, and increase the likelihood of effective pain management and of death not occurring in hospital
		Designs: comparative and qualitative studies
		Number of studies: 18 comparative, 4 qualitative
[41]	To inform future practice, research and policy in specialist palliative day-care by systematically reviewing the evidence for how the structure and process of this form of care relate to outcomes for adults with cancer	Search date: 1872-2003	Patients with cancer	Day care	Palliative day care	Low	Narrative	There is evidence for high satisfaction among patients selected into day-care, but not yet sufficient to judge whether this improves symptom control or QOL.
		Designs: Any, qualitative or quantitative
		Number of studies: 12
[57]	To evaluate the evidence on the transition process from child to adult services for young people with palliative care needs	Search date: 1990-2008	Children and young people with LLI	Transition from paediatric to adult services, any setting	Interventions aimed at easing transition	Medium	Narrative	Post-transition patients with cystic fibrosis (and in one study) parents described transition positively
		Designs: any
		Number of studies: 92, of which only 2 were evaluative
[45]	To identify the models of inter-professional working that provide the strongest evidence base for practice with community dwelling older people	Search date: 1990:2010	Older (age 65+) people	Community	Inter-professional case management, collaboration or integrated team models	Medium	Narrative	Weak evidence of effectiveness and cost-effectiveness, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use.
		Designs: RCTs
		Number of studies: 41
[51]	To assess whether there was an effect of palliative care teams	Search date: not given	Patients receiving palliative care and their families	Inpatient or community	Multi-disciplinary teams including staff trained to some extent in palliative care	Medium	Narrative and meta-analysis using effect sizes weighted by the square root of sample sizes	Most evidence is available for home care services (improved satisfaction and pain and symptom control with lower costs), with a smaller number of studies of inpatient hospice or palliative care (similar or greater satisfaction, particularly for carers and similar or improved symptom control, quality of life equivocal) and a small number of poor quality studies considering hospital support, although it does seem that these services reduce time in hospital.
		Designs: not defined
		Number of studies: 43
[52]	To identify studies that compare specialised palliative care models between them assessing their effectiveness or cost-effectiveness	Search date: 2003-2006	Terminally ill patients	Inpatient, community	Four hospice-based models (large free-standing hospice, hospital-based hospice, home-care hospice, telemedicine based hospice), one palliative care unit based at a general hospital and two models of referring specialists at hospital (a full service and a service limited to telephonic support to the staff caring the patient)	Medium	Narrative	No differences were found in control of symptoms, QOL, emotional support or satisfaction between a broad service provided by a team of referring specialists at hospital and telephonic support between specialised PCT and the staff caring for the patient. No differences in effectiveness was found between hospital-based hospices and home-based hospice.
		Designs: Comparative
		Number of studies: 4
[50]	To determine effectiveness of multi-component palliative care service delivery interventions for residents of care homes for older people.	Search date: to Feb 2010	Elderly people in aged care	RAC	Multi-component palliative care in RAC, including referral to external services or staff training	Good	Narrative	One study reported higher satisfaction with care and the other found lower observed discomfort in residents with end-stage dementia. Two studies reported higher referral to hospice services in their intervention group, one found fewer hospital admissions and days in hospital, the other found an increase in do-not-resuscitate orders and documented advance care plan discussions.
		Designs: Comparative
		Number of studies: 3
[46]	Not stated	Search date: 1975-2001	Family members or carers of people with cancer or other advanced disease	Community	Home nursing care, respite services, social networks and activity enhancement, problem solving and education, and group work	Medium	Narrative	The current evidence contributes more to understanding feasibility and acceptability than to effectiveness.
		Designs: Any evaluative
		Number of studies: 6
[47]	To update 2003 review to determine the effectiveness of subsequently published intervention studies targeting informal caregivers needs in cancer/advanced disease	Search date: 2001-2010	Family members or carers of people with cancer or other advanced disease	Community	One-to-one psychological models, Psychological interventions for patient/carer dyads, Palliative care/hospice interventions, Information and training interventions, Respite interventions, Group interventions, Physical interventions	Medium	Narrative	Of 6 studies evaluating palliative care/hospice interventions, one pre/post study found reduced family anxiety about caring at home but increased wakening and poorer physical health, one cross-sectional survey found high satisfaction; the others found no effect. The one study evaluating respite found caregivers to report satisfaction after implementation.
		Designs: Any evaluative
		Number of studies: 33
[58]	To systematically review the evidence base for the effectiveness of palliative care in improving patient outcomes in HIV/AIDS	Search date: 1980-2003	Patients with HIV requiring symptom control, psychosocial support or terminal care	Inpatient, hospice, community, long-term care	Multidisciplinary advice and support, terminal care, domestic support, care monitoring and planning,	Medium	Narrative	Home palliative care and inpatient hospice care significantly improve patient outcomes in the domains of pain and symptom control, anxiety, insight, and spiritual wellbeing.
		Designs:
		Comparative Number of studies: 22
[43]	To determine whether hospital-based palliative care teams improve the process or outcomes of care for patients and families at the end of life	Search date: 1977-1999	Patients with a progressive life-threatening illness, and their family, carers, or close friends.	Hospital	Palliative care teams working in hospitals, defined as two or more healthcare workers, at least one of whom had specialist training or worked principally in palliative care. Included interventions with a hospital/support team component within a broader intervention	Good	Narrative and meta-analysis using effect sizes	All studies except one indicated a small positive effect of the hospital team, including improved symptoms, fewer hospital days and better satisfaction, as well as improvements on process measures such as increased referrals, change in prescribing practices.
		Designs: Comparative
		Number of studies: 13
[53]	To determine whether specialist palliative care teams achieve their aims and improve outcomes for patients with advanced cancer and their caregivers, in terms of improving symptoms and quality of life and/or reducing the emotional concerns of family caregivers	Search date: 2000-2009	Patients with advanced cancer and their caregivers	Inpatient, community, outpatient, day care	Specialist palliative care offered by professionals specifically trained in palliative and hospice care	Medium	Narrative	The evidence (moderate and low) supports SPCTs working in home, hospitals, and inpatient units as a means to improve outcomes for cancer patients, such as pain, symptom control, and satisfaction, and in improving care more widely, including reducing hospital admissions. The benefit is demonstrated quantitatively.
		Designs: Comparative Number of studies: 40
		Studies indicated either benefit in favour of a palliative care team or no difference. Some studies suggested lower costs.
		Quality of life, when measured, less often was different between groups and tended to deteriorate over time.
[60]	To explore the use of telehealth in relation to palliative care in the UK	Search date: 1999-2011	Adults, relatives, or carers with palliative care needs or health professionals in the UK	Inpatient, community, outpatient, RAC	Telehealth	Low	Narrative	Advantages of telehealth include improved access to health professionals and decreased time loss and costs for patients, optimized time use and increased productivity for health professionals, and improved service efficiency for providers. On the negative side, the service becomes depersonalized for both patients and clinicians, confidentiality issues may arise, and potential legal implications for health professionals, including clinical risk management, may be a concern. Clinical staff may be required to perform additional research tasks such as data collection, which might not be considered the main objective when they must compete with the pressures of providing a service. Nonetheless, it appears
		Designs: Any
		Number of studies: 27
								to be both feasible and practical to make greater use of telehealth initiatives in order to provide a more equitable palliative care service that is meant not to replace but to enhance the traditional model.
[61]	To provide a comprehensive literature review and critical appraisal of intervention studies with family caregivers of loved ones on hospice	Search date: 1983-2008	Family caregivers of patients receiving palliative care at home in the US	Community	Videophone support, emotional support, self-care/stress reduction, massage	Low	Narrative	Generally positive findings but limited by methodological weakness and mixed results.
		Designs: Any evaluative
		Number of studies: 5
[54]	To assess evidence about interventions to improve palliative and end-of-life care	Search date: 1990-2005	People with terminal illness (for example, advanced cancer) and chronic, eventually fatal illness with ambiguous prognosis (for example, advanced dementia)	Any	Case management, coordinated supportive cancer care, nurse care management, in-home support, interventions targeting management and informational and relational aspects of continuity	Medium	Narrative	Moderate evidence supports multidisciplinary interventions that target continuity to affect utilization outcomes. Evidence is strong for reducing readmissions in heart failure, but insufficient evidence was available for other conditions. Successful interventions involved multidisciplinary teaming, addressed patient needs across settings and over time, and facilitated communication by personal and technological means.
		Designs: SRs and any evaluative
		Number of studies: 9 SRs and 12 studies focused on continuity
[48]	To establish whether community SPCS offering home nursing increase rates of home death compared with other models	Search date: Earliest records-2011	People with LLI receiving EOL care	Community	Practical nursing support with or without domestic support, education, transition support, tele-support	COI declared	Meta-analysis using OR	Meta-analysis indicated a significant effect on home deaths for SPCS with home nursing versus other care; however, the only two RCTs found no effect. Symptom management or QOL was not compromised and costs were not higher in any study that measured these.
		Designs: Comparative
		Number of studies:9
[62]	Does case conferencing improve care planning in palliative patients?	Search date: 1990-2005	Palliative population	Community, inpatient, RAC	Case conferencing between GPs and other healthcare professionals and families	Medium	Narrative	Case conferences were generally acceptable to GPs. Participant perceived benefits included: improved communications between participants; increased GP knowledge about the patient’s illness; interactive discussions with other healthcare professionals as a result of the face-to-face communication; improved inter-professional respect particularly as GPs often did not have a good idea of the roles played by other health providers; a learning opportunity for all participants; a mechanism for de-briefing, particularly when dealing with particularly difficult patients; reduced professional isolation; increased team building and promotion of a team approach to caring for terminally ill patients. Patient outcomes included: assisting in discharge from hospital; improved practice; reduced inappropriate medications, including identification of medication-related problems; increase patient and carer awareness of services; identification and resolution of problems; reduced primary care visits; maintenance of function and independence; increased use of services. No effect observed on quality of life or survival; effect seemed to be limited to outcomes the care teams had direct influence on.
		Designs: Any evaluative
		Number of studies: 20
[59]	To test the efficacy of a palliative care model in patients with dementia	Search date: 1966-2003	People with advanced dementia	RAC, acute hospital	Dementia Special Care Unit (DSCU), palliative care plans aimed at maximising comfort and minimising invasive or aggressive treatment (including hospitalisation)	Medium	Narrative	Patients in the DSCU had lower discomfort and fewer transfers to acute medical setting but higher mortality; the study in the acute hospital setting found no effect on length of hospital stay or reduction in painful interventions.
		Designs: Any evaluative
		Number of studies: 2
[49]	To determine if providing home-based end of life care reduces the likelihood of dying in hospital and what effect this has on patients’ symptoms, quality of life, health service costs and care givers compared with inpatient hospital or hospice care.	Search date: 1950-2009	Adults receiving terminal care at home who would otherwise require hospital or hospice inpatient care.	Community	EOL care at home providing active treatment for continuous periods of time by multidisciplinary healthcare professionals	Medium	Meta-analysis using risk ratio	Those receiving home-based end of life care were statistically significantly more likely to die at home. There was some evidence of increased patient satisfaction with home-based end of life care, and little evidence of the impact this form of care has on caregivers. No statistically significant differences were found for functional status, psychological well-being or cognitive status.
		Designs: Comparative
		Number of studies:4
[42]	To determine whether the provision of palliative day care services (PDS) have a measurable effect on attendees’ wellbeing	Search date: 1978-2009	Patients with LLI	Day care	Holistic, individualized palliative care, including medical and nursing care, allied health and complementary therapies, social support,	Medium	Little evidence of impact on QOL but people report that attending PDS is a valuable experience that allows them to engage with others and to be supported in a restorative environment.
		Designs: Any evaluative
		Number of studies:35
[63]	To review the impact of the Gold Standards Framework (GSF) since its introduction to the UK in 2001	Search date: NR-2008	People receiving EOL care	Primary care	Toolkit to improve the quality, coordination and organisation of EOL care	Medium	Narrative	Evaluation to date has focused on the GSF’s impact on care processes rather than outcomes. The GSF has proven acceptability and can influence multidisciplinary collaboration, communication, assessment and care planning
		Designs: Any
		Number of studies:27
[55]	To identify and analyse all published RCTs that focus on the organization of EOL care provided to persons who are terminally ill, near death, or dying	Search date: NR	People who are terminally ill, near death or dying	Inpatient, community	Multidisciplinary care, staff training	Low	Narrative	Community or home-based EOL care compares favourably with more traditional or conventional hospital-based and episodic medical care in improving symptoms and in the opinions of patients and caregivers
		Designs: RCTs
		Number of studies:23
[56]	To systematically review the evidence for effectiveness of specialized palliativecare	Search date: earliest records-2007	Terminally ill	Community, inpatients, outpatients	Multidisciplinary care and support, education, caregiver support, coordination,	Medium	Narrative	Evidence was most consistent for effectiveness of SPC in improvement of family satisfaction with care (7 of 10 studies). Only 4 of 13 studies assessing QOL and 1 of 14 assessing symptoms showed a significant benefit of the intervention; however, most studies lacked statistical power. There was evidence of significant cost savings in only 1 of 7 studies that assessed this outcome.
		Designs: RCTs
		Number of studies: 22

