Journal of palliative medicine Mar 2008 vol. 11 no. 2

Trial of angioembolization of advanced stage tumors feeding arteries exemplifying aggressive and active interventional palliation.
p. 250-3

A bien experience.
p. 248-9
Hernandez-Howard-R.
Case-Reports, Journal-Article.

Criminal prosecutions of physicians providing palliative or end-of- life care.
p. 233-41
Kollas-Chad-D, Boyer-Kollas-Beth, Kollas-James-W.
Abstract
Although medical malpractice suits commonly occur in medical practice, few physicians experienced criminal prosecution related to adverse clinical outcomes before 1990. Criminal prosecutions of physicians increased in frequency early in that decade, however, including a handful of cases involving palliative or end-of-life care. Reviews published around the end of the 1990s examined those prosecutions, listing causative factors and offering recommendations to prevent further cases. In this paper, we provide an updated review of criminal prosecutions of physicians providing palliative or end- of-life care, presenting three cases that occurred after 1998. We summarize these newer cases' chronologies and outcomes, comparing them to cases described in past reviews. Our analysis suggests that important factors not described in earlier reviews, especially conflicting views of the standard of care in hospice and palliative medicine, contributed to the development of these prosecutions.

Determinants of do-not-resuscitate orders in palliative home care.
p. 226-32
Brink-Peter, Smith-Trevor-Frise, Kitson-Maureen.
Abstract
OVERVIEW: Do-not-resuscitate (DNR) orders allow home care clients to communicate their own wishes over medical treatment decisions, helping to preserve their dignity and autonomy. To date, little is known about DNR orders in palliative home care. Basic research to identify rates of completion and determinants of DNR orders has yet to be examined in palliative home care. PURPOSE: The purpose of this exploratory study was to determine who in palliative home care has a DNR order as part of their advance directive. METHODS: Information on health was collected using the interRAI instrument for palliative care (interRAI PC). The sample included 470 home care clients from one community care access centre in Ontario. RESULTS: This study indicated that a preference to die at home (odds ratio (OR): 8.29, confidence interval (CI): 4.55-15.11); close proximity to death (OR: 0.99, CI: 0.99-1.00); daily incontinence (OR: 2.74, CI: 1.05-7.16); and sleep problems (OR: 1.85, CI: 1.02-3.37) are associated with DNR orders. In addition, clients who are more accepting of their situation are 5.67 times (CI: 1.67-19.27) more likely to have a DNR in place. CONCLUSION: This study represents an important first step to identifying issues related to DNR orders. In addition to proximity to death, incontinence, and sleep problems, acceptance of one's own situation and a preference to die at home are important determinants of DNR completion. The results imply that these discussions might often depend not only on the health of the clients but also on the clients' acceptance of their current situation and where they wish to die.

Improving end-of-life outcomes in nursing homes by targeting residents at high-risk of mortality for palliative care: program description and evaluation.
p. 217-25
Levy-Cari, Morris-Monica, Kramer-Andrew.
Abstract
OBJECTIVES: The objectives were (1) to describe the Making Advance Planning a Priority (MAPP) program, a program designed to identify nursing home (NH) residents at high risk of death and (2) to evaluate end-of-life care outcomes for NH residents at high risk of death. DESIGN: Program description and evaluation using a retrospective chart review before and after implementation of the MAPP program. PARTICIPANTS: NH residents who died 1 year before program implementation compared to NH residents who died 1 year after program implementation (n = 72). Program description: The MAPP program was designed to: (1) identify residents at high risk of death, (2) inform the attending physician of the residents' mortality risk, (3) obtain palliative care or, if the prognosis was 6 months of less, a hospice consultation, and (4) improve advance care planning documentation. Program evaluation: Site of death (hospital versus nursing home), presence of an advance directive, presence of an order for cardiopulmonary resuscitation, proportion of NH residents with palliative care and/or hospice consultation prior to death, length of palliative care and/or hospice services before death. Following implementation of the MAPP program, we hypothesized that there would be a reduction in hospitalizations, an increase in hospice/palliative care referrals, an increase hospice/palliative care length of service, an increase the utilization of advance directives, but no difference in days in the hospital before death. RESULTS: Following implementation of the MAPP program intervention, residents were less likely to die in the hospital (48.2% preintervention versus 8.9% postintervention, p < 0.0001). Every resident who died after implementation of the MAPP program had an advanced directive (p = 0.03). Residents were more also more likely to get palliative care referrals (7.4% preintervention versus 31.1% postintervention, p = 0.02). CONCLUSION: An intervention designed to address the end-of- life needs of NH residents at high risk of death improves end-of-life outcomes with a reduction in terminal hospitalizations, an increase in palliative care referrals and improvement of advance directive completion.

