Abstract
Mercadante S: Intravenous morphine for management of cancer pain. Lancet Oncology 2010;11:484–489.
Opioids are the cornerstone of pain management in patients with cancer. Although oral administration of opioids is preferable, many times parenteral routes may be necessary during progression of disease. In this review article, the well-known Dr. Mercadante provides an overview of the use of intravenous morphine to control pain in cancer patients. The article discusses various aspects of the use of intravenous morphine, including breakthrough pain, opioid titration, and potential interactions of morphine, and is recommended reading.
Johnson RW, Newby LK, Granger CB, Cook WA, Peterson ED, Echols M, Bride W, Granger BB: Differences in level of care at the end of life according to race. Am J Crit Care 2010;19:335–344.
An estimated 20% of American deaths now occur in intensive care units (ICUs). Although recent studies have evaluated the trends in increased costs of ICU care, little research has attempted to understand patients' preferences associated with the level of care at the end of life. In this study, the authors attempted to examine the factors associated with patients' choices for level of care at the end of life. Data on demographics and level of care (i.e., full code, do not resuscitate, withdrawal of life support) were collected on 1072 patients who died between January 1998 and June 2006 on a cardiac care unit. Results demonstrated that the median age of blacks was 64 years and of whites 70 years. At the time of death, level of care differed significantly between blacks and whites, with 41.8% of blacks and 26.7% of whites deemed full code, while 37.3% of blacks and 43.9% of whites chose do not resuscitate status. In addition, 20.9% of blacks and 29.3% of whites chose withdrawal of life support. After age, gender, diagnosis, and lengths of stay were controlled for, blacks were more likely than whites to choose full code status at the time of death. The authors conclude that blacks are 1.9 times as likely to choose full code at the time of death, and cultural differences should be acknowledged when providing end-of-life care.
Keating NL, Landrum MB, Lamont EB, Earle CC, Bozeman SR, McNeil BJ: End-of-life care for older cancer patients in the Veterans Health Administration versus the private sector. Cancer 2010;116:3732–3739.
Research has demonstrated significant variation in the costs and aggressive nature of care delivered to patients with cancer and other chronic illnesses at the end of life. In this study, the authors attempted to compare aggressiveness of end-of-life care of older metastatic cancer patients treated in the veterans Health Administration (VHA) and those under fee-for-service (FFS) Medicare arrangements. Using propensity score methods, the authors matched 2913 male veterans diagnosed with stage IV lung or colorectal cancer in 2001-2002 and died before 2006 with 2913 similar men enrolled in FFS Medicare living in Surveillance, Epidemiology, and End Results (SEER) areas. Results demonstrated that among matched cohorts, men treated in the VHA health care system were less likely than men in the private FFS sector to receive chemotherapy within 14 days of death, be admitted to an intensive care unit within 30 days of death, or have more than 1 emergency room visit within 30 days of death. The authors conclude that older men with metastatic lung or colorectal cancer treated in the VHA system received less aggressive end-of-life care than similar men in FFS Medicare. The authors contemplate that this may result from the absence of financial incentives for more intensive care in the VHA or because the VHA integrated delivery system better structured to limit potentially overaggressive care.
Chun ED, Rodgers PE, Vitale CA, Collins CD, Malani PN: Antimicrobial use among patients receiving palliative care consultation. Am J Hospice Palliat Med 2010;27:261–265.
Patients for whom palliative care consultations have been requested have often been hospitalized numerous times related to exacerbations of chronic conditions. The focus of care is usually directed at treating potentially reversible aspects of their disease, without full recognition by physicians, patients, and family members of overall functional decline and diminishing capacity for recovery. Often, major surgical procedures, chemotherapy, or other treatments that will not support function or comfort are not offered, but antibiotics are usually viewed as usual care and not aggressive care. In this study, the authors sought to characterize antimicrobial use among patients receiving palliative care consultation. A retrospective review of patients seen by the University of Michigan Health System Palliative Care Service from January 2008 until May 2008 was undertaken. Results demonstrated that of 131 patients seen in consultation, 70 received antibiotics. There were 92 infections among the 70 patients, of which therapy was empiric for 58. Piperacillin/tazobactam was the most frequently utilized agent, being used in 26 patients, while vancomycin was prescribed in 23 patients. Sixteen patients died in hospital, while 31 were enrolled in hospice. The authors conclude that this study suggests that significant use of broad-spectrum antimicrobial therapy occurs among patients hospitalized near the end of life.
Bruera E, Billings JA, Lupu D, Ritchie CS; Academic Palliative Medicine Task Force of the American Academy of Hospice and Palliative Medicine: AAHPM Position Paper: requirements for the successful development of academic palliative care programs. J Pain Symptom Manage 2010;39:743–755.
More palliative care programs are being developed, many taking place in academic medical centers. In this position paper from the American Academy of Hospice and Palliative Medicine, the authors provide a concrete and clear guidance to programs developing, or being considered for development. For anyone considering development of such a program, or struggling through the infancy of such a program, this is valuable information.