COI: conflict of interest; EOL= end of life; LLI = life limiting illness; RAC = residential aged care; SR = systematic review. *Quality has been rated using AMSTAR as follows: Good quality = 8–11; medium quality = 4–7; low quality = below 4 [].

Table 4

Randomised controlled trials (RCTs) comparing models of care to ‘usual care’ and reported in the peer-reviewed literature

Ref	Model of care	Setting/	Referral/	Delivery personnel	Communication/	Intensity/	Comparator	Outcomes	Findings	Quality*
		population	access		coordination	complexity
[64]	Case management	Community-dwelling ‘seriously chronically ill’ (<2 year life expectancy)with COPD or CHF (N=192)	Patients receiving treatment from one of multiple managed care organizations	Nurse case-managers, supported by medical director, social worker and pastoral counsellor	Primary care physician, health plan case manager and community agencies	NR	Usual care, including telephone-based medical and disease- oriented case management	Self-management, preparation for EOL, symptoms, QOL, medical service utilisation	IG reported lower symptom distress, greater vitality, better physical functioning and higher self-rated health. ED utilisation was equivalent across groups	Poor
[65,66]	Case management	Rural community-dwelling patients newly diagnosed with advanced cancer (N=322)	Patients identified by the VA Medical Centre’s tumour board	PC advanced practice nurses, supported by PC physician, psychologists, and ‘other team members’	Referral to medical teams and community resources as required	4 face-to-face sessions with monthly telephone follow-up and group shared medical meetings	Usual care at VA Medical Centre	QOL, symptoms, depression, days in hospital, ED visits	IG higher scores for QOL and mood, but did not have improvements in symptom intensity scores or reduced days in the hospital or ICU or ED visits.	Good
[68]	Consultation	ICU inpatients with a terminal or preterminal condition (N=20)	Patients identified by intensivist indicating that (s)he believed treatment should not be escalated or should be withdrawn	PC physician, registrar, resident and clinical nurse consultant	None indicated	Daily ward rounds	Usual ICU care	ICU and hospital length of stay and satisfaction with quality of care of families, intensivists, and bedside nursing staff, ICU and hospital mortality, the number of medical teams caring or consulting for the patient	No statistically significant differences	Poor
[69]	Consultation	Hospital inpatients with LLI	Referrals received from all medical services and inpatient units	PC physician and nurse, hospital social worker and chaplain	Liaised with hospital subspecialists, attended discharge meetings, electronic discharge information sent to GP	NR	Usual inpatient care	Symptom control, levels of emotional and spiritual support, patient satisfaction, total health services costs, survival, number of advance directives at discharge, and hospice utilisation	IG had fewer ICU admissions, lower 6-month net cost savings, and longer median hospice stays. There were no differences in survival or symptom control.	Good
[67]	Case management	Oncology inpatients and outpatients referred to PC service (N=159) and their caregivers	Referred by oncology inpatient or outpatient services	SPC service NOS, GP	Follow-up communication in both arms via faxed or posted letters, and telephone communication between family physician and specialist, or domiciliary nurses present at specialist team meetings acting as an intermediary	Single case conference via telephone and follow-up as required	Usual oncology inpatient or outpatient care	QOL, caregiver burden	No significant differences in magnitude of change in QOL from baseline but IG showed better maintenance of some physical and mental health measures of QoL in the 35 days before death	Poor
[70]	Consultation	Outpatients with New York Heart Association functional classes III and IV CHF (N=13)	NR	SPC NOS	NR	Initial consultation + monthly for 5 months	Usual cardiology care	Anxiety, depression and QOL	Low recruitment and attrition precluded analysis	Poor
[71]	Consultation	Acute care inpatients with advanced dementia (N=32) and their caregivers	Recruited from acute medical wards	SPC NOS	Copies of ACPs were placed in the medical notes and sent to GPs and RAC (where relevant)	Up to 4 consultations	Usual inpatient care	Caregiver distress, decision satisfaction, QOL and (if the patient died) satisfaction with EOL care	Attrition precluded analysis	Poor
[72]	Consultation	Oncology outpatients with newly diagnosed metastatic non–small-cell lung cancer (N=151)	Recruited from oncology outpatients	PC palliative care physicians and advanced-practice nurses	Care coordination NOS	Average number of 4 SPC visits	Usual oncologic care	Anxiety, depression, QOL, survival, health service use	IG had higher QOL, lower depression and longer survival despite less aggressive EOL care	Good

ACP = advance care plan, COPD = chronic obstructive pulmonary disease, CHF = chronic heart failure, ED = emergency department, EOL = end of life, IG = intervention group, ICU = intensive care unit, LLI = life-limiting illness, PC = palliative care, (N) = total sample size at baseline, NOS = not otherwise specified, NR = not reported, QOL = quality of life, RAC = residential aged care, SPC = specialist palliative care; *Quality was rated as ‘good’, ‘fair’ or ‘poor’ according to criteria for internal validity set by the US Agency for Healthcare Research and Quality [73].

In keeping with international policy, this review found a high level of interest in addressing the palliative care needs of populations beyond people with cancer to those with illnesses such as chronic heart failure [74], end-stage kidney disease [,], chronic obstructive pulmonary disease [] and dementia []. Research has highlighted the importance of better identifying the palliative phase of these conditions in order to appropriately time advance care planning, access to symptom management and provision of support to patients and their families. Many studies included patients with a range of diagnoses and did not distinguish care or effectiveness by disease group.

Variation in the content of models, contexts in which these were implemented and lack of detailed reporting meant that no two studies met the requirements for meta-analysis that had not previously been reported in a published review. Heterogeneity in the ways models were configured and described led to a focus on the attributes of effective palliative care and service elements effective at delivering these as the most meaningful unit of analysis, rather than models of care per se.

Attributes of effective palliative care

Table 5 contains a summary of the attributes of palliative care provision recommended by English-language national policies from OECD countries.

Table 5

Attributes of models for palliative care recommended by national policy documents from OECD countries available in English

