Abstract
Walling AM, Asch SM, Lorenz KA, et al. The quality of supportive care among inpatients dying of advanced cancer. Support Care Cancer 2012 (epub ahead of print; DOI 10.1007/s00520-12-1462-3).
Managing symptoms and communicating effectively are essential aspects of providing high-quality cancer care, especially among patients with advanced cancer. In this study the authors applied novel quality indicators to measure the quality of supportive care provided to patients with advanced cancer who died in a large university medical center. Cancer quality Assessing Symptoms Side Effects and Indicators of Supportive Treatment (ASSIST) is a comprehensive quality indicator (QI) set that includes 92 symptom and care planning indicators, of which the authors piloted 15 applicable to persons with advanced cancer who died in the hospital setting. Medical records of all adult terminal hospitalizations with lengths of stay ≥3 days at one university medical center between April 2005 and April 2006 were evaluated. Results demonstrated that of 496 decedents, 118 had advanced cancer (mean age 60, 54% male). Forty-five percent received chemotherapy or radiation in the month prior to or during admission. During the hospitalization, 56 % of the patients spent time in the ICU (median length of stay 8 days), one in five received first-time hemodialysis, and 23% had a ventilator withdrawn anticipating death. The 118 patients triggered 596 QIs of which 476 passed (QI level pass rate 80%, range 50% to 100%). Pain assessment and management were consistently performed; however, other cancer supportive care needed improvement: 26% of patients not receiving cancer therapy who had nausea and vomiting received inadequate follow-up, more than one quarter of patients with dyspnea had this symptom inadequately addressed, and 29% of patients taking long-acting opioids were not prescribed a bowel regimen. Timely discussion of patient preferences upon admission to the ICU or initiation of mechanical ventilation occurred in 64% and 69% of cases, respectively. The authors conclude that this set of QIs can evaluate supportive and end-of-life care provided to inpatients dying with advanced cancer—and can identify aspects of care that need improvement.
Salpeter SR, Luo EJ, Malter DS, Stuart B. Systematic review of noncancer presentations with a median survival of 6 months or less. Am J Med 2012;125:512.e1–512.e16.
In this article the authors report on clinical indicators of six-month mortality in advanced noncancer illnesses and the effect of treatment on survival. The MEDLINE database was searched comprehensively to find studies evaluating survival for common advanced noncancer illnesses. The authors retrieved and evaluated studies that reported a median survival of one year or less and evaluated prognostic factors or effect of treatment on survival. They extracted data on presentations with median survival of six months or less for heart failure, chronic obstructive pulmonary disease, dementia, geriatric failure to thrive, cirrhosis, and end-stage renal failure. Independent risk factors for survival were combined and included if their combination was associated with a six-month mortality of greater than 50%. The search identified 1000 potentially relevant studies, of which 475 were retrieved and evaluated, and 74 were included. The authors found that even though advanced noncancer syndromes differ clinically, a universal set of prognostic factors signals progression to terminal disease, including poor performance status, advanced age, malnutrition, comorbid illness, organ dysfunction, and hospitalization for acute decompensation. Generally, a six-month median survival is associated with the presence of two to four of these factors. With few exceptions, these terminal presentations are quite refractory to treatment. The authors conclude that this systematic review summarizes prognostic factors common to advanced noncancer illness, with little evidence at present that treatment prolongs survival at these terminal stages.
Teno JM, Gozalo P, Mitchell SL, et al. Feeding tubes and the prevention or healing of pressure ulcers. Arch Intern Med 2012;172:697–701.
