A communication model for encouraging optimal care at the end of life for hospitalized patients.
QJM : monthly journal of the Association of Physicians, Dec 2007, vol. 100, no. 12
p. 791-7
Workman-S.
Abstract
Multiple studies have demonstrated that treatment at or near the end of life is rarely optimal. Unwanted death-prolonging treatments are frequently provided and open communication about death and dying is often lacking. Early effective communication about goals, prognosis and options would improve patient care at or near the end of life by enhancing choice and facilitating palliative care. A five-step sequential approach to communicating with patients at risk of dying in hospital about treatment goals and outcomes (and/or their family members) is presented. The five steps are founded upon the recognition that trials of life-sustaining treatments are also, by definition, trials of palliative care. A narrative review of currently available qualitative and quantitative research is used to support the recommendations.
Journal-Article, Review.
Tuesday, 26 August 2008
Current opinion in oncology Jul 2008 vol. 20 no. 4
Delirium in cancer patients: a focus on treatment-induced psychopathology.
p. 360-6, 66 refs
Agar-Meera, Lawlor-Peter.
Abstract
PURPOSE OF REVIEW: Delirium is a neuropsychiatric syndrome that occurs frequently in cancer patients, especially in those with advanced disease. Recognition and effective management of delirium is particularly important in supportive and palliative care, especially in view of the projected increase in the elderly population and the consequent potential for the number of patients both diagnosed and living longer with cancer to increase substantively. RECENT FINDINGS: Studies of delirium in a variety of settings have generated new insights into phenomenology, assessment tools, the psychomotor subtypes, potential patho-physiological markers, pathogenesis, reversibility, and the role of sedation in symptom control. SUMMARY: Validated tools exist to assist in the assessment of delirium. Although our understanding of the pathogenesis of delirium has improved somewhat, there remains a compelling need to further elucidate the underlying pathophysiology, especially in relation to opioids and the other psychoactive medications that are used in supportive care. Further trials are needed, especially in patients with advanced disease to determine predictive models of reversibility, preventive strategies, outcomes, and to assess the role of antipsychotic and other medications in symptomatic management.
Depression and cancer: recent data on clinical issues, research challenges and treatment approaches.
p. 353-9
Reich-Michel
Abstract
PURPOSE OF REVIEW: Clinical guidelines for depression screening, assessment and management in the oncologic field and palliative care are becoming paramount in routine cancer care. This psychiatric comorbidity has several impacts on quality of life, anticancer treatment compliance, hospital stay duration, health-care costs, morbidity and possibly mortality even if discordant reports exist. RECENT FINDINGS: Recent development of brain imaging techniques (MRI, positron emission tomography), neurobiological and genetic tools allow new understanding of the pathophysiology process of depressive disorders in cancer populations besides the usual endocrinologic and psychoneuroimmunologic hypothesis. Broader indications besides depressive or anxiety disorders appear or must be investigated for the new generation of antidepressants (selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, noradrenergic specific serotonergic antidepressants) in oncology, such as hot flashes, neuropathic pain, fatigue, anorexia/cachexia. Psychosocial interventions seem to have a slight impact on well- being, quality of life and depressive symptomatology but not on survival. SUMMARY: The present article reviews recent literature on depression and cancer and highlights practical assessment and detection of depression, biological and physiopathological correlates and its pharmacologic and psychosocial treatment. Implementation of these several techniques must be supported by ongoing research about the complex relation between depressive disorders and generally mental health and oncology.
p. 360-6, 66 refs
Agar-Meera, Lawlor-Peter.
Abstract
PURPOSE OF REVIEW: Delirium is a neuropsychiatric syndrome that occurs frequently in cancer patients, especially in those with advanced disease. Recognition and effective management of delirium is particularly important in supportive and palliative care, especially in view of the projected increase in the elderly population and the consequent potential for the number of patients both diagnosed and living longer with cancer to increase substantively. RECENT FINDINGS: Studies of delirium in a variety of settings have generated new insights into phenomenology, assessment tools, the psychomotor subtypes, potential patho-physiological markers, pathogenesis, reversibility, and the role of sedation in symptom control. SUMMARY: Validated tools exist to assist in the assessment of delirium. Although our understanding of the pathogenesis of delirium has improved somewhat, there remains a compelling need to further elucidate the underlying pathophysiology, especially in relation to opioids and the other psychoactive medications that are used in supportive care. Further trials are needed, especially in patients with advanced disease to determine predictive models of reversibility, preventive strategies, outcomes, and to assess the role of antipsychotic and other medications in symptomatic management.
Depression and cancer: recent data on clinical issues, research challenges and treatment approaches.
p. 353-9
Reich-Michel
Abstract
PURPOSE OF REVIEW: Clinical guidelines for depression screening, assessment and management in the oncologic field and palliative care are becoming paramount in routine cancer care. This psychiatric comorbidity has several impacts on quality of life, anticancer treatment compliance, hospital stay duration, health-care costs, morbidity and possibly mortality even if discordant reports exist. RECENT FINDINGS: Recent development of brain imaging techniques (MRI, positron emission tomography), neurobiological and genetic tools allow new understanding of the pathophysiology process of depressive disorders in cancer populations besides the usual endocrinologic and psychoneuroimmunologic hypothesis. Broader indications besides depressive or anxiety disorders appear or must be investigated for the new generation of antidepressants (selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, noradrenergic specific serotonergic antidepressants) in oncology, such as hot flashes, neuropathic pain, fatigue, anorexia/cachexia. Psychosocial interventions seem to have a slight impact on well- being, quality of life and depressive symptomatology but not on survival. SUMMARY: The present article reviews recent literature on depression and cancer and highlights practical assessment and detection of depression, biological and physiopathological correlates and its pharmacologic and psychosocial treatment. Implementation of these several techniques must be supported by ongoing research about the complex relation between depressive disorders and generally mental health and oncology.