Country	Attributes of palliative care service delivery recommended by national policy
Australia [23]	• Provide enhanced, coordinated support for carers, volunteers, communities of carers and carer respite
	• Provide coordinated, flexible local care delivery for people at the end of life regardless of where they live and address any barriers
	• Further improve the skill and confidence of the generalist workforce
	• Enhance online palliative care support to ensure adequate numbers of skilled palliative care specialist providers across all disciplines
	• Include end of life and palliative care competencies in all care worker training packages
	• Enhance and legitimise the role of specialist consultancy services in providing direct clinical advice, education and training, advocacy for end of life issues and training places
	• Record and track advance care planning within electronic health records
	• Develop sustainable models of quality palliative care in the private sector
	• Develop the role of the general practitioner in palliative care
	• Undertake further research and ongoing monitoring of the relative cost of care
Canada [79]	• Availability and access to services
	• Education for healthcare providers
	• Ethical, cultural and spiritual considerations
	• Public education and awareness
	• Support for family, caregiver and significant others
Ireland [80]	• Provision of physical, psychological, social and spiritual support, with a mix of skills, delivered through a multi-professional, collaborative team approach
	• Patients and families are supported and involved in management plans
	• Patients are encouraged to express their preference about where they wish to be cared for and where they wish to die
	• Carers and families are supported through the illness into bereavement
	• The overall whole time equivalent (WTE) SPC nurse to bed ratio should not be less than 1:1
	• In each day care centre, there should be a minimum of one WTE SPC nurse to every 7 daily attendees.
	• There should be a minimum of one WTE specialist palliative care nurse per 150 beds in each acute general hospital
	• There should be a minimum of one WTE specialist palliative care nurse in the community per 25,000 populations.
	• There should be at least one WTE physiotherapist per 10 beds in the specialist palliative care inpatient unit, with a minimum of one physiotherapist in each unit
	• There should be a minimum of one WTE community physiotherapist specialising in palliative care per 125,000 population. This post should be based in the specialist palliative care unit
	• There should be at least one WTE occupational therapist per 10 beds in the specialist palliative care inpatient unit, with a minimum of one occupational therapist in each unit.
	• There should be a minimum of one WTE community occupational therapist specialising in palliative care per 125,000 populations. This post should be based in the specialist palliative care unit
	• There should be at least one WTE social worker employed per 10 beds in the specialist palliative care unit, with a minimum of one social worker in each unit
	• There should be a minimum of one WTE community social worker specialising in palliative care per 125,000 population. This post should be based in the specialist palliative care unit
	• Specialist palliative care services in all other settings, including general hospitals and the community, should be based in or have formal links with the specialist palliative care unit
	• All specialist palliative care units should provide day care facilities for patients and carers
	• Appropriate transport should be provided for patients to and from the centre
	• There should be one point of entry to hospital services for palliative care patients, and subsequent referrals should be speedily organised
	• In Accident and Emergency, the patient’s condition should be rapidly assessed, and the patient should be referred to the appropriate team without delay
	• The specialist palliative care team in the community should be an inter-disciplinary consultant-led team
	• The specialist palliative care team should be based in, and led by, the specialist palliative care unit in the area
	• Specialist palliative care nurses should provide a seven-day service to patients in the community
	• Arrangements should be made for the transport of patients receiving palliative care to different care settings, when required
	• Bereavement support should begin early in the disease process, long before the death of the patient.
	• Multidisciplinary assessment to ensure that all needs are identified early and individualised plan is established
	• Allocate a care coordinator to each dying person
	• Provide access to clinical care for each dying person (medical services, respite care, counselling, etc.)
New Zealand [81]	• Provide access to support services for dying patients and their families
	• Ensure dying people and their families have access to essential palliative care (initial and specialized palliative acre)- at least one local palliative care service in each district health board
	• Provide induction and ongoing training for volunteers in the community assisting in palliative care
	• Provide flexible palliative care to meet varying and specific needs
	• Inform the public about PCS.

Our review of research evidence found that few studies have been conducted across care settings, with most focusing on the provision of palliative care either in the community, acute care or aged care settings.

Attributes of home-based models of palliative care

Most commonly, models of palliative care have been aimed at supporting home-based end of life care, optimising use of SPC expertise, avoiding futile treatments and providing support for family-care givers and community health professionals [-,-,61]. The most important characteristics of home-based models of care have been documented as those that support communication and coordination, engage and enable skill enhancement both for the primary palliative care team (including general practitioners [GPs]) and informal caregivers/patients, and clarify goals of care through advance care planning.

Attributes of acute care models of palliative care

Models of palliative care adopted in the acute care sector largely consist of specialist consultative services, in-patient palliative units/beds or nurse practitioner models [,]. In a landmark study from the US, SPC consultation was found to improve not only quality of life but also surival for patients with advanced lung cancer []. Specialist consultative service models have tended to focus on: 1) discussions about prognosis and goals of care; 2) pursuing documentation of advance directives; 3) discussion about foregoing specific treatments and/or diagnostic interventions; 4) family and patient support; 5) discharge planning; and 6) symptom management []. Consultative services provided by hospital palliative care teams have been shown to improve symptom control and quality of life, alleviate emotional burden and improve caregiver and patient satisfaction [,]. In addition they have resulted in hospital cost saving [,]. Currently, SPC in the US acute care setting is more likely to be available in larger hospitals, academic medical centres, not-for-profit hospitals, and Veterans Affairs (VA) hospitals compared to others []. Dedicated palliative care units have been established but struggle to meet increasing demands.

The increasing pressure on emergency departments and recognition of their role in end-of-life care highlight the dearth of community based services and failure of advance care planning [-]. Commonly, emergency presentations result from inadequate symptom control in the community and/or absence of adequate care givers [-]. In some countries, financial issues also act as an incentive for patients to access treatment through the emergency department in preference to other services []. A particular issue is the uncertainty that emergency department health professionals face when forced to make decisions in the absence of a detailed case history and advance care plans []. Studies have identified the capacity of coordinated models of care to decrease unnecessary emergency department usage and inappropriate admission, especially to intensive care [,].

Attributes of residential aged care models of palliative care

A setting that has proven especially challenging to improvements in quality of end of life care is residential aged care []. Older people in aged care are less likely to be referred to SPC services for consultation or ongoing management and more likely to have poor symptom control, unnecessary hospitalisations, sub-optimal communication, inadequate advance care planning and families who are dissatisfied with end of life care []. A recent Cochrane Review [] examining multi-component palliative care interventions for older people in nursing homes identified three studies [-] graded as ‘poor quality’ that provided weak evidence for the following model of palliative care elements: i) communication - identifying residents who would benefit from an SPC referral and negotiating this with their doctor and family []; ii) development of palliative care leadership teams, technical assistance meetings for team members, education in palliative care for all staff, plus feedback on performance []; and iii) targeted symptom control strategies to improve discomfort [101]. Systematic reviews on the efficacy of palliative care in dementia have identified a very limited evidence-base with which to develop appropriate interventions or services [,].

Attributes of care required during transitions

Models of care are faced with special challenges during transitions between care settings (community, aged care and hospital) where support is needed to avoid patients ‘falling through the cracks’ [] and/or when a rapid response is required in the context of quickly changing clinical status or patient preferences for place of care (e.g. wishing to return home while still possible) []. As patients and caregivers may lack knowledge of what services are available and how to access them [], navigating the transition from inpatient to community based care requires intensive effort and coordination to put management plans and caregiver support in place. The importance of supporting transitions is especially underscored in advanced dementia where, unless a care plan is in place, health professionals in acute care may lack awareness that a palliative approach is appropriate and initiate treatments inappropriately aimed at prolonging life with negative effects on quality of life [,]. Transitional care between paediatric and adult palliative care services is also a focal point requiring intensive support [].

Elements of effective models of palliative care

This review identified a number of dynamic elements that have been integrated into palliative care models in a range of care settings to enable access to appropriate services, improve communication and coordination between providers, enhance palliative care skills of non-specialist and informal carers, and inrease capacity to respond rapidly to individual patient needs and preferences as these change over time.

Case management

Case management is a recurring feature of many successful models [-45,-,-] that seeks to assess and meet the full range of each individual’s palliative care and other needs, including those relating to activities of daily living (e.g. house-work) and social wellbeing. As a result, case management frequently requires coordination of services beyond the healthcare sector, including social services and pastoral care. Case management is informed by the principles of patient-centred care []; as such, patients and families themselves often play an active role in determining which services they receive.

Shared care

Whilst defintions of shared care have varied (Table 2), it has been frequently reported as an element of effective palliative care delivery, utilised by a number of different models []. Characteristics of shared care seem to have commonly included: an identifiable lead clinician working together with health professionals from other disciplines, a focus on communication and coordination, and a rapid needs-based response and navigational strategies.

A model of care that incorporates case management and shared care and has been recommended by policy in Australia in the absence of evaluation data is the ‘pop up’ model. This model was originally developed to extend palliative care to rural/remote adult services and has since been recommended for paediatric palliative care [110]. The model develops a rapid-response team around the patient and their family drawn from primary, community-based and SPC services as required to address each client’s care plan. The model relies on excellent coordination, established networks and a system of triggers for referrals, re-assessments and re-referrals to provide intensive support over brief periods. In the UK, a coordinating role for a similar model has been assigned to paediatric oncology outreach nurse specialists to support children dying from cancer [,]. The outreach nurse role is described as ‘empowering the primary healthcare team through advice and direct patient care; providing an interface between primary, secondary, and tertiary care services; and coordinating services’ [] (p.4474).

Specialist outreach services

Internationally, specialist outreach services have been widely adopted to improve care outcomes for underserved populations through the establishment of: i) specialist clinics in urban primary care practices; ii) specialist clinics in rural hospitals where no specialist services exist; and iii) sub-specialist clinics in regional centres []. A Cochrane review examined efficacy of specialist outreach services in primary care and rural hospital settings implemented as one element of complex multifaceted interventions involving collaboration with primary care, education or other health services []. This review concluded that specialist outreach services can improve health outcomes, ensure delivery of more efficient and consistent evidence-based care, and reduce the use of inpatient services. The additional costs associated with the provision of specialist outreach appear to be balanced by improved health outcomes. None of the studies in the review included comparisons of palliative care specialist outreach services; their widespread use raises a need for evaluation [].

Managed clinical networks and/or health networks (clinical networks)

Across the globe, clinical networks have been integrated into many healthcare systems as part of a wider reform agenda to ensure that underserved populations and those with poorer outcomes have better access to quality, clinically-effective health services [,]. Clinical networks facilitate the formal linking of groups of health professionals and organisations from primary, secondary and tertiary care to work in a coordinated manner, unconstrained by existing professional and organisational boundaries [117]. Many of these boundaries are driven by funding models and geographical boundaries. Although conceptually appealing, few empirical studies have been undertaken to evaluate the effectiveness of clinical networks. A literature review identified eight empirical studies, including comparative and observational designs [117]. The review concluded that clinical networks - when formally established, with governance and guidelines in place - facilitated access to care for people in underserved communities.

Integrated care

Numerous studies identified the crucial role of integrated care [-]. Integration refers to coordination of disparate services centred on the needs of each individual patient and family with the aim of ensuring continuity of care. Integrated care requires that patients and families are involved in informed decision-making and goal setting. It is based on principles of advocacy and respect that provide seamless, continuous care from referral through to bereavement and across organizational boundaries. Positive effects of integrated care in paediatrics have been demonstrated not only for patient and family outcomes, but also on organisational efficiencies and staff satisfaction [].