The evidence regarding the use of feeding tubes in persons with advanced dementia to prevent or heal pressure ulcers is conflicting. Using national data, the authors attempted to determine whether percutaneous endoscopic gastrostomy (PEG) tubes prevent or help heal pressure ulcers in nursing home (NH) residents with advanced cognitive impairment (ACI). A propensity-matched cohort study of NH residents with ACI and recent need for assistance in eating was conducted by matching each NH resident who had a feeding tube inserted during a hospitalization to three without a PEG tube inserted. Using the Minimum Data Set (MDS), the authors examined two outcomes: whether residents without a pressure ulcer developed a stage 2 or higher pressure ulcer (n=1124 with PEG insertion); and whether NH residents with a pressure ulcer (n=461) experienced improvement of the pressure ulcer by their first posthospitalization MDS assessment (mean [SD] time between evaluations, 24.6 [32.7] days). Results demonstrated that matched residents with and without a PEG insertion showed comparable sociodemographic characteristics, rates of feeding tube risk factors, and mortality. Adjusted for risk factors, hospitalized NH residents receiving a PEG tube were 2.27 times more likely to develop a new pressure ulcer (95%CI, 1.95–2.65). Conversely, those with a pressure ulcer were less likely to have the ulcer heal when they had a PEG tube inserted. The authors conclude that feeding tubes are not associated with prevention or improved healing of a pressure ulcer. Rather, their findings suggest that the use of PEG tube is associated with increased risk of pressure ulcers among NH residents with ACI.
Billings JA. The need for safeguards in advance care planning. J Gen Intern Med 2012;595–600.
In this well-written article, the author discusses the need for safeguards in advance care planning, writing, “A few recent reports show encouraging outcomes from advance care planning, but most studies indicate that the procedure is ineffective in protecting patients from unwanted treatments and may even undermine autonomy by leading to choices that do not reflect patient values, goals, and preferences.” The author further suggests, “Safeguards for advance care planning should be put in place, such as encouraging physicians to err on the side of preserving life when advance care directives are unclear, requiring a trained advisor to review nonemergent patient choices to limit life-sustaining treatment, training of clinicians in conducting such conversations, and structured discussion formats that first address values and goals rather than particular life-sustaining procedures.” Using a case-based approach, the author discusses the importance of advance directives, including whether physicians unduly influence patient choices, safeguards, and public policy; and he formulates a research agenda. This is an excellent article that is highly recommended for all clinicians, not only palliative care clinicians.
Toevs CC. Palliative medicine in the surgical intensive care unit and trauma. Anesthesiology Clin 2012;30:29–35.
The intensive care unit (ICU) plays a prominent role in medical care in the United States today. National data suggest 30% to 40% of all patients admitted to the ICU will die while in the ICU or before hospital discharge, with 22% of all deaths in the United States now occurring in or after admission to an ICU. Palliative medicine has an increasing role and presence in the ICU. This article discusses the growing and essential role of palliative medicine in comprehensive patient-centered care in the surgical intensive care unit (SICU) and in trauma. This is a valuable article, and is part of an issue (March) dedicated to palliative care.
Liao J. The art of medicine. Lancet 2012;379:1696–1697.
In this perspective piece, Joshua Liao writes a beautiful story of a patient (Mr. Thompson) he became close to that underwent a risky surgery due to infection of his spinal cord, but subsequently recovered. He talks of his time with the patient and his wife, and of learning about them as persons, not only the disease. He writes, “There will also potentially be periods of fatigue and frustration when I lose sight of the reasons I chose to pursue primary care medicine. But opposing these things will be my relationships with patients like Mr. Thompson, whose emails, letters, pictures, and stories will be sustaining reminders of the life-changing potential of medicine, and my place within it.” While not an evidence-based study or a randomized trial, this is a wonderful story that reminds us of why we entered medicine and nursing, and how honored and privileged we are to enter our patients' lives.
Kirchhoff KT, Hammes BJ, Kehl KA, et al. Effect of a disease-specific advance care planning intervention on end-of-life care. J Am Geriatr Soc 2012;60:946–950.
In this randomized controlled trial of individuals with congestive heart failure or end-stage renal disease and their surrogates, the authors attempted to compare patient preferences for end-of-life care with care received at the end of life. Patients enrolled in the study were randomized to receive patient-centered advance care planning (PC-ACP) or usual care. Of 313 people and their surrogates who completed data entry, 110 died. Results demonstrated that patients (74%) frequently continued to make their own decisions about care to the end. The experimental group had fewer (1/62) cases in which patients' wishes about cardiopulmonary resuscitation were not met than in the control group (6/48), but not significantly so. Significantly more experimental patients withdrew from dialysis than controls. The authors conclude that patients and their surrogates were generally willing to discuss preferences with a trained facilitator. Most patients received the care they desired at end of life or altered their preferences to be in accord with the care they could receive. A larger sample with surrogate decision makers is needed to detect significant differences.