Journal of pain and symptom management, May 2008, vol. 35, no. 5
Factors correlated with fatigue in terminally ill cancer patients: a longitudinal study.
Okuyama-Toru, Akechi-Tatsuo, Shima-Yasuo, Sugahara-Yuriko et al
Abstract
Fatigue is among the most distressing symptoms experienced by terminally ill cancer patients. It is necessary to clarify factors correlated with fatigue to develop effective management strategies. A consecutive sample of cancer patients newly registered in the Palliative Care Unit (PCU) was assessed on three occasions: at the second visit to the outpatient clinic of the PCU (Time 1), three weeks after the Time 1 session over the telephone (Time 2), and at admission to the PCU (Time 3). The patients' fatigue and a broad range of biopsychosocial factors were assessed using the validated questionnaires, structured interviews, and medical record reviews at Time 1 and Time 3. Fatigue was the only factor assessed at Time 2. Two hundred patients participated in the Time 1 session, and 129 and 73 were followed at Time 2 and Time 3, respectively. Greater fatigue at Time 1 was significantly correlated with psychological distress, lower Karnofsky Performance Status score, dyspnea, and appetite loss (adjusted coefficients of determination (R(2))=0.49). Greater fatigue at Time 2 was significantly correlated with psychological distress, lower Karnofsky Performance Status and fatigue at Time 1 (adjusted R (2)=0.51). Greater fatigue at Time 3 was significantly correlated with changes for the worse in psychological distress, Karnofsky Performance Status, and dyspnea severity during the period between Time 1 and Time 3, after adjusting for Time 1 fatigue (adjusted R(2) =0.54). The results indicate that fatigue in terminally ill cancer patients is determined by both physical and psychological factors. It may be important to include psychological intervention in the multidimensional management of fatigue in this population, in addition to physical and nursing interventions.
Potential drug interactions in cancer patients receiving supportive care exclusively.
p. 535-43
Riechelmann-Rachel-P, Zimmermann-Camilla, Chin-Sheray-N, Wang-Lisa et al
Abstract
Cancer patients at the end of life often take many medications and are at risk for drug interactions. The purpose of this study was to describe the epidemiology of potential drug interactions in cancer patients receiving supportive care exclusively. We retrospectively reviewed the charts of consecutive adult cancer outpatients attending palliative care clinics at the Princess Margaret Hospital, Toronto, Canada. Drugs were screened for interactions by the Drug Interaction Facts software, which classifies interactions by levels of severity (major, moderate, and minor) and scientific evidence (1-5, with 1=the strongest level of evidence). Among 372 eligible patients, 250 potential drug interactions were identified in 115 patients (31%, 95% confidence interval 26%-36%). The most common involved warfarin and phenytoin. Most interactions were classified as being of moderate severity (59%) and 42% of them were supported by Levels 1-3 of evidence. In multivariable analysis, increasing age (P<0.001), presence of comorbidity (P=0.001), cancer type (brain tumors, P<0.001), and increasing number of drugs (P<0.001) were associated with risk of drug interactions. Potential drug interactions are common in palliative care and mostly involve warfarin and anticonvulsants. Older patients, those with comorbid conditions, brain tumor patients, and those taking many medications are at greater risk of drug interactions.
Mapping levels of palliative care development: a global view.
p. 469-85
Wright-Michael, Wood-Justin, Lynch-Thomas, Clark-David.
Abstract
Palliative care is coming to be regarded as a human right. Yet globally, palliative care development appears patchy and comparative data about the distribution of services are generally unavailable. Our purpose is to categorize hospice-palliative care development, country by country, throughout the world, and then depict this development in a series of world and regional maps. We adopt a multimethod approach, which involves the synthesis of evidence from published and grey literature, regional experts, and a task force of the European Association of Palliative Care. Development is categorized using a four-part typology constructed during a previous review of palliative care in Africa. The four categories are (1) no identified hospice-palliative care activity, (2) capacity building activity but no service, (3) localized palliative care provision, and (4) countries where palliative care activities are approaching integration with mainstream service providers. We found palliative care services in 115/234 countries. Total countries in each category are as follows: (1) no identified activity 78 (33%), (2) capacity building 41 (18%), (3) localized provision 80 (34%), and (4) approaching integration 35 (15%). The ratio of services to population among Group 4 countries ranges from 1:43,000 (in the UK) to 1:4.28 million (in Kenya); among Group 3 countries it ranges from 1:14,000 (in Gibraltar) to 1:158 million (in Pakistan). The typology differentiates levels of palliative care development across the four hemispheres and in rich and poor settings. Although half of the world's countries have a palliative care service, far more are needed before such services are generally accessible worldwide.
Okuyama-Toru, Akechi-Tatsuo, Shima-Yasuo, Sugahara-Yuriko et al
Abstract
Fatigue is among the most distressing symptoms experienced by terminally ill cancer patients. It is necessary to clarify factors correlated with fatigue to develop effective management strategies. A consecutive sample of cancer patients newly registered in the Palliative Care Unit (PCU) was assessed on three occasions: at the second visit to the outpatient clinic of the PCU (Time 1), three weeks after the Time 1 session over the telephone (Time 2), and at admission to the PCU (Time 3). The patients' fatigue and a broad range of biopsychosocial factors were assessed using the validated questionnaires, structured interviews, and medical record reviews at Time 1 and Time 3. Fatigue was the only factor assessed at Time 2. Two hundred patients participated in the Time 1 session, and 129 and 73 were followed at Time 2 and Time 3, respectively. Greater fatigue at Time 1 was significantly correlated with psychological distress, lower Karnofsky Performance Status score, dyspnea, and appetite loss (adjusted coefficients of determination (R(2))=0.49). Greater fatigue at Time 2 was significantly correlated with psychological distress, lower Karnofsky Performance Status and fatigue at Time 1 (adjusted R (2)=0.51). Greater fatigue at Time 3 was significantly correlated with changes for the worse in psychological distress, Karnofsky Performance Status, and dyspnea severity during the period between Time 1 and Time 3, after adjusting for Time 1 fatigue (adjusted R(2) =0.54). The results indicate that fatigue in terminally ill cancer patients is determined by both physical and psychological factors. It may be important to include psychological intervention in the multidimensional management of fatigue in this population, in addition to physical and nursing interventions.