Integrated care is especially important when supporting adults or children in the community, the enablement of which is increasingly prioritised by policy in many countries [118,119]. While the role of primary care at the end of life is important everywhere, palliative care support for primary healthcare is most essential in rural and regional areas, where the burden for coordinating and providing medical care falls predominantly on general practitioners (GPs) and nursing care to community nurses [,]. Data suggest that in some jurisdictions, including Australia, many GPs want to be involved in palliative care delivery but have decreasing capacity to undertake visits to homes or aged care facilities due to workload, time constraints and inadequate remuneration [,-]. Whilst there are no evidence-based models for palliative care in the primary healthcare setting [,], there is emerging evidence that the UK’s Gold Standards Framework (GST) has improved communication, collaboration, assessment and planning since its introduction in 2001 []. It should be noted, however, that the UK’s National Health Service has unique drivers not readily transferrable to countries such as Australia with different healthcare funding models and multiple jurisdictions.

Volunteers

Use of volunteers may have potential where informal caregivers are lacking; however, appropriate governance models are needed. Volunteer models have been used across a range of palliative care settings but evidence of implementation and evaluation is limited [-132].

Cost-effectiveness

Most studies that have examined cost-effectiveness of palliative care services versus usual care have found either no significant difference or palliative care to compare favourably [,45,]. However, there remains controversy as to appropriate methods of measuring cost-effectiveness in care for the dying. The limited survival of this patient population proves a challenge for cost-utility methods; most analyses to date have focused on costs alone, with little integration of data on efficacy. Furthermore, relatively little attention has been given to costs incurred by family caregivers who may absorb costs shed by the healthcare system via community care interventions aimed at avoiding hospital admissions. No data were found comparing cost-effectiveness of different models of palliative care beyond usual care.

Discussion

Like previous systematic reviews in palliative care [], we found few well-designed RCTs comparing models of palliative care with each another, or even with usual care. Systematic reviews have tended to include service-level interventions defined by setting (e.g. day care []) and/or the population served (e.g. people with dementia []) rather than by model of care. This consideration led us to redirect our synthesis away from whole models to focus on service elements consistently featured in models found to be effective. Of these elements, case management has been perhaps the most commonly supported [-45,-,-], albeit usually contributing to a complex intervention alongside a number of interacting components, different in each study. These considerations limit our ability to state with confidence that positive outcomes have resulted from case management per se.

Our review also identified the role required of political drivers in leveraging health system reform. Case management demands care across jurisdictions and care settings, which is not easy to achieve in a state/federal funding structure of the kind seen in Australia. The influence of local drivers also means that some models of care have been based on geo-political boundaries that may not be readily transferrable to other regions [,-].

Two new systematic reviews published since our search was conducted have provided important data on cost-effectiveness of palliative care. The value of home based palliative care has been demonstrated in a recent meta-analysis which found that receiving home palliative care doubles the odds of dying at home and reduces symptom burden, especially for patients with cancer, without having an adverse impact on caregiver grief []. A systematic review using narrative synthesis concluded that palliative care of all kinds was generally found to be cost-effective compared with usual care, usually statistically so [].

Limitations and areas for future research

The rapid nature of the current review is associated with a number of methodological limitations [,]. Limiting the scope of our search and associated terms is likely to have resulted in relevant references having been missed and increased the risk of publication and country/language biases []. Our inclusion criteria and approach to synthesis favoured reviews over original research and relied on a somewhat ‘blunt’ comparison that did not control for overlap between reviews. Limitations in time and resources also required us to forego the level of documentation commonly associated with full systematic reviews. These limitations were moderated somewhat by the use of the online resource ‘CareSearch’ which was designed by experts specifically to identify palliative care evidence [] and quality assessment involving experts, including the authors of key research []. However, the emphasis we placed on models of care relevant to the Australian healthcare system will inevitably limit applicability of findings to some other countries.

As mentioned, the current review was also limited by variations in reporting of service models that precluded comparison and accumulation of evidence for any given model. The term ‘model of care’ was itself used inconsistently and relatively infrequently in the literature; a Medline search using terms for ‘palliative care’ combined with ‘model(s) of care’ returned only 1% of articles returned by searching for palliative care alone. Inconsistency and incompleteness in reporting impairs not only synthesis of research but also replication of successful models in future evaluations and implementation into practice. Researchers are encouraged to follow guidance on key variables to report that would enable greater comparability and support replication and refinement of models in research and practice [].

The literature’s focus on elements rather than models raises important questions about how these elements might interact to the betterment or detriment of care quality and outcomes. The pop up model is one example of a model of care that has been recommended by policy without evidence for its effectiveness as a whole but rather an assumption that effective elements can be combined to optimise benefit [110]. Future evaluations should use factorial designs and process measures to clarify causal mechanisms between elements and identify influential contextual factors to inform ongoing development and tailoring to local needs and resources [].

Finally, our review was limited by the problem we encountered in mapping between evidence at the outcome levels of patient (e.g. symptoms), caregiver (e.g. satisfaction), provider (e.g. knowledge of palliative care needs) and service (e.g. hospital days). A recent systematic review identified 15 patient-level domains alone, including quality of life, quality of care, symptoms and problems, performance status, psychological symptoms, decision-making and communication, place of death, stage of disease, mortality and survival, distress and wish to die, spirituality and personality, disease-specific outcomes, clinical features, meaning in life and needs []. The plethora of outcomes and associated measures is a recognised barrier to comparability between studies [-]. Whilst the WHO palliative care definition provides a framework for evaluating palliative care at the levels of the patient, provider and system, this has not yet been undertaken for any known model of palliative care. There is also a need for comprehensive economic evaluations that include descriptions of patient preferences as well as consideration of costs incurred by family caregivers and sub-group analyses examining the influence of disease and socio-demographic factors [,].

Conclusion

Heterogeneity in definitions and reporting mechanisms limit the focus of conclusions from this rapid review to attributes and elements of successful palliative care services rather than whole models. Best practice palliative care should be accessible to all who need it, tailored to individual patient and family’s palliative care needs in a timely manner, and extend beyond organisational and disciplinary boundaries as required via strategies that support communication and coordination. Population-based models of palliative care should therefore include elements that support case management via integration of SPC with primary and community care services, and enable transitions across settings, including residential aged care.

While palliative care models may have once been relatively homogenous, dynamic models are increasingly required to accommodate rapidly changing population demands and health system structure and drivers. Access to specialist services for rural and regional patients and carers has been identified as especially in need of targeted intervention. The current focus on medical and nursing service delivery should also be broadened to incorporate services addressing social and environmental determinants of health as required.

Increasing complexity in service configuration warrants consideration by future research of the roles played by contextual factors such as funding and policy in order to inform planning at the population level. Research should ideally test the impact of changes over time both within and between regions using standard measures of process and outcomes.

Abbreviations

GP: General practitioner; SPC: Specialist palliative care.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

All authors contributed to design and conduct of the review, synthesis and interpretation of results and reporting. All authors read and approved the final manuscript.

Pre-publication history

The pre-publication history for this paper can be accessed here:

Funding

The research team was commissioned by the Sax Institute to undertake this rapid review for New South Wales Ministry of Health in April 2012.

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(Redirected from Steampunk music)

A steampunk-themed photo

Steampunk outfit with leather vest, heavy gun, vambrace, backpack time machine, mask, and Victorian clothes

'Maison tournante aérienne' (aerial rotating house) by Albert Robida for his book Le Vingtième Siècle, a 19th-century conception of life in the 20th century

Steampunk is a subgenre of science fiction or science fantasy that incorporates technology and aesthetic designs inspired by 19th-century industrialsteam-powered machinery.^[1][2] Although its literary origins are sometimes associated with the cyberpunk genre,^[3] steampunk works are often set in an alternative history of the 19th century British Victorian era or the American 'Wild West', in a future during which steam power has maintained mainstream usage, or in a fantasy world that similarly employs steam power. However, steampunk and neo-Victorian are different in that the neo-Victorian movement does not extrapolate on technology while technology is a key aspect of steampunk.^[4]

Steampunk most recognizably features anachronistic technologies or retrofuturistic inventions as people in the 19th century might have envisioned them, and is likewise rooted in the era's perspective on fashion, culture, architectural style, and art.^{[citation needed]} Such technologies may include fictional machines like those found in the works of H. G. Wells and Jules Verne,^[5] or of the modern authors Philip Pullman, Scott Westerfeld, Stephen Hunt, and China Miéville.^{[original research?]} Other examples of steampunk contain alternative-history-style presentations of such technology as steam cannons, lighter-than-airairships, analogue computers, or such digital mechanical computers as Charles Babbage's Analytical Engine.^{[citation needed]}

Steampunk may also incorporate additional elements from the genres of fantasy, horror, historical fiction, alternate history, or other branches of speculative fiction, making it often a hybrid genre.^{[citation needed]} The first known appearance of the term steampunk was in 1987, though it now retroactively refers to many works of fiction created as far back as the 1950s or 1960s.^{[citation needed]}

Steampunk also refers to any of the artistic styles, clothing fashions, or subcultures that have developed from the aesthetics of steampunk fiction, Victorian-era fiction, art nouveau design, and films from the mid-20th century.^[6] Various modern utilitarian objects have been modded by individual artisans into a pseudo-Victorian mechanical 'steampunk' style, and a number of visual and musical artists have been described as steampunk.^[7]

• 1History
• 2Art, entertainment, and media
  • 2.3Literature
    • 2.3.1Steampunk settings
• 3Culture and community

History[edit]

Precursors[edit]

Print (c. 1902) by Albert Robida showing a futuristic view of air travel over Paris in the year 2000 as people leave the opera

Steampunk is influenced by and often adopts the style of the 19th-century scientific romances of Jules Verne, H. G. Wells, Mary Shelley, and Edward S. Ellis's The Steam Man of the Prairies.^[8] Several more modern works of art and fiction significant to the development of the genre were produced before the genre had a name. Titus Alone (1959), by Mervyn Peake, is widely regarded by scholars as the first novel in the genre proper,^{[9][10][page needed][11]} while others point to Michael Moorcock's 1971 novel The Warlord of the Air,^[12][13][14] which was heavily influenced by Peake's work. The film Brazil (1985) was an important early cinematic influence that helped codify the aesthetics of the genre. The Adventures of Luther Arkwright was an early (1970s) comic version of the Moorcock-style mover between timestreams.^[15][16]

In fine art, Remedios Varo's paintings combine elements of Victorian dress, fantasy, and technofantasy imagery.^{[17][page needed]} In television, one of the earliest manifestations of the steampunk ethos in the mainstream media was the CBS television series The Wild Wild West (1965–69), which inspired the later film.^[8][18]

Origin of the term[edit]

Although many works now considered seminal to the genre were published in the 1960s and 1970s, the term steampunk originated in the late 1980s as a tongue-in-cheek variant of cyberpunk. It was coined by science fiction author K. W. Jeter,^[19] who was trying to find a general term for works by Tim Powers (The Anubis Gates, 1983), James Blaylock (Homunculus, 1986), and himself (Morlock Night, 1979, and Infernal Devices, 1987)—all of which took place in a 19th-century (usually Victorian) setting and imitated conventions of such actual Victorian speculative fiction as H. G. Wells' The Time Machine. In a letter to science fiction magazine Locus, printed in the April 1987 issue, Jeter wrote:

Dear Locus,

Enclosed is a copy of my 1979 novel Morlock Night; I'd appreciate your being so good as to route it to Faren Miller, as it's a prime piece of evidence in the great debate as to who in 'the Powers/Blaylock/Jeter fantasy triumvirate' was writing in the 'gonzo-historical manner' first. Though of course, I did find her review in the March Locus to be quite flattering.

