Friday, 11 July 2008

The American journal of hospice & palliative care, Apr-May 2008, vol. 25, no. 2,

Palliative care in overdrive: patients in danger.
The American journal of hospice & palliative care, Apr-May 2008, vol. 25, no. 2,
p. 155-60

Prediction of patient survival by healthcare professionals in a specialist palliative care inpatient unit: a prospective study.
p. 139-45
Twomey-Feargal, O-Leary-Norma, O-Brien-Tony.
Accurate prognostication is an enormous challenge for professionals caring for patients with advanced disease. Few studies have compared the prognostic accuracy of different professional groups within a hospice setting. The aim of this study was to compare the ability of 5 professional groups to estimate the survival of patients admitted to a specialist palliative care unit. No group accurately predicted the length of patient survival more than 50% of the time. Nursing and junior medical staff were most accurate while care assistants were least accurate. When in error, senior clinical staff tended to under- estimate survival. Independent mobility on admission was the only variable predictive of length of survival. Thus, professional groups differ in their prognostic accuracy. An awareness of a group's propensity to over- or under-estimate prognosis should be incorporated into future work on prognostication models.

Some common problems faced by hospice palliative care volunteers.
p. 121-6
Claxton-Oldfield-Stephen, Claxton-Oldfield-Jane.
This paper examines 4 common problems that many hospice palliative care volunteers in Canada (and the United States) encounter, namely, being underutilized, being placed with a patient too late in the patient's illness, feeling undervalued by some members of the medical staff, and not being able to do more to help patients and their families. The implications of each of these problems are discussed along with suggestions for overcoming them. Finally, some ideas for future research are proposed.

Pediatric palliative care: an assessment of physicians' confidence in skills, desire for training, and willingness to refer for end-of-life care.
p. 100-5
Sheetz-M-Joan, Bowman-Mary-Ann-Sontag.
This study determines the confidence levels of physicians in providing components of pediatric palliative care and identifies their willingness to obtain training and to make palliative care referrals. Surveys were mailed to all physicians at Primary Children's Medical Center. The survey instrument includes 3 demographic items, 9 items designed to assess physician confidence in core palliative care skills, and 4 items designed to assess what steps physicians would be likely to take to assure that patients receive palliative care. Physicians were asked to rate their confidence levels to provide palliative care components on a 4-point scale for each of the items. Five hundred ninety-seven surveys were mailed, with 323 usable surveys returned. The proportion of physicians who rate their ability to provide palliative care as confident or very confident ranges from 74% for giving difficult news to families to 23% for managing end-of-life symptoms. Thirty-six percent of the physicians say they would be likely or very likely to attend training to improve their ability to provide palliative care to children. Eighty-six percent would be likely or very likely to refer for a palliative care consult and 91% to a home health agency or hospice. There is wide variation in the confidence levels of physicians to provide the core components of palliative care. Few are interested in obtaining additional training, but most are willing to obtain consultation or to refer to a palliative care service. These results argue in favor of hospital-based palliative care teams and for specialty training and certification in pediatric palliative care.

End-of-life care in Hancock County, Maine: a community snapshot.
p. 132-8
Ostertag-Susan-G, Forman-Walter-B.
This study presents a model for identifying end-of-life concerns in 1 rural community: Hancock County, Maine. Focus groups and structured interviews were held with primary care physicians, hospice staffs, clergy, hospice board members, long-term care facility staffs, and families of patients who had died either with or without hospice services. A list of suggestions for action within the community was generated from the interviews. Specific ideas targeted for implementation as a result of this project were educational sessions for long-term care facility staff, hospital grand rounds for primary care physicians, collaboration to bring information to the general public, stronger liaisons between long-term care facility and hospice staffs, and investigation of the development of a dedicated hospice facility. This is a simple, easily accomplished model to evaluate hospice needs in a small community.