Is there a higher risk of respiratory depression in opioid-naive palliative care patients during symptomatic therapy of dyspnea with strong opioids?
p. 204-16
Clemens-Katri-Elina, Quednau-Ines, Klaschik-Eberhard.
Abstract OBJECTIVE: Dyspnea is a highly prevalent symptom in palliative care patients. Opioids are the first-line therapy for symptomatic relief of dyspnea. However, respiratory depression is still a feared side effect of therapy with WHO III opioids. The risk of respiratory depression in opioid-naive patients and in patients pretreated with strong opioids during symptomatic therapy of dyspnea was investigated in palliative care patients. PATIENTS AND METHODS: Twenty-seven patients were included in a prospective, nonrandomized study. All patients suffered from moderate to severe dyspnea. Transcutaneous measurement (earlobe sensor) of carbon dioxide partial pressure (tcpa CO(2)), pulse oximetry oxygen saturation (SaO(2)), and pulse frequency (PF) were monitored with SenTec Digital Monitor (SenTec AG, Therwill, CH). The following monitoring data were compared: baseline recording for 15 minutes, and 30, 60, 90, and 120 minutes after opioid application. RESULTS: The data obtained with transcutaneous measurement showed that there were no significant differences between the groups of opioid-naive patients and those pretreated with strong opioids with regard to tcpaCO(2) increase or SaO(2) decrease after the first opioid application. Neither SaO(2) decreased significantly nor tcpaCO(2) increased significantly after the initial opioid application, which means there was no opioid-induced respiratory depression. The first opioid application, however, resulted in a significant decrease in the intensity of dyspnea and respiratory rate. CONCLUSIONS: No higher risk of respiratory depression and increase in tcpaCO2 in opioid-naive palliative care patients, compared to patients pretreated with strong opioids, during symptomatic therapy of dyspnea with strong opioids could be found.

End-of-life care in adults with cystic fibrosis
p. 198-203
Philip-Jennifer-A-M, Gold-Michelle, Sutherland-Sharon et al
BACKGROUND: Cystic fibrosis (CF) is a life-limiting congenital disease, with most patients dying at a young age of progressive lung disease. Lung transplantation offers hope for many but may not occur. There is little to guide the provision of palliative care to this young population who maintain hope in the possibility of lung transplantation. METHODS: To inform the development of an appropriate model of palliative care, a medical record review of CF patients dying within a 5-year period without lung transplantation was undertaken. The aspects of care that were preventative, therapeutic, or palliative were quantified. RESULTS: Of the 20 records studied, all died in hospital. Only 15% of patients had a do-not-resuscitate order agreed to more than 1 week prior to death, increasing to 90% at the time of death (median of 2 days before death). Opioids were prescribed for 1 patient (5%) at 1 week prior to death, increasing to 85% of patients in the last 24 hours of life (median of 36 hours before death). During the last 24 hours of life, intravenous antibiotics continued in 85%, and assisted ventilation in 90% of subjects. CONCLUSION: We conclude that the circumstances surrounding the death of patients with CF holds challenges for their effective palliative care. CF patients continue life prolonging and preventative treatments until the last hours of life. There is an urgent need to examine palliative care approaches that may usefully coexist with maintaining transplantation options in the end-of-life care of this population.

Clinical findings of a palliative care consultation team at a comprehensive cancer center.
p. 191-7
Dhillon-Navneet, Kopetz-Scott, Pei-Be-Lian, Fabbro-Egidio-Del, Zhang- Tao, Bruera-Eduardo. Abstract BACKGROUND: Palliative care consultation teams (PCCTs) are being established in cancer centers for the management of patients' physical and psychosocial distress. As clinical findings of these teams have been reported infrequently, we aim to describe the experience of our high-volume inpatient PCCT. PATIENTS AND METHODS: We obtained clinical and demographic data on patients referred to our PCCT from the palliative care departmental database from September 1, 2003, to August 31, 2004. RESULTS: In 1 year, 1067 consultations took place for 922 hospitalized patients. The patients' mean age was 60 (range, 3-98) years. The most common cancers were thoracic/head and neck, gastrointestinal, genitourinary, gynecologic cancers, and lymphoma. Thirty-four percent of the patients were transferred to the inpatient palliative care unit, while the remainder were followed by the PCCT as consultants. The main problems requiring PCCT consultation were pain (56%), delirium (34%), dyspnea (25%), fatigue (14%), and end-of-life psychosocial (EOL) issues (12%). Twenty-four percent of patients died during the hospitalization. Death during the hospitalization was more common in patients with delirium, dyspnea, and EOL issues and less likely in patients referred to the PCCT for pain or depression. Constipation was more common in patients with solid tumors, whereas EOL issues were more common in patients with hematologic malignancies. Of the patients who were able to be discharged, 56% went home, 37% to hospice, and 7% elsewhere. CONCLUSIONS: These results provide insight into the demand and utility of this service for those considering the establishment of a PCCT.