Personally, I think Victorian fantasies are going to be the next big thing, as long as we can come up with a fitting collective term for Powers, Blaylock and myself. Something based on the appropriate technology of the era; like 'steam-punks,' perhaps..

— K.W. Jeter^[20][21]

Modern steampunk[edit]

While Jeter's Morlock Night and Infernal Devices, Powers' The Anubis Gates, and Blaylock's Lord Kelvin's Machine were the first novels to which Jeter's neologism would be applied, the three authors gave the term little thought at the time.^[22]:48 They were far from the first modern science fiction writers to speculate on the development of steam-based technology or alternative histories. Keith Laumer's Worlds of the Imperium (1962) and Ronald W. Clark's Queen Victoria's Bomb (1967) apply modern speculation to past-age technology and society.^{[23][page needed]}Michael Moorcock's Warlord of the Air (1971)^[24] is another early example. Professor Finbarr Calamitous quote is relevant here; 'SteamPunk: Colonizing the Past so we can dream the future'. Harry Harrison's novel A Transatlantic Tunnel, Hurrah! (1973) portrays a British Empire of an alternative year 1973, full of atomic locomotives, coal-powered flying boats, ornate submarines, and Victorian dialogue. The Adventures of Luther Arkwright (mid-1970s) was the first steampunk comic.^{[citation needed]} In February 1980, Richard A. Lupoff and Steve Stiles published the first 'chapter' of their 10-part comic stripThe Adventures of Professor Thintwhistle and His Incredible Aether Flyer.^[25]

The first use of the word in a title was in Paul Di Filippo's 1995 Steampunk Trilogy,^[26] consisting of three short novels: 'Victoria', 'Hottentots', and 'Walt and Emily', which, respectively, imagine the replacement of Queen Victoria by a human/newt clone, an invasion of Massachusetts by Lovecraftian monsters, and a love affair between Walt Whitman and Emily Dickinson.

Truth Coffee, a steampunk café in Cape Town

Relationships to retrofuturism, DIY craft and making[edit]

Superficially, steampunk may resemble retrofuturism. Indeed, both sensibilities recall 'the older but still modern eras in which technological change seemed to anticipate a better world, one remembered as relatively innocent of industrial decline.'^[2]

One of steampunk's most significant contributions is the way in which it mixes digital media with traditional handmade art forms. As scholars Rachel Bowser and Brian Croxall put it, 'the tinkering and tinker-able technologies within steampunk invite us to roll up our sleeves and get to work re-shaping our contemporary world.'^[27] In this respect, steampunk bears more in common with DIY craft and making.^[28]

Art, entertainment, and media[edit]

Art and design[edit]

Paris metro station 'Arts et Métiers'

Aura Crystall Instrument - 1987 - by Marc van den Broek

Steampunk locomotive outside Steampunk HQ, Oamaru, New Zealand

Many of the visualisations of steampunk have their origins with, among others, Walt Disney's film 20,000 Leagues Under the Sea (1954),^[29] including the design of the story's submarine the Nautilus, its interiors, and the crew's underwater gear; and George Pal's film The Time Machine (1960), especially the design of the time machine itself. This theme is also carried over to Six Flags Magic Mountain and Disney parks, in the themed area the 'Screampunk District' at Six Flags Magic Mountain and in the designs of The Mysterious Island section of Tokyo DisneySea theme park and Disneyland Paris' Discoveryland area.^{[citation needed]}

Aspects of steampunk design emphasise a balance between form and function.^[30] In this it is like the Arts and Crafts Movement. But John Ruskin, William Morris, and the other reformers in the late nineteenth century rejected machines and industrial production. On the other hand, steampunk enthusiasts present a 'non-luddite critique of technology'.^[31]

Various modern utilitarian objects have been modified by enthusiasts into a pseudo-Victorian mechanical 'steampunk' style.^[16][32] Examples include computer keyboards and electric guitars.^[33] The goal of such redesigns is to employ appropriate materials (such as polished brass, iron, wood, and leather) with design elements and craftsmanship consistent with the Victorian era,^[24][34] rejecting the aesthetic of industrial design.^[30]

In 1994, the Paris Metro station at Arts et Métiers was redesigned by Belgian artist Francois Schuiten in steampunk style, to honor the works of Jules Verne. The station is reminiscent of a submarine, sheathed in brass with giant cogs in the ceiling and portholes that look out onto fanciful scenes.^[35][36]

Paul St George's Telectroscopeinstallation at London City Hall (May 24, 2008)

The artist group Kinetic Steam Works^[37] brought a working steam engine to the Burning Man festival in 2006 and 2007.^[38] The group's founding member, Sean Orlando, created a Steampunk Tree House (in association with a group of people who would later form the Five Ton Crane Arts Group^[39]) that has been displayed at a number of festivals.^[40][41] The Steampunk Tree House is now permanently installed at the Dogfish Head Brewery in Milton, Delaware.^[42]

The Neverwas Haul is a three-story, self-propelled mobile art vehicle built to resemble a Victorian house on wheels. Designed by Shannon O’Hare, it was built by volunteers in 2006 and presented at the Burning Man festival from 2006 through 2015.^[43] When fully built, the Haul propelled itself at a top speed of 5 miles per hour and required a crew of ten people to operate safely. Currently, the Neverwas Haul makes her home at Obtainium Works, an 'art car factory' in Vallejo, CA, owned by O’Hare and home to several other self-styled 'contraptionists'.^[44]

In May–June 2008, multimedia artist and sculptor Paul St George exhibited outdoor interactive video installations linking London and Brooklyn, New York, in a Victorian era-styled telectroscope.^[45][46] Utilizing this device, New York promoter Evelyn Kriete organised a transatlantic wave between steampunk enthusiasts from both cities,^[47] prior to White Mischief'sAround the World in 80 Days steampunk-themed event.^[48]

Tim Wetherell's Clockwork Universe sculpture at Questacon, Canberra, Australia (September 24, 2009)

In 2009, for Questacon, artist Tim Wetherell created a large wall piece that represented the concept of the clockwork universe. This steel artwork contains moving gears, a working clock, and a movie of the moon's terminator in action. The 3D moon movie was created by Antony Williams.^[49]

From October 2009 through February 2010, the Museum of the History of Science, Oxford, hosted the first major exhibition of steampunk art objects, curated and developed by New York artist and designer Art Donovan,^[50] who also exhibited his own 'electro-futuristic' lighting sculptures, and presented by Dr. Jim Bennett, museum director.^[51] From redesigned practical items to fantastical contraptions, this exhibition showcased the work of eighteen steampunk artists from across the globe. The exhibition proved to be the most successful and highly attended in the museum's history and attracted more than eighty thousand visitors. The event was detailed in the official artist's journal The Art of Steampunk, by curator Donovan.^[52]

In November 2010, The Libratory Steampunk Art Gallery^[53] was opened by Damien McNamara in Oamaru, New Zealand. Created from papier-mâché to resemble a large subterranean cave and filled with industrial equipment from yesteryear, rayguns, and general steampunk quirks, its purpose is to provide a place for steampunkers in the region to display artwork for sale all year long. A year later, a more permanent gallery, Steampunk HQ, was opened in the former Meeks Grain Elevator Building across the road from The Woolstore, and has since become a notable tourist attraction for Oamaru.^[54]

In 2012, the Mobilis in Mobili: An Exhibition of Steampunk Art and Appliance made its debut. Originally located at New York City's Wooster Street Social Club (itself the subject of the television series NY Ink), the exhibit featured working steampunk tattoo systems designed by Bruce Rosenbaum, of ModVic and owner of the Steampunk House,^[55] Joey 'Dr. Grymm' Marsocci,^[33] and Christopher Conte.^[56] with different approaches.^[29] '[B]icycles, cell phones, guitars, timepieces and entertainment systems'^[56] rounded out the display.^[33] The opening night exhibition featured a live performance by steampunk band Frenchy and the Punk.^[57]

Author G. D. Falksen, wearing a steampunk-styled arm prosthesis (created by Thomas Willeford), exemplifying one take on steampunk fashion

Fashion[edit]

Roku Device Models

Model Ulorin Vex wearing post-apocalyptic steampunk attire designed by Kato

Steampunk fashion has no set guidelines but tends to synthesize modern styles with influences from the Victorian era. Such influences may include bustles, corsets, gowns, and petticoats; suits with waistcoats, coats, top hats^[58] and bowler hats (themselves originating in 1850 England), tailcoats and spats; or military-inspired garments. Steampunk-influenced outfits are usually accented with several technological and 'period' accessories: timepieces, parasols, flying/driving goggles,^[59] and ray guns. Modern accessories like cell phones or music players can be found in steampunk outfits, after being modified to give them the appearance of Victorian-era objects. Post-apocalyptic elements, such as gas masks, ragged clothing, and tribal motifs, can also be included. Aspects of steampunk fashion have been anticipated by mainstream high fashion, the Lolita and aristocrat styles, neo-Victorianism, and the romantic goth subculture.^[15][60][61]

In 2005, Kate Lambert, known as 'Kato', founded the first steampunk clothing company, 'Steampunk Couture',^[62] mixing Victorian and post-apocalyptic influences. In 2013, IBM predicted, based on an analysis of more than a half million public posts on message boards, blogs, social media sites, and news sources, 'that 'steampunk,' a subgenre inspired by the clothing, technology and social mores of Victorian society, will be a major trend to bubble up and take hold of the retail industry'.^[63][64] Indeed, high fashion lines such as Prada,^[65] Dolce & Gabbana, Versace, Chanel,^[66] and Christian Dior^[64] had already been introducing steampunk styles on the fashion runways. And in episode 7 of Lifetime's 'Project Runway: Under the Gunn' reality series, contestants were challenged to create avant-garde 'steampunk chic' looks.^[67]America's Next Top Model tackled Steampunk fashion in a 2012 episode where models competed in a Steampunk themed photo shoot, posing in front of a steam train while holding a live owl.^{[68][unreliable source]}

Literature[edit]

The educational book Elementary BASIC - Learning to Program Your Computer in BASIC with Sherlock Holmes (1981), by Henry Singer and Andrew Ledgar, may have been the first fictional work to depict the use of Charles Babbage's Analytical Engine in an adventure story. The instructional book, aimed at young programming students, depicts Holmes using the engine as an aid in his investigations, and lists programs that perform simple data processing tasks required to solve the fictional cases. The book even describes a device that allows the engine to be used remotely, over telegraph lines, as a possible enhancement to Babbage's machine. Companion volumes—Elementary Pascal - Learning to Program Your Computer in Pascal with Sherlock Holmes and From Baker Street to Binary - An Introduction to Computers and Computer Programming with Sherlock Holmes—were also written.