Use of thromboprophylaxis in palliative care patients: a survey among experts in palliative care, oncology, intensive care, and anticoagulation.
p. 127-31
Kierner-Katharina-A, Gartner-Verena, Schwarz-Maria, Watzke-Herbert-H.
Study-based guidelines on thromboprophylaxis are not available for palliative care patients. The authors asked a panel of academic medical experts in palliative care, oncology, blood coagulation, and intensive care to select a prophylactic regimen out of 5 predefined options for a virtual patient with advanced bronchial cancer in different clinical settings. Primary prophylaxis for venous thromboembolism was withdrawn by all physicians when the patient had a Karnovsky's index of 10 and was described as dying. It was given by 25% of physicians when the patient had a Karnovsky's index of 20 and by 85% when Karnovsky's index 40 was still 40. Similar results were obtained in the situation of secondary prophylaxis of venous thromboembolism and when the patient was described as having a history of chronic atrial fibrillation. This data clearly show that thromboprophylaxis is delivered according to a compound estimate of risks and benefits of such prophylaxis in a specific palliative care situation.

To die, to sleep: US physicians' religious and other objections to physician-assisted suicide, terminal sedation, and withdrawal of life support.
p. 112-20
Curlin-Farr-A, Nwodim-Chinyere, Vance-Jennifer-L, Chin-Marshall-H, Lantos-John-D.
This study analyzes data from a national survey to estimate the proportion of physicians who currently object to physician-assisted suicide (PAS), terminal sedation (TS), and withdrawal of artificial life support (WLS), and to examine associations between such objections and physician ethnicity, religious characteristics, and experience caring for dying patients. Overall, 69% of the US physicians object to PAS, 18% to TS, and 5% to WLS. Highly religious physicians are more likely than those with low religiosity to object to both PAS (84% vs 55%, P < .001) and TS (25% vs 12%, P < .001). Objection to PAS or TS is also associated with being of Asian ethnicity, of Hindu religious affiliation, and having more experience caring for dying patients. These findings suggest that, with respect to morally contested interventions at the end of life, the medical care patients receive will vary based on their physicians' religious characteristics, ethnicity, and experience caring for dying patients.

p. 88-92,
What bothers you the most? Initial responses from patients receiving palliative care consultation
Shah-Mindy, Quill-Timothy, Norton-Sally, Sada-Yvonne, Buckley-Marcia, Fridd-Charlotte. Abstract
The purpose of this investigation is to describe how hospitalized palliative care patients respond to the question What bothers you the most? at the time of initial consultation. A retrospective descriptive content analysis of first person responses routinely recorded during initial interview (n = 286) was carried out. Responses were grouped in 7 major categories: physical distress (44%) ; emotional, spiritual, existential, or nonspecific distress (16%); relationships (15%); concerns about the dying process and death (15%) ; loss of function and normalcy (12%); distress about location (11%); and distress with medical providers or treatment (9%). Fifteen percent of responses were unable to be reliably categorized. Although many of our patients were not able to answer open-ended questions because of illness, those who did shared a wide range of concerns that provided a starting point for clinical prioritization. Further research into the use of such simple questions at time of initial consultation is warranted.

p. 93-9
Lullament: lullaby and lament therapeutic qualities actualized through music therapy
Lullabies and laments promote new awareness, enculturation, adaptation, and grief expression. These concepts' relevance to palliative care, however, has not been examined. In this study, a music therapist used a grounded theory-informed design to reflexively analyze lullaby and lament qualities, evident in more than 20 years of personal palliative care practice. Thus, the construct lullament emerged, which signified helpful moments when patients' and families' personal and sociohistorical relationship with lullabies and laments were actualized. Specific music could be both a lullaby and a lament. A music therapist can enable the lullament through providing opportunities for music-contextualized restorative resounding, expressed psychobiologically, verbally, musically, and metaphorically.

p. 106-11
Needs of elderly patients in palliative care
Wijk-Helle, Grimby-Agneta.
A pilot study on elderly patients' end-of-life needs was performed at a Swedish geriatric palliative ward. Thirty patients (15 men and 15 women; mean age, 79 years) with a primary diagnosis of cancer and admitted for palliative care were interviewed by a nurse using semistructured interviews. The study included demographic data, physical and psychologic status, and naming and ranking of individual needs. Elimination of physical pain was ranked as the primary need of half of the patients. Only when pain was eliminated or absent did other important needs (psychological, social, spiritual) appear frequently.

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