Potential drug interactions in cancer patients receiving supportive care exclusively.
p. 535-43
Riechelmann-Rachel-P, Zimmermann-Camilla, Chin-Sheray-N, Wang-Lisa et al
Abstract
Cancer patients at the end of life often take many medications and are at risk for drug interactions. The purpose of this study was to describe the epidemiology of potential drug interactions in cancer patients receiving supportive care exclusively. We retrospectively reviewed the charts of consecutive adult cancer outpatients attending palliative care clinics at the Princess Margaret Hospital, Toronto, Canada. Drugs were screened for interactions by the Drug Interaction Facts software, which classifies interactions by levels of severity (major, moderate, and minor) and scientific evidence (1-5, with 1=the strongest level of evidence). Among 372 eligible patients, 250 potential drug interactions were identified in 115 patients (31%, 95% confidence interval 26%-36%). The most common involved warfarin and phenytoin. Most interactions were classified as being of moderate severity (59%) and 42% of them were supported by Levels 1-3 of evidence. In multivariable analysis, increasing age (P<0.001), presence of comorbidity (P=0.001), cancer type (brain tumors, P<0.001), and increasing number of drugs (P<0.001) were associated with risk of drug interactions. Potential drug interactions are common in palliative care and mostly involve warfarin and anticonvulsants. Older patients, those with comorbid conditions, brain tumor patients, and those taking many medications are at greater risk of drug interactions.
Mapping levels of palliative care development: a global view.
p. 469-85
Wright-Michael, Wood-Justin, Lynch-Thomas, Clark-David.
Abstract
Palliative care is coming to be regarded as a human right. Yet globally, palliative care development appears patchy and comparative data about the distribution of services are generally unavailable. Our purpose is to categorize hospice-palliative care development, country by country, throughout the world, and then depict this development in a series of world and regional maps. We adopt a multimethod approach, which involves the synthesis of evidence from published and grey literature, regional experts, and a task force of the European Association of Palliative Care. Development is categorized using a four-part typology constructed during a previous review of palliative care in Africa. The four categories are (1) no identified hospice-palliative care activity, (2) capacity building activity but no service, (3) localized palliative care provision, and (4) countries where palliative care activities are approaching integration with mainstream service providers. We found palliative care services in 115/234 countries. Total countries in each category are as follows: (1) no identified activity 78 (33%), (2) capacity building 41 (18%), (3) localized provision 80 (34%), and (4) approaching integration 35 (15%). The ratio of services to population among Group 4 countries ranges from 1:43,000 (in the UK) to 1:4.28 million (in Kenya); among Group 3 countries it ranges from 1:14,000 (in Gibraltar) to 1:158 million (in Pakistan). The typology differentiates levels of palliative care development across the four hemispheres and in rich and poor settings. Although half of the world's countries have a palliative care service, far more are needed before such services are generally accessible worldwide.
Nerve blocks in palliative care.
Nerve blocks in palliative care.
British journal of anaesthesia, Jul 2008 (epub: 20 May 2008), vol. 101, no. 1,
p. 95-100
Chambers-W-A.
Abstract
Although between 85% and 90% of patients with advanced cancer can have their pain well controlled with the use of analgesic drugs and adjuvants, there are some patients who will benefit from an interventional procedure. This includes a variety of nerve blocks and also some neurosurgical procedures. Approximately 8-10% of patients may benefit from a peripheral nerve block and around 2% from a central neuraxial block. The most common indication is because opioid dose escalation is limited by signs of opioid toxicity but some patients will benefit from one component of their pain being relieved by a simple peripheral block. Most patients about to undergo these procedures are already taking high doses of opiods and obtaining valid consent may pose problems. The use of peripheral nerve blocks, epidural and intrathecal infusions, and plexus blocks is discussed.
British journal of anaesthesia, Jul 2008 (epub: 20 May 2008), vol. 101, no. 1,
p. 95-100
Chambers-W-A.
Abstract
Although between 85% and 90% of patients with advanced cancer can have their pain well controlled with the use of analgesic drugs and adjuvants, there are some patients who will benefit from an interventional procedure. This includes a variety of nerve blocks and also some neurosurgical procedures. Approximately 8-10% of patients may benefit from a peripheral nerve block and around 2% from a central neuraxial block. The most common indication is because opioid dose escalation is limited by signs of opioid toxicity but some patients will benefit from one component of their pain being relieved by a simple peripheral block. Most patients about to undergo these procedures are already taking high doses of opiods and obtaining valid consent may pose problems. The use of peripheral nerve blocks, epidural and intrathecal infusions, and plexus blocks is discussed.
Awake palliative thoracic surgery
Awake palliative thoracic surgery in a high-risk patient: one-lung, non-invasive ventilation combined with epidural blockade.
Anaesthesia, Jul 2008 (epub: 12 Feb 2008), vol. 63, no. 7
p. 761-3
Guarracino-F, Gemignani-R, Pratesi-G, Melfi-F, Ambrosino-N.