The August 1927 issue of Amazing Stories featuring work by H. G. Wells

In 1988, the first version of the science fiction roleplaying gameSpace: 1889 was published. The game is set in an alternative history in which certain now discredited Victorian scientific theories were probable and led to new technologies. Contributing authors included Frank Chadwick, Loren Wiseman, and Marcus Rowland.^[69]

William Gibson and Bruce Sterling's novel The Difference Engine (1990) is often credited with bringing about widespread awareness of steampunk.^[18][70] This novel applies the principles of Gibson and Sterling's cyberpunk writings to an alternative Victorian era where Ada Lovelace and Charles Babbage's proposed steam-powered mechanical computer, which Babbage called a difference engine (a later, more general-purpose version was known as an analytical engine), was actually built, and led to the dawn of the information age more than a century 'ahead of schedule'. This setting was different from most steampunk settings in that it takes a dim and dark view of this future, rather than the more prevalent utopian versions.

Nick Gevers's original anthology Extraordinary Engines (2008) features newer steampunk stories by some of the genre's writers, as well as other science fiction and fantasy writers experimenting with neo-Victorian conventions. A retrospective reprint anthology of steampunk fiction was released, also in 2008, by Tachyon Publications. Edited by Ann and Jeff VanderMeer and appropriately entitled Steampunk, it is a collection of stories by James Blaylock, whose 'Narbondo' trilogy is typically considered steampunk; Jay Lake, author of the novel Mainspring, sometimes labeled 'clockpunk';^[71] the aforementioned Michael Moorcock; as well as Jess Nevins, known for his annotations to The League of Extraordinary Gentlemen (first published in 1999).

Younger readers have also been targeted by steampunk themes, by authors such as Philip Reeve and Scott Westerfeld.^[72] Reeve's quartet Mortal Engines is set far in Earth's future where giant moving cities consume each other in a battle for resources, a concept Reeve coined as Municipal Darwinism. Westerfeld's Leviathan trilogy is set during an alternate First World War fought between the 'clankers' (Central Powers), who use steam technology, and 'darwinists' (Allied Powers), who use genetically engineered creatures instead of machines.

'Mash-ups' are also becoming increasingly popular in books aimed at younger readers, mixing steampunk with other genres. Suzanne Lazear's Aether Chronicles series mixes steampunk with faeries, and The Unnaturalists, by Tiffany Trent, combines steampunk with mythological creatures and alternate history.^[73]

While most of the original steampunk works had a historical setting,^{[citation needed]} later works often place steampunk elements in a fantasy world with little relation to any specific historic era. Historical steampunk tends to be science fiction that presents an alternate history; it also contains real locales and persons from history with alternative fantasy technology. 'Fantasy-world steampunk', such as China Miéville's Perdido Street Station, Alan Campbell'sScar Night, and Stephen Hunt's Jackelian novels, on the other hand, presents steampunk in a completely imaginary fantasy realm, often populated by legendary creatures coexisting with steam-era and other anachronistic technologies. However, the works of China Miéville and similar authors are sometimes referred to as belonging to the 'New Weird' rather than steampunk.

Self-described author of 'far-fetched fiction' Robert Rankin has increasingly incorporated elements of steampunk into narrative worlds that are both Victorian and re-imagined contemporary. In 2009, he was made a Fellow of the Victorian Steampunk Society.^[74]

The comic book series Hellboy, created by Mike Mignola, and the two Hellboy films featuring Ron Perlman and directed by Guillermo del Toro, all have steampunk elements. In the comic book and the first (2004) film, Karl Ruprecht Kroenen is a Nazi SS scientist who has an addiction to having himself surgically altered, and who has many mechanical prostheses, including a clockwork heart. The character Johann Krauss is featured in the comic and in the second film, Hellboy II: The Golden Army (2008), as an ectoplasmic medium (a gaseous form in a partly mechanical suit). This second film also features the Golden Army itself, which is a collection of 4,900 mechanical steampunk warriors.

Steampunk settings[edit]

Alternative world[edit]

Steampunk-style composite apparatus

Since the 1990s, the application of the steampunk label has expanded beyond works set in recognisable historical periods, to works set in fantasy worlds that rely heavily on steam- or spring-powered technology.^[18] One of the earliest short stories relying on steam-powered flying machines is 'The Aerial Burglar' of 1844.^[75] An example from juvenile fiction is The Edge Chronicles by Paul Stewart and Chris Riddell.

Fantasy steampunk settings abound in tabletop and computer role-playing games. Notable examples include Skies of Arcadia,^[76]Rise of Nations: Rise of Legends,^[77] and Arcanum: Of Steamworks and Magick Obscura.^[8]

One of the first steampunk novels set in a Middle Earth-like world was the Forest of Boland Light Railway by BB, about gnomes who build a steam locomotive. 50 years later, Terry Pratchett wrote the Discworld novel Raising Steam, about the ongoing industrial revolution and railway mania in Ankh-Morpork.

The gnomes and goblins in World of Warcraft also have technological societies that could be described as steampunk,^[78] as they are vastly ahead of the technologies of men, but still run on steam and mechanical power.

The Dwarves of the Elder Scrolls series, described therein as a race of Elves called the Dwemer, also use steam powered machinery, with gigantic brass-like gears, throughout their underground cities. However, magical means are used to keep ancient devices in motion despite the Dwemer's ancient disappearance.^[79]

The 1998 game Thief: The Dark Project, as well as the other sequels including its 2014 reboot, feature heavy steampunk-inspired architecture, setting, and technology.

Amidst the historical and fantasy subgenres of steampunk is a type that takes place in a hypothetical future or a fantasy equivalent of our future involving the domination of steampunk-style technology and aesthetics. Examples include Jean-Pierre Jeunet and Marc Caro's The City of Lost Children (1995), Turn A Gundam (1999–2000), Trigun,^[80] and Disney's film Treasure Planet (2002). In 2011, musician Thomas Dolby heralded his return to music after a 20-year hiatus with an online steampunk alternate fantasy world called the Floating City, to promote his album A Map of the Floating City.^[8]

American West[edit]

Another setting is 'Western' steampunk, which overlaps with both the Weird West and Science fiction Western subgenres. One of the earliest steampunk books set in America was The Steam Man of the Prairies by Edward S. Ellis. Several other categories have arisen, sharing similar names, including dieselpunk, clockwork-punk, and others. Most of these terms were coined as supplements to the GURPS role playing game, and are not used in other contexts.^[81]

Fantasy and horror[edit]

A steampunk horror costume

Kaja Foglio introduced the term 'Gaslight Romance',^[22]:78gaslamp fantasy, which John Clute and John Grant define as 'steampunk stories .. most commonly set in a romanticised, smoky, 19th-century London, as are Gaslight Romances. But the latter category focuses nostalgically on icons from the late years of that century and the early years of the 20th century—on Dracula, Jekyll and Hyde, Jack the Ripper, Sherlock Holmes and even Tarzan—and can normally be understood as combining supernatural fiction and recursive fantasy, though some gaslight romances can be read as fantasies of history.'^[82] Author/artist James Richardson-Brown^[83] coined the term steamgoth to refer to steampunk expressions of fantasy and horror with a 'darker' bent.

Post-apocalyptic[edit]

Mary Shelley's The Last Man, set near the end of the 21st century after a plague had brought down civilization, was probably the ancestor of post-apocalyptic steampunk literature. Post-apocalyptic steampunk is set in a world where some cataclysm has precipitated the fall of civilization and steam power is once again ascendant, such as in Hayao Miyazaki's post-apocalyptic anime Future Boy Conan (1978),^[80] where a war fought with superweapons has devastated the planet. Robert Brown's novel, The Wrath of Fate (as well as much of Abney Park's music) is set in A Victorianesque world where an apocalypse was set into motion by a time-traveling mishap. Cherie Priest's Boneshaker series is set in a world where a zombie apocalypse happened during the Civil War era. The Peshawar Lancers by S.M. Stirling is set in a post-apocalyptic future in which a meteor shower in 1878 caused the collapse of Industrialized civilization. The movie 9 (which might be better classified as 'stitchpunk' but was largely influenced by steampunk)^[84] is also set in a post-apocalyptic world after a self-aware war machine ran amok. Steampunk Magazine even published a book called A Steampunk's Guide to the Apocalypse, about how steampunks could survive should such a thing actually happen.

Victorian[edit]

Original illustration of Jules Verne's Nautilus engine room

In general, this category includes any recent science fiction that takes place in a recognizable historical period (sometimes an alternate history version of an actual historical period) in which the Industrial Revolution has already begun, but electricity is not yet widespread, 'usually Britain of the early to mid-nineteenth century or the fantasized Wild West-era United States',^[85] with an emphasis on steam- or spring-propelled gadgets. The most common historical steampunk settings are the Victorian and Edwardian eras, though some in this 'Victorian steampunk' category are set as early as the beginning of the Industrial Revolution and as late as the end of World War I.