Impact of an inpatient palliative care team: a randomized control trial.
p. 180-90
Gade-Glenn, Venohr-Ingrid, Conner-Douglas, McGrady-Kathleen, Beane- Jeffrey et al
Abstract BACKGROUND: Palliative care improves care and reduces costs for hospitalized patients with life-limiting illnesses. There have been no multicenter randomized trials examining impact on patient satisfaction, clinical outcomes, and subsequent health care costs. OBJECTIVE: Measure the impact of an interdisciplinary palliative care service (IPCS) on patient satisfaction, clinical outcomes, and cost of care for 6 months posthospital discharge. METHODS: Multicenter, randomized, controlled trial. IPCS provided consultative, interdisciplinary, palliative care to intervention patients. Controls received usual hospital care (UC). SETTING AND SAMPLE: Five hundred seventeen patients with life-limiting illnesses from a hospital in Denver, Portland, and San Francisco enrolled June 2002 to December 2003. MEASURES: Modified City of Hope Patient Questionnaire, total health care costs, hospice utilization, and survival. RESULTS: IPCS reported higher scores for the Care Experience scale (IPCS: 6.9 versus UC: 6.6, p = 0.04) and for the Doctors, Nurses/Other Care Providers Communication scale (IPCS: 8.3 versus UC: 7.5, p = 0.0004). IPCS patients had fewer intensive care admissions (ICU) on hospital readmission (12 versus 21, p = 0.04), and lower 6-month net cost savings of $4,855 per patient (p = 0.001). IPCS had longer median hospice stays (24 days versus 12 days, p = 0.04). There were no differences in survival or symptom control. CONCLUSIONS: IPCS patients reported greater satisfaction with their care experience and providers' communication, had fewer ICU admissions on readmission, and lower total health care costs following hospital discharge.

Building the field of cancer pain
p. 176-9
Foley-Kathleen-M.

Growing pains: health care enters team-age
p. 171-5
Periyakoil-Vyjeyanthi-S.

Introduction of a pediatric palliative care curriculum for pediatric residents.
p. 164-70
Schiffman-Joshua-D, Chamberlain-Lisa-J, Palmer-Laura, Contro-Nancy et al
Abstract INTRODUCTION: The Pediatric Palliative Care Curriculum (PPCC) was introduced as a pilot study in response to the published need for increased pediatric education in end-of-life (EOL) care. The PPCC was designed to better train residents in EOL issues so they could become more comfortable and knowledgeable in caring for children and adolescents with life-threatening illnesses. METHOD: The PPCC consisted of six hour-long sessions run by a clinical psychologist, a licensed social worker, and faculty with experience in EOL care. The curriculum repeated every 6 weeks for 1 year. Residents in the training program at Stanford University rotating through oncology, pulmonology, and pediatric intensive care unit (PICU) were invited to attend. Session topics included: (1) personal coping skills, (2) being a caring professional, (3) recognizing cultural and familial differences, (4) pain management, (5) practical issues, and (6) meeting a bereaved parent. Pretest and posttest surveys with five- point Likert scale questions were used to measure curricular impact. RESULTS: Statistically significant improvement was found in resident self-report of: feeling prepared to initiate do-not-resuscitate discussions

Journal of palliative medicine, Jan-Feb 2008, vol. 11, no. 1

To sleep before we die...: when is palliative sedation an option for the dying person?
p. 131-2
Stewart-Tanya-Lugliani.
Author affiliation

Health literacy in palliative medicine #153.
p. 105-6
Reisfield-Gary-M, Wilson-George-R.

Palliative medicine review: prognostication.
p. 84-103, 93 refs
Glare-Paul-A, Sinclair-Christian-T.
Abstract
Prognostication, along with diagnosis and treatment, is a traditional core clinical skill of the physician. Many patients and families receiving palliative care want information about life expectancy to help plan realistically for their futures. Although underappreciated, prognosis is, or at least should be, part of every clinical decision. Despite this crucial role, expertise in the art and science of prognostication diminished during the twentieth century, due largely to the ascendancy of accurate diagnostic tests and effective therapies. Consequently, Doctor, how long do I have? is a question most physicians find unprepared to answer effectively. As we focus on palliative care in the twenty-first century, prognostication will need to be restored as a core clinical proficiency. The discipline of palliative medicine can provide leadership in this direction. This paper begins by discussing a framework for understanding prognosis and how its different domains might be applied to all patients with life limiting illness, although the main focus of the paper is predicting survival in patients with cancer. Examples of prognostic tools are provided, although the subjective assessment of prognosis remains important in the terminally ill. Other issues addressed include: the importance of prognostication in terms of clinical decision-making, discharge planning, and care planning; the impact of prognosis on hospice referrals and patient/family satisfaction; and physicians' willingness to prognosticate.