Abstract
We report the case of a terminally ill cancer patient with recurrent pericardial and bilateral pleural effusions who was scheduled for video-assisted thoracoscopic surgery. The operation was performed with the patient awake under epidural anaesthesia. The patient's cough reflex in response to lung manipulation was successfully minimised by the inhalation of aerosolised lidocaine. Video-assisted thoracic surgery requires the exclusion of a lung from ventilation. In order to support one-lung spontaneous ventilation in this high- risk patient, we successfully used non-invasive bilevel positive airway pressure ventilation via a facemask. Based on this preliminary experience, we think that critically ill patients scheduled for palliative surgery can be successfully managed with the combination of minimally invasive surgical techniques and neuraxial block with non-invasive lung ventilation.
Anaesthesia, Jul 2008 (epub: 12 Feb 2008), vol. 63, no. 7
p. 761-3
Guarracino-F, Gemignani-R, Pratesi-G, Melfi-F, Ambrosino-N.
Abstract
We report the case of a terminally ill cancer patient with recurrent pericardial and bilateral pleural effusions who was scheduled for video-assisted thoracoscopic surgery. The operation was performed with the patient awake under epidural anaesthesia. The patient's cough reflex in response to lung manipulation was successfully minimised by the inhalation of aerosolised lidocaine. Video-assisted thoracic surgery requires the exclusion of a lung from ventilation. In order to support one-lung spontaneous ventilation in this high- risk patient, we successfully used non-invasive bilevel positive airway pressure ventilation via a facemask. Based on this preliminary experience, we think that critically ill patients scheduled for palliative surgery can be successfully managed with the combination of minimally invasive surgical techniques and neuraxial block with non-invasive lung ventilation.
Views of nurse prescribing among Macmillan nurses
Exploring the views of nurse prescribing among Macmillan nurses.
Full text available at Ebsco CINAHL Athens
British journal of community nursing, Apr 2008, vol. 13, no. 4, p. 171-2, 174-7
Ryan-Woolley-Bernadette, McHugh-Gretl, Luker-Karen.
Abstract
Nurse prescribing is a key government initiative which aims to enhance patient care. The aim of this study was to investigate the prescribing practice of specialist nurses working in cancer and palliative care and to explore the benefits of and barriers to uptake of nurse prescribing training. A national postal survey of 2252 Macmillan nurses was undertaken using a structured questionnaire with open-ended questions. Data were analyzed using thematic content analysis for 1575 respondents (70% response rate). Only 13% (203) had undergone prescribing training and of these 105 provided responses to the open questions concerning training and of the 87% (1372) who had not undergone the training, 423 provided details on barriers to nurse prescribing training. The data presented in this paper draw from this data. The findings indicate that those who prescribed gave the prospect of improving care as the main reason for undertaking nurse prescribing training. The main reasons why these specialist nurses did not undertake training were: resource issues particularly with respect to backfill while training, lack of medical support and mentorship, concerns about the relevance of prescribing as a nursing role and prioritizing other courses. If nurse prescribing is to be more widely available for cancer and palliative care patients it is important in both primary and secondary care to address the resource and support issues.
Full text available at Ebsco CINAHL Athens
British journal of community nursing, Apr 2008, vol. 13, no. 4, p. 171-2, 174-7
Ryan-Woolley-Bernadette, McHugh-Gretl, Luker-Karen.
Abstract
Nurse prescribing is a key government initiative which aims to enhance patient care. The aim of this study was to investigate the prescribing practice of specialist nurses working in cancer and palliative care and to explore the benefits of and barriers to uptake of nurse prescribing training. A national postal survey of 2252 Macmillan nurses was undertaken using a structured questionnaire with open-ended questions. Data were analyzed using thematic content analysis for 1575 respondents (70% response rate). Only 13% (203) had undergone prescribing training and of these 105 provided responses to the open questions concerning training and of the 87% (1372) who had not undergone the training, 423 provided details on barriers to nurse prescribing training. The data presented in this paper draw from this data. The findings indicate that those who prescribed gave the prospect of improving care as the main reason for undertaking nurse prescribing training. The main reasons why these specialist nurses did not undertake training were: resource issues particularly with respect to backfill while training, lack of medical support and mentorship, concerns about the relevance of prescribing as a nursing role and prioritizing other courses. If nurse prescribing is to be more widely available for cancer and palliative care patients it is important in both primary and secondary care to address the resource and support issues.
BMC health services research
A method to determine spatial access to specialized palliative care services using GIS.
BMC health services research, 2008 (epub), vol. 8, p. 140
Cinnamon-Jonathan, Schuurman-Nadine, Crooks-Valorie-A.
Abstract
BACKGROUND: Providing palliative care is a growing priority for health service administrators worldwide as the populations of many nations continue to age rapidly. In many countries, palliative care services are presently inadequate and this problem will be exacerbated in the coming years. The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there is little distinction made at present between levels of service provision. There is a pressing need to determine which populations do not enjoy access to specialized palliative care services in particular. METHODS: Catchments around existing specialized palliative care services in the Canadian province of British Columbia were calculated based on real road travel time. Census block face population counts were linked to postal codes associated with road segments in order to determine the percentage of the total population more than one hour road travel time from specialized palliative care. RESULTS: Whilst 81% of the province's population resides within one hour from at least one specialized palliative care service, spatial access varies greatly by regional health authority. Based on the definition of specialized palliative care adopted for the study, the Northern Health Authority has, for instance, just two such service locations, and well over half of its population do not have reasonable spatial access to such care. CONCLUSION: Strategic location analysis methods must be developed and used to accurately locate future palliative services in order to provide spatial access to the greatest number of people, and to ensure that limited health resources are allocated wisely. Improved spatial access has the potential to reduce travel-times for patients, for palliative care workers making home visits, and for travelling practitioners. These methods are particularly useful for health service planners - and provide a means to rationalize their decision-making. Moreover, they are extendable to a number of health service allocation problems.
