Abstract
Zang B, Nilsson ME, Prigerson HG: Factors important to patients' quality of life at the end of life. Arch Intern Med 2012; published online first: doi:10.1001/archinternmed.2012.2364.
When curative treatments are no longer options for patients dying of cancer, the focus of care often turns from prolonging life to promoting quality of life (QOL). Few data exist on what predicts a better QOL at the end of life (EOL) for advanced cancer patients. The purpose of this multisite, prospective, longitudinal cohort study was to determine the factors that most influence QOL at the EOL, thereby identifying promising targets for interventions to promote QOL at the EOL. Three-hundred ninety-six advanced cancer patients and their informal caregivers were enrolled from September 1, 2002, through February 28, 2008. Patients were followed up from enrollment to death a median of 4.1 months later. Patient QOL in the last week of life was a primary outcome of the study. Results demonstrated that the following set of nine factors, preceded by a sign indicating the direction of the effect and presented in rank order of importance, explained the most variance in patients' QOL at the EOL: 1=(−) intensive care unit stays in the final week (explained 4.4% of the variance in QOL at the EOL), 2=(−) hospital deaths (2.7%), 3=(−) patient worry at baseline (2.7%), 4=(+) religious prayer or meditation at baseline (2.5%), 5=site of cancer care (1.8%), 6=(−) feeding tube use in the final week (1.1%), 7=(+) pastoral care within the hospital or clinic (1.0%), 8=(−) chemotherapy in the final week (0.8%), and 9=(+) patient-physician therapeutic alliance at baseline (0.7%). The vast majority of the variance in QOL at the EOL, however, remained unexplained. The authors conclude that advanced cancer patients who avoid hospitalizations and the intensive care unit, who are less worried, who pray or meditate, who are visited by a pastor in the hospital/clinic, and who feel a therapeutic alliance with their physicians have the highest QOL at the EOL.
Kelley AS, Ettner SL, Morrison S, Du Q, Sarkisian CA: Disability and decline in physical function associated with hospital use at end of life. J Gen Intern Med 2012;27:794–800.
Hospital use near the end of life (EOL) is often undesirable to patients, represents considerable Medicare cost, and varies widely across regions. In this study, the authors concurrently examined regional and patient factors, including disability and functional decline, associated with EOL hospital use. They sampled decedents aged 65 and older (n=2,493) from the Health and Retirement Study (2000–2006), and linked data from individual Medicare claims and the Dartmouth Atlas of Health Care. Two-part regression models estimated the relationship between total hospital days in the last six months and patient characteristics including physical function, while adjusting for regional resources and hospital care intensity (HCI). Results demonstrated that median hospital days was 7 (range=0–183), with 53% of respondents exhibiting functional decline. Compared with decedents without functional decline, those with severe disability or decline had more regression-adjusted hospital days (range 3.47–9.05, depending on category). Dementia was associated with fewer days (−3.02); while chronic kidney disease (2.37), diabetes (2.40), stroke or transient ischemic attack (2.11), and congestive heart failure (1.74) were associated with more days. African Americans and Hispanics had more days (5.91 and 4.61, respectively). Those with family nearby had 1.62 fewer days and hospice enrollees had 1.88 fewer days. Additional hospital days were associated with urban residence (1.74) and residence in a region with more specialists (1.97) and higher HCI (2.27). The authors conclude that functional decline is significantly associated with EOL hospital use among older adults. To improve care and reduce costs, health care programs and policies should address specific needs of patients with functional decline and disability.
Mercadante S: Switching methadone: A 10-year experience of 345 patients in an acute palliative care unit. Pain Med 2012;13:399
The aim of this study was to retrospectively review the charts of cancer patients switched to methadone for unfavorable response to the use of a previous opioid. Consecutive medical records of patients undergoing opioid switching to methadone were retrospectively reviewed and evaluated. Patients were selected who were switched from different opioids to methadone, because of poor pain relief in the presence of adverse effects limiting further dose increases despite symptomatic treatment. After the initial oral dose, the subsequent doses were flexible and were changed in a timely manner to fit the patients' needs in an attempt to find the best balance between pain and opioid-related symptoms. Results demonstrated that 345 patients underwent switching to methadone. Twenty-seven patients were not considered feasible for analysis. Only one patient required the use of naloxone for the occurrence of bradypnea. A total of 77.4% substitutions for methadone were considered successful. The median time to achieve daily dose stabilization in patients successfully switched was three days. Fifty-one substitutions failed. For all previous opioids, no significant differences between initial conversion ratios and ratios achieved after stabilization were found (P=0.42). No significant correlation between the previous opioid dose and the final conversion ratio was found (P=0.19). The author concludes that switching to methadone from different opioids, using an initial fixed ratio followed by a flexible dosing according to the clinical need, is highly effective and safe when performed in an acute pain relief and palliative care unit. The author also notes that further studies should assess this approach in other settings.