Prognosticating: the end of a series. Introduction.
p. 82-3
Liao-Solomon, Arnold-Robert-M.

Palliative sedation as part of a continuum of palliative care.
p. 76-81
Carr-Mark-F, Mohr-Gina-Jervey.
Abstract
Three issues seem to animate those who advocate the move toward a broad allowance of physician-assisted death. The first is the supposed failure of palliative care in extreme cases. We challenge the notion that palliative care ever fails. When palliative sedation is understood to be a routine continuation of palliative care, as opposed to a last-ditch response to a dramatic failure, then palliative care will never fail. The second focuses on helping patients maintain a sense of control in their final days and hours. We believe that continued intimate involvement in each of the final stages that is essential in the palliative care-palliative sedation continuum will be more effective palliative care and still grant control to the patient under the principle of respect for autonomy. The third issue is the charge that palliative sedation is a euphemism for physician-assisted death. We reject that charge.

A nationwide VA palliative care quality measure: the family assessment of treatment at the end of life.
p. 68-75
Casarett-David, Pickard-Amy, Bailey-F-Amos, Ritchie-Christine-Seel et al
Abstract
OBJECTIVES: To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system. DESIGN: Nationwide telephone survey. SETTING: Five VA medical centers. PARTICIPANTS: Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate. MEASUREMENTS: The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patient's death (3 items). RESULTS: Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001). CONCLUSIONS: The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

(Using) complementary and alternative medicine: the perceptions of palliative patients with cancer.
p. 58-67
Eliott-Jaklin-A, Kealey-Colin-P, Olver-Ian-N.
Abstract
Use of complementary and alternative medicine (CAM) is increasingly common within Western societies, including Australia. This parallels calls for or claims of integration of CAM into mainstream medical practice, with oncology and palliative care specifically nominated as appropriate arenas for integration. However, there is an absence of studies examining patient perceptions of both CAM and CAM users. In this study, 28 adult patients with cancer close to death were interviewed regarding treatment decisions at the end of life, including decisions about CAM. Thematic analysis of transcribed interviews found consistent differences in talk around CAM between 12 users and 16 nonusers of CAM, primarily related to the perceived value of these treatments. Drawing upon a mind-body discourse that holds individuals responsible for their health, users valued CAM for the perceived benefit to physical or psychological well-being and compatibility with a holistic approach to health care, deemed to complement or augment conventional medicine. However, some were self- critical of their failure to continue with CAM, despite practical and financial difficulties experienced. Nonusers devalued CAM as unable to cure their disease (but did not similarly devalue conventional medicine), and negatively construed CAM users as desperate, or as challenging medical wisdom. Despite increased legitimation and medicalization of CAM, patients assess CAM differently to allopathic medicine, with different (positive and negative) assessments attributable to users. The misperception by many (nonusers) that CAM are intended to cure and available negative moral and social judgments centred around CAM use may deter patient uptake of CAM in areas where they have proven efficacy in symptom control.

Interval between first palliative care consult and death in patients diagnosed with advanced cancer at a comprehensive cancer center.
p. 51-7
Osta-Badi-El, Palmer-J-Lynn, Paraskevopoulos-Timotheos et al
Abstract
PURPOSE: Most referrals to palliative care and hospice occur late in the trajectory of the disease although an earlier intervention could decrease patients' symptom distress. The purpose of this study was to determine the interval between first palliative care consult (PC1) and death (D) in patients diagnosed with advanced cancer (aCA) at our comprehensive cancer center and if such interval has increased over time. METHODS: The study group was 2868 consecutive patients who had their PC1 during a 30-month period. We reviewed the charts for information about demographics, cancer type, date of cancer (CA) diagnosis, aCA diagnosis, PC1, and D. aCA was defined as locally recurrent or metastatic. RESULTS: One thousand four hundred four patients (49%) were female, 1791 (62%) were less than 65 years old, 2563 (89%) had solid tumors, and 2004 (70%) were white. The median PC1-D, aCA-PC1, aCA-D, and CA-D intervals were 42, 147, 250, and 570 days, respectively. The median PC1-D interval was longer in patients with solid tumors (p < 0.0001), less than 65 years old (p = 0.002), and females (p = 0.004). PC1-D was not affected by ethnicity (p = 0.42). The median PC1-D interval in 5 consecutive half-years was 46, 56, 42, 41, and 34 days, respectively (p = 0.02). The number of PC1 in this period increased from 544 to 654 (20%). The ratio of PC involvement in the aCA-D period (PC1-D/aCA-D) decreased from 0.30 to 0.26 over the 5 half-year periods (p = 0.0004). CONCLUSIONS: The first palliative care consultation to death interval has decreased over time at our center. Education is needed among our referring physicians for earlier access to palliative care. Prospective studies are needed to establish the appropriate timing of the first palliative care consultation.