BMC health services research, 2008 (epub), vol. 8, p. 140
Cinnamon-Jonathan, Schuurman-Nadine, Crooks-Valorie-A.
Abstract
BACKGROUND: Providing palliative care is a growing priority for health service administrators worldwide as the populations of many nations continue to age rapidly. In many countries, palliative care services are presently inadequate and this problem will be exacerbated in the coming years. The provision of palliative care, moreover, has been piecemeal in many jurisdictions and there is little distinction made at present between levels of service provision. There is a pressing need to determine which populations do not enjoy access to specialized palliative care services in particular. METHODS: Catchments around existing specialized palliative care services in the Canadian province of British Columbia were calculated based on real road travel time. Census block face population counts were linked to postal codes associated with road segments in order to determine the percentage of the total population more than one hour road travel time from specialized palliative care. RESULTS: Whilst 81% of the province's population resides within one hour from at least one specialized palliative care service, spatial access varies greatly by regional health authority. Based on the definition of specialized palliative care adopted for the study, the Northern Health Authority has, for instance, just two such service locations, and well over half of its population do not have reasonable spatial access to such care. CONCLUSION: Strategic location analysis methods must be developed and used to accurately locate future palliative services in order to provide spatial access to the greatest number of people, and to ensure that limited health resources are allocated wisely. Improved spatial access has the potential to reduce travel-times for patients, for palliative care workers making home visits, and for travelling practitioners. These methods are particularly useful for health service planners - and provide a means to rationalize their decision-making. Moreover, they are extendable to a number of health service allocation problems.
BMC Palliative Care
Palliative care in advanced dementia; a mixed methods approach for the development of a complex intervention
Elizabeth L Sampson ; Ingela Thune - Boyle ; Riitta Kukkastenvehmas ; Louise Jones ; Adrian Tookman ; Michael King and Martin R Blanchard
ISSUE: 2008 ; VOL 7
[PDF] [Abstract]
Page: 8
Elizabeth L Sampson ; Ingela Thune - Boyle ; Riitta Kukkastenvehmas ; Louise Jones ; Adrian Tookman ; Michael King and Martin R Blanchard
ISSUE: 2008 ; VOL 7
[PDF] [Abstract]
Page: 8
International Journal of Palliative Nursing 2008 Vol 14 Part 6
Discussions at the end of life
Mula , C
Page: 263
What do community nurse specialists do? An activity analysis
Newbury , J . ; de Leeuw , W . ; Newton , C .
Page: 264-273
Spirituality in palliative care: what language do we need ?
Byrne , M
Page: 274-280
Saying it in song: music therapy as a carer support intervention
O Kelly , J
Page: 281-286
Families' transition to a Canadian paediatric hospice. Part two: results of a pilot study
Author(s): Steele , R . ; Derman , S . ; Cadell , S . ; Davies , B . ; Siden , H . ; Straatman , L
Page: 287-296
The grief experience of same-sex couples within an Irish context
Author(s): Glackin , M . ; Higgins , A .
Page: 297-302
Transferring knowledge: evaluating the use of a telephone advice line
Author(s): Carr , S . M . ; Lhussier , M . ; Wilcockson , J .
Page: 303-308
Mula , C
Page: 263
What do community nurse specialists do? An activity analysis
Newbury , J . ; de Leeuw , W . ; Newton , C .
Page: 264-273
Spirituality in palliative care: what language do we need ?
Byrne , M
Page: 274-280
Saying it in song: music therapy as a carer support intervention
O Kelly , J
Page: 281-286
Families' transition to a Canadian paediatric hospice. Part two: results of a pilot study
Author(s): Steele , R . ; Derman , S . ; Cadell , S . ; Davies , B . ; Siden , H . ; Straatman , L
Page: 287-296
The grief experience of same-sex couples within an Irish context
Author(s): Glackin , M . ; Higgins , A .
Page: 297-302
Transferring knowledge: evaluating the use of a telephone advice line
Author(s): Carr , S . M . ; Lhussier , M . ; Wilcockson , J .
Page: 303-308
Friday, 22 August 2008
Paediatric palliative care.
Paediatric palliative care.
Lancet, 28 Jun 2008, vol. 371, no. 9631,
p. 2169
Darlington-Anne-Sophie-E, van-den-Heuvel-Eibrink-Marry-M, Passchier- Jan.
Publication type
Comment, Letter.
Comment on: Lancet. 2008 Mar 8; 371(9615):852-64.
Paediatric palliative care.
Lancet 28 Jun 2008, vol. 371, no. 9631, p. 2169
Vissers-Kris-C-P, Engels-Yvonne, Verhagen-Constans.
Comment, Letter.
Comment on: Lancet. 2008 Mar 8; 371(9615):852-64.
Lancet, 28 Jun 2008, vol. 371, no. 9631,
p. 2169
Darlington-Anne-Sophie-E, van-den-Heuvel-Eibrink-Marry-M, Passchier- Jan.
Publication type
Comment, Letter.
Comment on: Lancet. 2008 Mar 8; 371(9615):852-64.
Paediatric palliative care.
Lancet 28 Jun 2008, vol. 371, no. 9631, p. 2169
Vissers-Kris-C-P, Engels-Yvonne, Verhagen-Constans.
Comment, Letter.
Comment on: Lancet. 2008 Mar 8; 371(9615):852-64.
Impact of specialty on attitudes of Australian medical practitioners to end-of-life decisions.
Impact of specialty on attitudes of Australian medical practitioners to end-of-life decisions.
Full text available at ProQuest
The Medical journal of Australia 21 Apr 2008, vol. 188, no. 8
p. 450-6
Parker-Malcolm-H, Cartwright-Colleen-M, Williams-Gail-M.