Some examples of this type include the novel The Difference Engine,^[86] the comic book series League of Extraordinary Gentlemen, the Disney animated film Atlantis: The Lost Empire,^[8]Scott Westerfeld's Leviathan trilogy,^[87] and the roleplaying gameSpace: 1889.^[8] The anime film Steamboy (2004) is another good example of Victorian steampunk, taking place in an alternate 1866 where steam technology is far more advanced than it ever was in real life.^[88] Some, such as the comic series Girl Genius,^[8] have their own unique times and places despite partaking heavily of the flavor of historic settings. Other comic series are set in a more familiar London, as in the Victorian Undead, which has Sherlock Holmes, Doctor Watson, and others taking on zombies, Doctor Jekyll and Mister Hyde, and Count Dracula, with advanced weapons and devices.

Karel Zeman's film The Fabulous World of Jules Verne (1958) is a very early example of cinematic steampunk. Based on Jules Verne novels, Zeman's film imagines a past that never was, based on those novels.^[89] Other early examples of historical steampunk in cinema include Hayao Miyazaki's anime films such as Laputa: Castle in the Sky (1986) and Howl's Moving Castle (2004), which contain many archetypal anachronisms characteristic of the steampunk genre.^[90][91]The Steampunk Bible called Laputa: Castle in the Sky 'one of the first modern steampunk classics.'^[92]

'Historical' steampunk usually leans more towards science fiction than fantasy, but a number of historical steampunk stories have incorporated magical elements as well. For example, Morlock Night, written by K. W. Jeter, revolves around an attempt by the wizard Merlin to raise King Arthur to save the Britain of 1892 from an invasion of Morlocks from the future.^[18]

Paul Guinan's Boilerplate, a 'biography' of a robot in the late 19th century, began as a website that garnered international press coverage when people began believing that Photoshop images of the robot with historic personages were real.^[93] The site was adapted into the illustrated hardbound book Boilerplate: History's Mechanical Marvel, which was published by Abrams in October 2009.^[94] Because the story was not set in an alternative history, and in fact contained accurate information about the Victorian era,^[95] some^[specify] booksellers referred to the tome as 'historical steampunk'.

Asian (silkpunk)[edit]

Fictional settings inspired by Asian rather than Western history have been called 'silkpunk'. The term appears to originate with the author Ken Liu, who defined it as 'a blend of science fiction and fantasy [that] draws inspiration from classical East Asian antiquity', with a 'technology vocabulary (..) based on organic materials historically important to East Asia (bamboo, paper, silk) and seafaring cultures of the Pacific (coconut, feathers, coral)', rather than the brass and leather associated with steampunk.^[96] Other authors whose work has been described as silkpunk are JY Yang^[97] and Elizabeth Bear.

Music[edit]

Robert Brown and Finn Von Claret from Abney Park

Steampunk music is very broadly defined. Abney Park’s lead singer Robert Brown defined it as 'mixing Victorian elements and modern elements'. There is a broad range of musical influences that make up the Steampunk sound, from industrial dance and world music^[61] to folk rock, dark cabaret to straightforward punk,^[98]Carnatic^[99] to industrial, hip-hop to opera (and even industrial hip-hop opera),^[100][101]darkwave to progressive rock, barbershop to big band.

Joshua Pfeiffer (of Vernian Process) is quoted as saying, 'As for Paul Roland, if anyone deserves credit for spearheading Steampunk music, it is him. He was one of the inspirations I had in starting my project. He was writing songs about the first attempt at manned flight, and an Edwardian airship raid in the mid-80s long before almost anyone else..'^[102]Thomas Dolby is also considered one of the early pioneers of retro-futurist (i.e., Steampunk and Dieselpunk) music.^[103][104]Amanda Palmer was once quoted as saying, 'Thomas Dolby is to Steampunk what Iggy Pop was to Punk!'^[105]

Steampunk has also appeared in the work of musicians who do not specifically identify as Steampunk. For example, the music video of 'Turn Me On', by David Guetta and featuring Nicki Minaj, takes place in a Steampunk universe where Guetta creates human droids. Another music video is 'The Ballad of Mona Lisa', by Panic! at the Disco, which has a distinct Victorian Steampunk theme. A continuation of this theme has in fact been used throughout the 2011 album Vices & Virtues, in the music videos, album art, and tour set and costumes. In addition, the album Clockwork Angels (2012) and its supporting tour by progressive rock band Rush contain lyrics, themes, and imagery based around Steampunk. Similarly, Abney Park headlined the first 'Steamstock' outdoor steampunk music festival in Richmond, California, which also featured Thomas Dolby, Frenchy and the Punk, Lee Presson and the Nails, Vernian Process, and others.^[104]

The music video for the Lindsey Stirling song 'Roundtable Rival', has a Western Steampunk setting.

Television and films[edit]

'20,000 Leagues Under the Sea: Submarine Voyage' ride at Walt Disney World (1971-1994)

Arliss Loveless character in steampunk wheelchair costume from the 1999 film Wild Wild West

The Fabulous World of Jules Verne (1958) and The Fabulous Baron Munchausen (1962), both directed by Karel Zeman have steampunk elements. The 1965 television series The Wild Wild West, as well as the 1999 film of the same name, features many elements of advanced steam-powered technology set in the Wild West time period of the United States.

Two Years' Vacation (or The Stolen Airship) (1967) directed by Karel Zeman

The BBC series Doctor Who also incorporates steampunk elements. During season 14 of the show (in 1976), the formerly futuristic looking interior set was replaced with a Victorian-styled wood-panel and brass affair.^[106] In the 1996 American co-production, the TARDIS interior was re-designed to resemble an almost Victorian library with the central control console made up of an eclectic array of anachronistic objects. Modified and streamlined for the 2005 revival of the series, the TARDIS console continued to incorporate steampunk elements, including a Victorian typewriter and gramophone. Several storylines can be classed as steampunk, for example: The Evil of the Daleks (1966), wherein Victorian scientists invent a time travel device.^[107]

Dinner for Adele (1977), directed by Oldřich Lipský

The 1979 film Time After Time has Herbert George 'H.G.' Wells following a surgeon named John Leslie Stevenson into the future, as John is suspected of being Jack the Ripper. Both separately use Wells's time machine to travel.

The Mysterious Castle in the Carpathians (1981), directed by Oldřich Lipský

The 1982 American TV series Q.E.D. is set in Edwardian England, stars Sam Waterston as Professor Quentin Everett Deverill (from whose initials, by which he is primarily known, the series title is derived, initials which also stand for the Latin phrase quod erat demonstrandum, which translates as 'which was to be demonstrated'). The Professor is an inventor and scientific detective, in the mold of Sherlock Holmes.

The plot of the Soviet film Kin-dza-dza! (1986) centers on a desert planet, depleted of its resources, where an impoverished dog-eat-dog society uses steam-punk machines, the movements and functions of which defy earthly logic.

In making his 1986 Japanese film Castle in the Sky, Hayao Miyazaki was heavily influenced by steampunk culture, the film featuring various air ships and steam-powered contraptions as well as a mysterious island that floats through the sky, accomplished not through magic as in most stories, but instead by harnessing the physical properties of a rare crystal—analogous to the lodestone used in the Laputa of Swift'sGulliver's Travels—augmented by massive propellers, as befitting the Victorian motif.^[108]

The first 'Wallace & Gromit' animation 'A Grand Day Out' (1989) features a space rocket in the steampunk style.^{[citation needed]}

The Adventures of Brisco County, Jr., a 1993 Fox Network TV science fiction-western set in the 1890s, features elements of steampunk as represented by the character Professor Wickwire, whose inventions were described as 'the coming thing'.^[109]

The short-lived 1995 TV show Legend, on UPN, set in 1876 Arizona, features such classic inventions as a steam-driven 'quadrovelocipede', trigoggle and night-vision goggles (à la teslapunk), and stars John de Lancie as a thinly disguised Nikola Tesla.^{[citation needed]}

Alan Moore's and Kevin O'Neill's 1999 The League of Extraordinary Gentlemengraphic novel series (and the subsequent 2003 film adaption) greatly popularised the steampunk genre.^[60]

Steamboy (2004) is a Japanese animated action film directed and co-written by Katsuhiro Otomo (Akira). It is a retro science-fiction epic set in a Steampunk Victorian England. It features steamboats, trains, airships and inventors.

The 2007 Syfy miniseries Tin Man incorporates a considerable number of steampunk-inspired themes into a re-imagining of L. Frank Baum's The Wonderful Wizard of Oz.

Despite leaning more towards gothic influences, the 'parallel reality' of Meanwhile City, within the 2009 film Franklyn, contains many steampunk themes, such as costumery, architecture, minimal use of electricity (with a preference for gaslight), and absence of modern technology (such as there being no motorised vehicles or advanced weaponry, and the manual management of information with no use of computers).

The 2009–2014 Syfy television series Warehouse 13 features many steampunk-inspired objects and artifacts, including computer designs created by steampunk artisan Richard Nagy, a.k.a. 'Datamancer'.^[110]

The 2010 episode of the TV series Castle entitled 'Punked' (which first aired on October 11, 2010) prominently features the steampunk subculture and uses Los Angeles-area steampunks (such as the League of STEAM) as extras.^[111]

The 2011 film The Three Musketeers has many steampunk elements, including gadgets and airships.

The 2012 Kickstarter-funded webseries, The World of Steam,^[112] written, directed, and produced by Matthew Yang King and featuring King as Mr. Liang, the narrator. The series is still in development for television. The pilot episode, 'The Clockwork Heart,' features Gail and Scott Fulsom of the League of STEAM.

The Legend of Korra, a 2012–2014 Nickelodeon animated series, incorporates steampunk elements in an industrialized world with East Asian themes.The Penny Dreadful (2014) television series is a Gothic Victorian fantasy series with steampunk props and costumes.

The 2015 GSNreality televisiongame showSteampunk'd features a competition to create steampunk-inspired art and designs which are judged by notable Steampunks Thomas Willeford, Kato, and Matthew Yang King (as Matt King).^[113]

Based on the work of cartoonist Jacques Tardi, April and the Extraordinary World (2015) is an animated movie set in a steampunk Paris. It features airships, trains, submarines, and various other steam-powered contraptions.

Tim Burton's 2016 film Alice Through the Looking Glass features steampunk costumes, props, and vehicles.

Video games[edit]

A variety of styles of video games have used steampunk settings.

The Chaos Engine (1993) is a run and gun video game inspired by the Gibson/Sterling novel The Difference Engine (1990), set in a Victorian steampunk age. Developed by the Bitmap Brothers, it was first released on the Amiga in 1993; a sequel was released in 1996.^[114]

The graphic adventurepuzzle video gamesMyst (1993), Riven (1997), Myst III: Exile (2001), and Myst IV: Revelation (all produced by or under the supervision of Cyan Worlds) take place in an alternate steampunk universe, where elaborate infrastructures have been built to run on steam power.