Research funding for palliative medicine.
p. 36-43, 12 refs
Gelfman-Laura-P, Morrison-R-Sean.
Abstract
BACKGROUND: Medical care for seriously ill patients has been acknowledged to be inadequate and multiple reports have called for increased investment in palliative medicine research. OBJECTIVE: To identify funding sources of palliative medicine research published form 2003-2005 and to examine National Institutes of Health (NIH) funding of palliative medicine research from 2001-2005. METHODS: We sought to identify United States publications related to adult palliative medicine research from 2003-2005 and their funding sources. We reviewed all articles published in the major palliative medicine journals and additionally, we reviewed all articles published in major medicine journals and relevant sub-specialty journals which were identified in Pub-Med using the key words palliative care, end-of-life care, hospice and end-of-life. From all identified articles, we abstracted all sources of funding detailed. We then compiled a list of U.S. palliative medicine researchers from 2001-2005 using the published first and last authors in the above article review, the editorial boards of palliative medicine journals, and other organizations. To examine NIH funding, we cross-matched this list of researchers against all NIH grants funded from 2001-2005. RESULTS: We identified 388 palliative medicine research articles and 2,197 investigators. Seventy-two percent of papers identified received extramural funding: 31% from the NIH, 51% from foundations, and 16% from other sources. Only 109 investigators received NIH funding and the National Cancer Institute (NCI), National Institute of Nursing Research (NINR), and National Institute on Aging (NIA) funded 85% of all NIH awards. CONCLUSIONS: Research funding, particularly federal funding, for palliative medicine research is inadequate to support improvements in care for the most seriously ill patients and their families.

Borders without Doctors.
p. 31-2
Periyakoil-Vyjeyanthi-S.

Expressive writing in patients receiving palliative care: a feasibility study.
p. 15-9
Bruera-Eduardo, Willey-Jie, Cohen-Marlene, Palmer-J-Lynn.
Abstract
BACKGROUND: Patients with advanced cancer receiving palliative care often experience severe physical and psychosocial symptoms. However, there are limited resources for psychological and emotional support. Expressive writing has shown decreased anxiety level in young and healthy people suffering from a number of stressors. OBJECTIVE: The purpose of this study was to determine the feasibility of expressive writing in patients receiving palliative care and the most suitable outcomes of expressive writing in this patient population. DESIGN: In this pilot study, patients were randomly assigned to either the expressive writing group (EW) or the neutral writing group (NW). Anxiety level before and after the writing session was compared between the two groups. Writing materials were content analyzed using standard qualitative research methods. RESULTS: A total of 24 patients (12 in EW and 12 in NW) were enrolled in the study between October 2006 and January 2007. Although the majority of patients (83%-100%) were able to complete all baseline assessments, poor adherence was observed during the follow-ups. Only 8% of patients completed the 2-week study. There was no significant difference in the State-Trait Anxiety Inventory (STAI) State-Anxiety scores at baseline, before and after each writing session between the EW and NW groups. DISCUSSION: Our rapid accrual suggests that palliative care patients are interested in participating in studies such as expressive writing. The high level of adherence to the baseline assessments indicates that these assessments were not particularly difficult for our patients to complete. Future studies may need to include patients with better performance status, better patient education, means of emotional expression (i.e., audio recording, telephone interview) and improved adherence. CONCLUSION: We conclude that clinical trials of expressive writing in the palliative care setting are not feasible unless they undergo major modification in methods compared to those previous reported in other patient population. Our findings will hopefully assist researchers considering similar studies.

Social workers advocate for a seat at palliative care table.
p. 10-4
Meier-Diane-E, Beresford-Larry.

Team, diversity, and building communities.
p. 5-7
Muir-J-Cameron.

Evidence-based medicine and palliative care.
p. 2-4
Hallenbeck-James.