Abstract
OBJECTIVE: To compare attitudes and practices of Australian medical practitioners, by specialty, to a range of medical decisions at the end of life. DESIGN, SETTING AND PARTICIPANTS: As part of an international study, in 2003, a structured questionnaire was mailed to 2964 medical practitioners drawn from membership registers of Australian and Australasian professional colleges. Data from 1478 questionnaires were statistically analysed using validated instruments. MAIN OUTCOME MEASURES: Practitioners' willingness to comply with requests from patients and/or their relatives for symptom relief which might also hasten death; provision of terminal sedation and euthanasia, or willingness to provide these on their own initiative. RESULTS: Respondents reported being much more willing to comply with a patient's request for increasing symptom relief, even at risk of hastening death, than for terminal sedation. Over a quarter of respondents would provide terminal sedation to competent patients on their own initiative. A small number of respondents would intentionally hasten death. There were significant differences by specialty for all three actions. Oncologists, palliative care physicians and geriatricians were least likely to actively hasten death, and more likely to act unilaterally to relieve symptoms as a medical necessity. CONCLUSIONS: Perceptions about the causation of death and aspects of medical culture appear to influence physicians' attitudes towards medical decisions at the end of life. Our findings have implications for medical education, interprofessional communication and discussion between the medical profession and the community.
Full text available at ProQuest
The Medical journal of Australia 21 Apr 2008, vol. 188, no. 8
p. 450-6
Parker-Malcolm-H, Cartwright-Colleen-M, Williams-Gail-M.
Abstract
OBJECTIVE: To compare attitudes and practices of Australian medical practitioners, by specialty, to a range of medical decisions at the end of life. DESIGN, SETTING AND PARTICIPANTS: As part of an international study, in 2003, a structured questionnaire was mailed to 2964 medical practitioners drawn from membership registers of Australian and Australasian professional colleges. Data from 1478 questionnaires were statistically analysed using validated instruments. MAIN OUTCOME MEASURES: Practitioners' willingness to comply with requests from patients and/or their relatives for symptom relief which might also hasten death; provision of terminal sedation and euthanasia, or willingness to provide these on their own initiative. RESULTS: Respondents reported being much more willing to comply with a patient's request for increasing symptom relief, even at risk of hastening death, than for terminal sedation. Over a quarter of respondents would provide terminal sedation to competent patients on their own initiative. A small number of respondents would intentionally hasten death. There were significant differences by specialty for all three actions. Oncologists, palliative care physicians and geriatricians were least likely to actively hasten death, and more likely to act unilaterally to relieve symptoms as a medical necessity. CONCLUSIONS: Perceptions about the causation of death and aspects of medical culture appear to influence physicians' attitudes towards medical decisions at the end of life. Our findings have implications for medical education, interprofessional communication and discussion between the medical profession and the community.
End-of-life care in the trauma intensive care unit
Changing the culture around end-of-life care in the trauma intensive care unit.
The Journal of trauma Jun 2008, vol. 64, no. 6
p. 1587-93
Abstract
BACKGROUND: Ten percent to 20% of trauma patients admitted to the intensive care unit (ICU) will die from their injuries. Providing appropriate end-of-life care in this setting is difficult and often late in the patients' course. Patients are young, prognosis uncertain, and conflict common around goals of care. We hypothesized that early, structured communication in the trauma ICU would improve end-of-life care practice. METHODS: Prospective, observational, prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into standard ICU care. The program included part I, early (at admission) family bereavement support, assessment of prognosis, and patient preferences, and part II (within 72 hours) interdisciplinary family meeting. Data on goals of care discussions, do-not-resuscitate (DNR) orders and withdrawal of life support (W/D) were collected from physician rounds, family meetings, and medical records. RESULTS: Eighty-three percent of patients received part I and 69% part II intervention. Discussion of goals of care by physicians on rounds increased from 4% to 36% of patient-days. During intervention, rates of mortality (14%), DNR (43%), and W/D (24%) were unchanged, but DNR orders and W/D were instituted earlier in hospital course. ICU length of stay was decreased in patients who died. CONCLUSIONS: Structured communication between physician and families resulted in earlier consensus around goals of care for dying trauma patients. Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU.
The Journal of trauma Jun 2008, vol. 64, no. 6
p. 1587-93
Abstract
BACKGROUND: Ten percent to 20% of trauma patients admitted to the intensive care unit (ICU) will die from their injuries. Providing appropriate end-of-life care in this setting is difficult and often late in the patients' course. Patients are young, prognosis uncertain, and conflict common around goals of care. We hypothesized that early, structured communication in the trauma ICU would improve end-of-life care practice. METHODS: Prospective, observational, prepost study on consecutive trauma patients admitted to the ICU before and after a structured palliative care intervention was integrated into standard ICU care. The program included part I, early (at admission) family bereavement support, assessment of prognosis, and patient preferences, and part II (within 72 hours) interdisciplinary family meeting. Data on goals of care discussions, do-not-resuscitate (DNR) orders and withdrawal of life support (W/D) were collected from physician rounds, family meetings, and medical records. RESULTS: Eighty-three percent of patients received part I and 69% part II intervention. Discussion of goals of care by physicians on rounds increased from 4% to 36% of patient-days. During intervention, rates of mortality (14%), DNR (43%), and W/D (24%) were unchanged, but DNR orders and W/D were instituted earlier in hospital course. ICU length of stay was decreased in patients who died. CONCLUSIONS: Structured communication between physician and families resulted in earlier consensus around goals of care for dying trauma patients. Integration of early palliative care alongside aggressive trauma care can be accomplished without change in mortality and has the ability to change the culture of care in the trauma ICU.