Kopp LM, Gupta P, Pelayo-Katsanis L, et al.: Late effects in adult survivors of pediatric cancer: A guide for the primary care physician. Am J Med 2012;125:636–641.
Due to significant medical advances in the past 50 years, the number of adult survivors of childhood/adolescent cancer has increased dramatically. Unfortunately, more than 60% of these survivors will have at least one long-term side effect from treatment. This growing population requires dedicated care by primary physicians, because they have specific risk factors depending on their initial cancer diagnosis and the treatment modalities they received. Internists and family physicians play an integral role in providing appropriate screening, treatment, and counseling to prevent morbidity and mortality in these patients. Lingering effects of childhood cancer treatment that are discussed in this article include endocrine, cardiovascular, pulmonary, central nervous system, genitourinary, gastrointestinal, musculoskeletal, and secondary malignancies.
Osmonov D, Ozcan KS, Altay S, et al.: Alzheimer's disease: Is pacemaker implantation safe? Am J Alzheimers Dis Other Demen 2012;27:202–205.
In this study the authors attempted to evaluate the safety of pacemaker implantation in patients with Alzheimer's disease (AD). They reviewed all cases admitted to their institution between January 2008 and June 2009, with symptomatic bradyarrhythmia for whom a permanent pacemaker was implanted. Beginning in June 2009, the authors prospectively collected data from all patients with the same diagnosis and procedure. Patients with a diagnosis of AD were included in the study. The risks and frequency of complications due to the pacemaker implantation were evaluated. Because of the older age of patients, they were divided into two groups to define the effect of age on complication rate. Group 1 consisted of patients aged less than 75 years of age, and group 2 consisted of those 75 years of age or older. Results demonstrated that among the 574 patients with a permanent pacemaker, 20 patients (3.4%) had a diagnosis of AD. Three patients with AD experienced a complication and all were in group 2. However, the rate of complication was not significant within groups (P=1.000). Reoperation was needed for all of them, and it was significantly higher in patients with AD than in patients without a concomitant disease (P=.006). Patients in group 2 had a rate of complication (21.4%) three times higher than those without an AD and aged 75 years or older. The authors conclude that pacemaker implantation may be of risk in patients with AD, especially in those aged 75 years or older.
Phelps AC, Lauderdale KE, Alcorn S, et al.: Addressing spirituality within the care of patients at the end of life: Perspectives of patients with advanced cancer, oncologists, and oncology nurses. J Clin Oncol 2012;30:2538–2544.
There is encouragement for attention to patients' religious and spiritual needs in national guidelines for high-quality EOL care, but little data exist to guide spiritual care.
To address this deficiency, the authors studied 75 patients with advanced cancer and 339 cancer physicians and nurses in this multi-institution, quantitative-qualitative study.
Patients underwent semistructured interviews, and care providers completed a Web-based survey exploring their perspectives on the routine provision of spiritual care by physicians and nurses. Theme extraction was performed following triangulated procedures of interdisciplinary analysis. Multivariable ordinal logistic regression models assessed relationships between participants' characteristics and attitudes toward spiritual care. Results demonstrated that the majority of patients (77.9%), physicians (71.6%), and nurses (85.1%) believed that routine spiritual care would have a positive impact on patients. Only 25% of patients had previously received spiritual care. Among patients, prior spiritual care (adjusted odds ratio [AOR], 14.65; 95% CI, 1.51 to 142.23), increasing education (AOR, 1.26; 95% CI, 1.06 to 1.49), and religious coping (AOR, 4.79; 95% CI, 1.40 to 16.42) were associated with favorable perceptions of spiritual care. Physicians held more negative perceptions of spiritual care than patients (P<.001) and nurses (P=.008). Qualitative analysis identified benefits of spiritual care, including supporting patients' emotional well-being and strengthening patient-provider relationships. Objections to spiritual care frequently related to professional role conflicts. Participants described ideal spiritual care to be individualized, voluntary, inclusive of chaplains/clergy, and based on assessing and supporting patient spirituality. The authors conclude that most patients with advanced cancer, oncologists, and oncology nurses value spiritual care. Themes described provide an empirical basis for engaging spiritual issues within clinical care.