The 2001 CRPG called Arcanum: Of Steamworks and Magick Obscura mixed fantasy tropes with steampunk.

The SteamWorld series of games has the player controlling steam-powered robots.

Both Thief: The Dark Project and its sequel, Thief II are set in a steampunk metropolis.

The Professor Layton series of games has several entries showcasing steampunk machinary and vehicles. Notably Professor Layton and the Unwound Future features a quasi-steampunk future setting.

Solatorobo (2010) is a role-playing video game developed by CyberConnect2 set in a floating island archipelago populated by anthropomorphic cats and dogs, who pilot steampunk airships and engage in combat with robots.

Resonance of Fate (2010) is a role-playing video game developed by tri-Ace and published by Sega for the PlayStation 3 and Xbox 360. It is set in a steampunk environment with combat involving guns.

Minecraft (2011) has a steampunk-themed texture pack.

Guns of Icarus Online (2012) is multiplayer game with steampunk thematic.

Dishonored (2012) and Dishonored 2 (2016) are set within a fictional world with heavy steampunk influences, wherein whale oil, as opposed to coal, served as catalyst of their industrial revolution.

BioShock Infinite (2013) is a FPS game set in 1912, in a fictional city called Columbia, which uses technology to float in the sky and has many historical and religious scenes.

Code: Realize − Guardian of Rebirth (2014), a Japanese otome game for the PS Vita is set in a steampunk Victorian London, and features a cast with several historical figures with steampunk aesthetics.

Code Name S.T.E.A.M. (2015), a Japanese tactical RPG game for the 3DS sets in a steampunk fantasy version of London and where you are conscript in the strike force S.T.E.A.M. (short for Strike Team Eliminating the Alien Menace).

They Are Billions (2017), is a Steampunk strategy game in a post-apocalyptic setting. Players build a colony and attempt to ward off waves of zombies.

Frostpunk (2018) is a city-building game set in 1888, but where the Earth is in the midst of a great ice age. Players must construct a city around a large steampunk heat generator with many steampunk aesthetics and mechanics, such as a 'Steam Core.'

The Elder Scrolls (since 1994, last release in 2014) is a Role-playing video game where one can found an ancient gone race called dwemers or dwarves. All its mechanisms are based in steam, levers and multiple gears in conjecture with magical technics to maintain these working over the centures. Most of those are made with a copper/ bronze material, with clear steampunk reference.

Toys[edit]

Mattel's Monster High dolls Rebecca Steam and Hexiciah Steam.

The Pullip Dolls by Japanese manufacturer Dal have a steampunk range.

Culture and community[edit]

Cover of Steampunk Magazine

Because of the popularity of steampunk, there is a growing movement of adults that want to establish steampunk as a culture and lifestyle.^[115] Some fans of the genre adopt a steampunk aesthetic through fashion,^[116] home decor, music, and film. While Steampunk is considered the amalgamation of Victorian aesthetic principles with modern sensibilities and technologies,^[15] it can be more broadly categorised as neo-Victorianism, described by scholar Marie-Luise Kohlke as 'the afterlife of the nineteenth century in the cultural imaginary'.^[117] The subculture has its own magazine, blogs, and online shops.^[118]

Is it ethical to withhold information about the error? Is it ethical to respond to only those questions the reporter has asked?

In September 2012, a panel, chaired by steampunk entertainer Veronique Chevalier and with panelists including magician Pop Hadyn and members of the steampunk performance group the League of STEAM, was held at Stan Lee's Comikaze Expo. The panel suggested that because steampunk was inclusive of and incorporated ideas from various other subcultures such as goth, neo-Victorian, and cyberpunk, as well as a growing number of fandoms, it was fast becoming a super-culture rather than a mere subculture.^[119] Other steampunk notables such as Professor Elemental have expressed similar views about steampunk's inclusive diversity.^[120]

Some have proposed a steampunk philosophy that incorporates punk-inspired anti-establishment sentiments typically bolstered by optimism about human potential.^[121]

Steampunk became a common descriptor for homemade objects sold on the craft network Etsy between 2009 and 2011,^[122] though many of the objects and fashions bear little resemblance to earlier established descriptions of steampunk. Thus the craft network may not strike observers as 'sufficiently steampunk' to warrant its use of the term. Comedian April Winchell, author of the book Regretsy: Where DIY meets WTF, cataloged some of the most egregious and humorous examples on her website 'Regretsy'.^[123] The blog was popular among steampunks and even inspired a music video that went viral in the community and was acclaimed by steampunk 'notables'.^[124]

Social events[edit]

June 19, 2005 marked the grand opening of the world's first steampunk club night, 'Malediction Society', in Los Angeles.^[125][126] The event ran for nearly 12 years at The Monte Cristo nightclub, interrupted by a single year residency at Argyle Hollywood, until both the club night and The Monte Cristo closed in April 2017.^[126] Though the steampunk aesthetic eventually gave way to a more generic goth and industrial aesthetic, Malediction Society celebrated its roots every year with 'The Steampunk Ball'.^[127]

2006 saw the first 'SalonCon', a neo-Victorian/steampunk convention. It ran for three consecutive years and featured artists, musicians (Voltaire and Abney Park), authors (Catherynne M. Valente, Ekaterina Sedia, and G. D. Falksen), salons led by people prominent in their respective fields, workshops and panels on steampunk—as well as a seance, ballroom dance instruction, and the Chrononauts' Parade. The event was covered by MTV^[128] and The New York Times.^[15] Since then, a number of popular steampunk conventions have sprung up the world over, with names like Steamcon (Seattle, WA), the Steampunk World's Fair (Piscataway, NJ), Up in the Aether: The Steampunk Convention (Dearborn, MI),^[129] Steampunk NZ (Oamaru, New Zealand), Steampunk Unlimited (Strasburg Railroad, Lancaster, PA).^[130] Each year, on Mother's Day weekend, the city of Waltham, MA, turns over its city center and surrounding areas to host the Watch City Steampunk Festival, a US outdoor steampunk festival.

A steampunk couple at Carnevale 2012 in Boise, Idaho

In recent years, steampunk has also become a regular feature at San Diego Comic-Con International, with the Saturday of the four-day event being generally known among steampunks as 'Steampunk Day', and culminating with a photo-shoot for the local press.^[131][132] In 2010, this was recorded in the Guinness Book of World Records as the world's largest steampunk photo shoot.^[133] In 2013, Comic-Con announced four official 2013 T-shirts, one of them featuring the official Rick Geary Comic-Con toucan mascot in steampunk attire.^[134] The Saturday steampunk 'after-party' has also become a major event on the steampunk social calendar: in 2010, the headliners included The Slow Poisoner, Unextraordinary Gentlemen, and Voltaire, with Veronique Chevalier as Mistress of Ceremonies and special appearance by the League of STEAM;^[135][136] in 2011, UXG returned with Abney Park.^[137]

Steampunk has also sprung up recently at Renaissance Festivals and Renaissance Faires, in the US. Some festivals have organised events or a 'Steampunk Day', while others simply support an open environment for donning steampunk attire. The Bristol Renaissance Faire in Kenosha, Wisconsin, on the Wisconsin/Illinois border, featured a Steampunk costume contest during the 2012 season, the previous two seasons having seen increasing participation in the phenomenon.^[138]

Steampunk also has a growing following in the UK and Europe. The largest European event is 'Weekend at the Asylum', held at The Lawn, Lincoln, every September since 2009. Organised as a not-for-profit event by the Victorian Steampunk Society, the Asylum is a dedicated steampunk event which takes over much of the historical quarter of Lincoln, England, along with Lincoln Castle. In 2011, there were over 1000 steampunks in attendance. The event features the Empire Ball, Majors Review, Bazaar Eclectica, and the international Tea Duelling final.^[139][140] The Surrey Steampunk Convivial was originally held in New Malden, but since 2019 has been held in Stoneleigh in southwestern London, within walking distance of H. G. Wells's home.^[141] The Surrey Steampunk Convivial started as an annual event in 2012, and now takes place thrice a year, and has spanned three boroughs and five venues.^[142] Attendees have been interviewed by BBC Radio 4 for Phil Jupitus^[143] and filmed by the BBC World Service.^[144] The West Yorkshire village of Haworth has held an annual Steampunk weekend since 2013,^[145] on each occasion as a charity event raising funds for Sue Ryder's 'Manorlands' hospice in Oxenhope.

See also[edit]

References[edit]

Device Models

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Portable Breath Device Models

Further reading[edit]

• Alkon, Paul K. (1994). Science fiction before 1900. ISBN978-0-8057-0952-0.
• Donovan, Art (2011). The Art of Steampunk: Extraordinary Devices and Ingenious Contraptions from the Leading Artists of the Steampunk Movement. Fox Chapel Publishers. ISBN978-1-56523-573-1.
• Erlich, Richard D.; Dunn, Thomas P. (1983). Clockwork worlds. ISBN978-0-313-23026-4.
• Guillemois, Alban (2006). Louis la Lune. ISBN978-2-226-16675-3.
• Landon, Brooks (2002). Science fiction after 1900. ISBN978-0-415-93888-4.
• Nevins, Jess (2005). The Encyclopedia of Fantastic Victoriana. MonkeyBrain Books. ISBN978-1-932265-15-6.
• Person, Lawrence (Winter 1988). 'Nova Express'. Volume 2. Austin, TX, USA.
• Slusser, George; Shippey, Tom (1992). Fiction 2000: cyberpunk and the future of narrative. ISBN978-0-8203-1425-9.
• Suvin, Darko (1983). Victorian science fiction in the UK. ISBN978-0-8161-8435-4.
• Westfahl, Gary; Slusser, George; Leiby, David (2002). Worlds enough and time. ISBN978-0-313-31706-4.
• Strongman, Jay (2010). Steampunk: The Art of Victorian Futurism. Korero. ISBN978-1-907621-03-1.

Hamburg Wheel Tracking Device Models

External links[edit]

Wikimedia Commons has media related to Steampunk.

• Off Book: Steampunk Documentary produced by Off Book
• 'Steampunk Hanger' at UnnaturalHistoryMuseum.org An archive of unrealized, implausible inventions by authentic nineteenth and twentieth-century inventors.

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