Palliative care - Annals of Oncology
Palliative care
Annals of Oncology July 2008 ; VOL 19 ; PART suppl_5
Page: v160 - v160
Annals of Oncology July 2008 ; VOL 19 ; PART suppl_5
Page: v160 - v160
Tuesday, 29 July 2008
New Library book
In the Health Sciences Library:
Royal College of Physicians
Palliative care services : meeting the needs of patients Nov 2007
Shelved at 616.994 ROY
Royal College of Physicians
Palliative care services : meeting the needs of patients Nov 2007
Shelved at 616.994 ROY
Thursday, 17 July 2008
Delivering effective end-of-life care: developing partnership working
Delivering effective end-of-life care: developing partnership working
Wednesday 15 October 2008, 10.00am–4.15pm Royal College of Obstetricians and Gynaecologists, London
Recognition of the need for good-quality end-of-life care is at the heart of the government's new End of Life Care Strategy. Produced in partnership between The King's Fund, Marie Curie Cancer Care and the National Council for Palliative Care, this one-day conference will highlight the key challenges involved in implementing the strategy.
Much pioneering work has been done by a wide range of organisations across health and social care. In order to enable greater choice for those at the end of their life, there is now a move towards more effective commissioning and co-ordination of this care. We will share good practice and innovation using case studies and interactive workshops, with a focus on partnership working.
We are delighted to announce that Professor Mike Richards CBE, Chair, End of Life Care Strategy Advisory Board and National Clinical Director for Cancer, will give the keynote address and that the full conference programme is available on our website.
Confirmed speakers include the following:
Dr James Beattie, National Clinical Lead, NHS Heart Improvement Programme and Consultant Cardiologist, Birmingham Heartlands Hospital, on delivering effective end-of-life care for non-cancer patients.
Dr Andrew Daley, Consultant, Bradford Teaching Hospitals NHS Foundation Trust, on identifying and better understanding your palliative care patients.
Martin Green, Chief Executive, English Community Care Association, on the challenges of partnership working.
Penny Hansford, Director of Nursing, St Christopher's Hospice, on delivering staff skills.
Martin McShane, Director of Strategic Planning and Health Outcomes, Lincolnshire Primary Care Trust, on the challenges of commissioning.
Wednesday 15 October 2008, 10.00am–4.15pm Royal College of Obstetricians and Gynaecologists, London
Recognition of the need for good-quality end-of-life care is at the heart of the government's new End of Life Care Strategy. Produced in partnership between The King's Fund, Marie Curie Cancer Care and the National Council for Palliative Care, this one-day conference will highlight the key challenges involved in implementing the strategy.
Much pioneering work has been done by a wide range of organisations across health and social care. In order to enable greater choice for those at the end of their life, there is now a move towards more effective commissioning and co-ordination of this care. We will share good practice and innovation using case studies and interactive workshops, with a focus on partnership working.
We are delighted to announce that Professor Mike Richards CBE, Chair, End of Life Care Strategy Advisory Board and National Clinical Director for Cancer, will give the keynote address and that the full conference programme is available on our website.
Confirmed speakers include the following:
Dr James Beattie, National Clinical Lead, NHS Heart Improvement Programme and Consultant Cardiologist, Birmingham Heartlands Hospital, on delivering effective end-of-life care for non-cancer patients.
Dr Andrew Daley, Consultant, Bradford Teaching Hospitals NHS Foundation Trust, on identifying and better understanding your palliative care patients.
Martin Green, Chief Executive, English Community Care Association, on the challenges of partnership working.
Penny Hansford, Director of Nursing, St Christopher's Hospice, on delivering staff skills.
Martin McShane, Director of Strategic Planning and Health Outcomes, Lincolnshire Primary Care Trust, on the challenges of commissioning.
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
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
End-of-life care in UK critical care units
End-of-life care in UK critical care units - a literature review.
Nursing in critical care, May-Jun 2008, vol. 13, no. 3
p. 152-61
Morgan-Jane.
Abstract
AIM: To appraise literature concerning end-of-life care (ELC) in adult critical care units in the UK in order to improve clinical practice. OBJECTIVE: To understand the interplay between legal and ethical, political, societal aspects of ELC for sustainable quality care. BACKGROUND: Significant changes in health care policy for the critically ill patient have occurred since 1999. Simultaneously, the government is committed to improving care for the dying by integrating the palliative care ethos across the National Institutes of Health (NHS) to include non-cancer sufferers. Death continues to be a feature of critical illness, particularly following the decision to withhold/withdraw life-prolonging treatments. SEARCH STRATEGY: A search of MEDLINE, BNI, CINAHL and PSYCinfo using key words revealed very few results; consequently, the search was broadened to include ASSIA, King's Fund, TRIP, Healthstar, NHS Economic Evaluation Data, Cochrane, professional journals and government documents. CONCLUSIONS: The literature reveals a paradigm shift from critical to palliative care, in other words, from a reductionist approach to a more humanistic approach in the acute setting. When treatment is deemed futile, quality ELC involving the assessment, ongoing assessment and care after death becomes the new goal for the critical care team. To practice ELC competently, nurses require organizational and educational support at local and national levels. RELEVANCE TO CLINICAL PRACTICE: Although medico-legal decision-making is not part of their professional role, critical care nurses have an extraordinary opportunity to make a difference to the dying patient and their family and their acceptance of death.
Nursing in critical care, May-Jun 2008, vol. 13, no. 3
p. 152-61
Morgan-Jane.
Abstract
AIM: To appraise literature concerning end-of-life care (ELC) in adult critical care units in the UK in order to improve clinical practice. OBJECTIVE: To understand the interplay between legal and ethical, political, societal aspects of ELC for sustainable quality care. BACKGROUND: Significant changes in health care policy for the critically ill patient have occurred since 1999. Simultaneously, the government is committed to improving care for the dying by integrating the palliative care ethos across the National Institutes of Health (NHS) to include non-cancer sufferers. Death continues to be a feature of critical illness, particularly following the decision to withhold/withdraw life-prolonging treatments. SEARCH STRATEGY: A search of MEDLINE, BNI, CINAHL and PSYCinfo using key words revealed very few results; consequently, the search was broadened to include ASSIA, King's Fund, TRIP, Healthstar, NHS Economic Evaluation Data, Cochrane, professional journals and government documents. CONCLUSIONS: The literature reveals a paradigm shift from critical to palliative care, in other words, from a reductionist approach to a more humanistic approach in the acute setting. When treatment is deemed futile, quality ELC involving the assessment, ongoing assessment and care after death becomes the new goal for the critical care team. To practice ELC competently, nurses require organizational and educational support at local and national levels. RELEVANCE TO CLINICAL PRACTICE: Although medico-legal decision-making is not part of their professional role, critical care nurses have an extraordinary opportunity to make a difference to the dying patient and their family and their acceptance of death.
Understanding palliative nursing care
Understanding palliative nursing care.
Full text available at ProQuest
The Journal of practical nursing, Spring 2008, vol. 58, no. 1
p. 6-9; quiz 10-1
Geoghan-Darlene-A.
Abstract
Palliative care is care that is given to patients and their significant others who are experiencing life-threatening or life- altering illnesses by providing emotional, spiritual, and physical support. Patients can continue to receive aggressive medical treatment while receiving palliative care and recovery is possible. Pain control is a top priority in palliative care. Non- pharmacological interventions have also been shown to be effective in palliative care as well. Palliative care is truly a holistic, collaborative practice engaging many disciplines in the care of the patient and their love ones.
Full text available at ProQuest
The Journal of practical nursing, Spring 2008, vol. 58, no. 1
p. 6-9; quiz 10-1
Geoghan-Darlene-A.
Abstract
Palliative care is care that is given to patients and their significant others who are experiencing life-threatening or life- altering illnesses by providing emotional, spiritual, and physical support. Patients can continue to receive aggressive medical treatment while receiving palliative care and recovery is possible. Pain control is a top priority in palliative care. Non- pharmacological interventions have also been shown to be effective in palliative care as well. Palliative care is truly a holistic, collaborative practice engaging many disciplines in the care of the patient and their love ones.
BMC medical research methodology, 2008 (epub) , vol. 8
The changing causal foundations of cancer-related symptom clustering during the final month of palliative care: a longitudinal study.
p. 36
Olson-Karin, Hayduk-Leslie, Cree-Marilyn, Cui-Ying et al
Abstract
BACKGROUND: Symptoms tend to occur in what have been called symptom clusters. Early symptom cluster research was imprecise regarding the causal foundations of the coordinations between specific symptoms, and was silent on whether the relationships between symptoms remained stable over time. This study develops a causal model of the relationships between symptoms in cancer palliative care patients as they approach death, and investigates the changing associations among the symptoms and between those symptoms and well-being. METHODS: Complete symptom assessment scores were obtained for 82 individuals from an existing palliative care database. The data included assessments of pain, anxiety, nausea, shortness of breath, drowsiness, loss of appetite, tiredness, depression and well-being, all collected using the Edmonton Symptom Assessment System (ESAS). Relationships between the symptoms and well-being were investigated using a structural equation model. RESULTS: The model fit acceptably and explained between 26% and 83% of the variation in appetite, tiredness, depression, and well-being. Drowsiness displayed consistent effects on appetite, tiredness and well-being. In contrast, anxiety's effect on well-being shifted importantly, with a direct effect and an indirect effect through tiredness at one month, being replaced by an effect working exclusively through depression at one week. CONCLUSION: Some of the causal forces explaining the variations in, and relationships among, palliative care patients' symptoms changed over the final month of life. This illustrates how investigating the causal foundations of symptom correlation or clustering can provide more detailed understandings that may contribute to improved control of patient comfort, quality of life, and quality of death.
p. 36
Olson-Karin, Hayduk-Leslie, Cree-Marilyn, Cui-Ying et al
Abstract
BACKGROUND: Symptoms tend to occur in what have been called symptom clusters. Early symptom cluster research was imprecise regarding the causal foundations of the coordinations between specific symptoms, and was silent on whether the relationships between symptoms remained stable over time. This study develops a causal model of the relationships between symptoms in cancer palliative care patients as they approach death, and investigates the changing associations among the symptoms and between those symptoms and well-being. METHODS: Complete symptom assessment scores were obtained for 82 individuals from an existing palliative care database. The data included assessments of pain, anxiety, nausea, shortness of breath, drowsiness, loss of appetite, tiredness, depression and well-being, all collected using the Edmonton Symptom Assessment System (ESAS). Relationships between the symptoms and well-being were investigated using a structural equation model. RESULTS: The model fit acceptably and explained between 26% and 83% of the variation in appetite, tiredness, depression, and well-being. Drowsiness displayed consistent effects on appetite, tiredness and well-being. In contrast, anxiety's effect on well-being shifted importantly, with a direct effect and an indirect effect through tiredness at one month, being replaced by an effect working exclusively through depression at one week. CONCLUSION: Some of the causal forces explaining the variations in, and relationships among, palliative care patients' symptoms changed over the final month of life. This illustrates how investigating the causal foundations of symptom correlation or clustering can provide more detailed understandings that may contribute to improved control of patient comfort, quality of life, and quality of death.
Friday, 11 July 2008
BMC Health Services Research 2008 Vol 8
A method to determine spatial access to specialized palliative care services using GIS
Jonathan Cinnamon ; Nadine Schuurman and Valorie A Crooks
2008 ; VOL 8 (2008-01-07)
From BioMed Central [PDF] [Abstract]
Page: 140
Jonathan Cinnamon ; Nadine Schuurman and Valorie A Crooks
2008 ; VOL 8 (2008-01-07)
From BioMed Central [PDF] [Abstract]
Page: 140
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