Abstract
Burton CZ, Twamley EW, Lee LC, Palmer BW, Jeste DV, Dunn LB, Irwin SA. Undetected cognitive impairment and decision-making capacity in patients receiving hospice care. Am J Geriatr Psychiatry 2012;20:306–316.
Cognitive dysfunction is common in patients with advanced, life-threatening illness, and can be attributed to a variety of factors such as advanced age and medication use. Such dysfunction likely affects decisional capacity, which is a crucial consideration as the end-of-life approaches and patients face multiple choices regarding treatment and family and estate planning. In this study, the authors examined the prevalence of cognitive impairment and its impact on decision-making abilities among hospice patients with neither a chart diagnosis of a cognitive disorder nor clinically-apparent cognitive deficits. A total of 110 participants receiving hospice services completed a 1-hour neuropsychological battery, a measure of decisional capacity, and accompanying interviews. The results demonstrated that in general, participants were mildly impaired on measures of verbal learning, verbal memory, and verbal fluency; 54% of the sample was classified as having significant, previously undetected cognitive impairments. These individuals performed significantly worse than the other participants on all neuropsychological and decisional capacity measures, with effect sizes ranging from medium to very large (0.43–2.70). A number of verbal abilities as well as global cognitive functioning significantly predicted decision-making capacity. The authors conclude that despite an absence of documented or clinically obvious impairment, more than half of the sample had significant cognitive impairments. As such, assessment of cognition in hospice patients is warranted, including assessment of verbal abilities that may interfere with understanding or reasoning related to treatment decisions. Identification of patients at risk for impaired cognition and decision making may lead to effective interventions to improve decision making and honor the wishes of patients and families. (This issue of American Journal of Geriatric Psychiatry is dedicated to palliative care.)
Morden NE, Chang CH, Jacobson JO, Berke EM, Bynum JP, Murray KM, Goodman DC. End-of-life care for Medicare beneficiaries with cancer is highly intensive overall and varies widely. Health Affairs 2012;31:786–796.
Studies have shown that cancer care near the end of life is more aggressive than many patients prefer. Using a cohort of deceased Medicare beneficiaries with poor-prognosis cancer, meaning that they were likely to die within a year, the authors examined the association between hospital characteristics and 11 end-of-life care measures, such as hospice use and hospitalization. Results of the study revealed a relatively high intensity of care in the last weeks of life. At the same time, there was more than a twofold variation within hospital groups with common features, such as cancer center designation and for-profit status. The authors found that these hospital characteristics explained little of the observed variation in intensity of end-of-life cancer care and that none reliably predicted a specific pattern of care. These findings raise questions about what factors may be contributing to this variation. They also suggest that best practices in end-of-life cancer care can be found in many settings, and that efforts to improve the quality of end-of-life care should include every hospital category.
Traeger L, Greer JA, Fernandez-Robles, C, Temel JS, Pirl WF. Evidence-based treatment of anxiety in patients with cancer. J Clin Oncol 2012;30:1197–1205.
Anxiety is a vigorous response to perceived threat that is common among patients with cancer and fluctuates at critical points in the disease trajectory. A substantial minority of patients may experience clinically significant anxiety resulting from a range of potential etiologic factors. This review summarizes evidence-based recommendations for the treatment of anxiety in oncology settings. Recommendations are based on the nature and time course of anxiety, and the results of meta-analyses, systematic reviews, and individual trials in cancer populations. The evidence-based literature supports the use of psychosocial and psychopharmacologic treatments to prevent or alleviate anxiety symptoms. However, conclusions are tempered by study heterogeneity and methodologic limitations, and a lack of trials that included patients with clinically significant anxiety. In oncology settings, accessibility and acceptability of evidence-based treatments vary, and patients may seek a variety of resources to manage cancer concerns. Treatment planning should incorporate contributing factors to anxiety and patient preferences for psychiatric care. Various headings in the article include prevalence of anxiety and anxiety disorders, diagnostic considerations, anxious behaviors in patients, treatments, and future perspectives. (This issue of Journal of Clinical Oncology is dedicated to psychosocial issues.)
Pope TM. Legal fundamentals of surrogate decision making. Chest 2012;141:1074–1081.
Patient autonomy is highly valued in the United States to the extent that the patient does not lose the right of self-determination when he or she loses the capacity to make health care decisions for him- or herself. The law has devised several tools to promote “prospective autonomy.” One mechanism is the instructional advance directive or living will. However, most of us do not write such directives. Another mechanism is the proxy directive or durable power of attorney for health care, designating another person, a surrogate, to direct the course of our medical treatment upon our incapacity. But most of us do not do that either. Therefore, the most common mechanism by which our prospective autonomy is protected and promoted is through the informal selection of surrogates based on statutory priority lists. These “default” surrogates are the most numerous type of surrogate. This useful article explains the importance and legal fundamentals of surrogate decision making, and first describes five basic types of surrogates. The article then looks at the role of these surrogates and how they are supposed to make decisions on the patient's behalf. Unfortunately, surrogate performance is often mediocre or poor. There are significant and persistent obstacles to good surrogate decision making. After explaining these problems, the article concludes by identifying several solutions. This is an excellent article and recommended reading.
Mercadante S, Ferrera P, Villari P, Adile C, Casuccio A. Switching from oxycodone to methadone in advanced cancer patients. Support Care Cancer 2012;20:191–194.
The aim of this study was to evaluate the outcomes and the conversion ratio of switching from oxycodone to methadone in advanced cancer patients admitted to an acute palliative care unit. A prospective study was carried out on a cohort of consecutive patients receiving oxycodone, who were switched for different reasons, but primarily because of an inconvenient balance between analgesia and adverse effects. The initial conversion ratio between oxycodone and methadone was 3.3:1. Intensity of pain and symptoms associated with opioid therapy were recorded, and a distress score (DS) was also calculated as a sum of symptom intensity. A successful switching was recorded when the intensity of pain and/or DS or the principal symptom requiring switching decreased at least of 33% of the value recorded before switching. The results demonstrated that 19 out of 542 patients admitted to the unit in 1 year underwent a switch from oxycodone to methadone. Almost all substitutions were successful. The prevalent indication for opioid switching was uncontrolled pain and adverse effects (12 patients). No significant changes between the initial conversion ratio and final conversion ratio between the two opioids were found. The authors conclude that switching from oxycodone to methadone is a reliable method to improve the opioid response in advanced cancer patients. A ratio of 3.3:1 appears to be reliable, even at high doses. However, the authors recommend that further studies be performed to confirm these results.
Hannon B, O'Reilly V, Bennett K, Breen K, Lawlor PG. Meeting the family: Measuring effectiveness of family meetings in a specialist inpatient palliative care unit. Palliat Support Care 2012;10:43–49.
The World Health Organization's (WHO) definition of palliative care as “an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness …” recognizes the importance of family members in this setting. In practice, family meetings account for a significant amount of the weekly workload in a specialist inpatient palliative care unit as well as palliative care consultations. Despite this, there is little empirical evidence to support the benefits of family meetings from the perspective of family members. In this prospective study over 6 months, a designated family member was invited to complete a self-report instrument (SRI) and the Family Inventory of Needs (FIN) questionnaire prior to, immediately following, and 48 hours after a planned family meeting attended by several members of the multidisciplinary team. The results demonstrated that 31 designated family members completed the study. The SRIs completed prior to a family meeting identified particular areas of concern and worry for family members, and also helped to generate an agenda based on the family's particular needs. The pre-meeting FIN identified areas of patient care of greatest importance to each family member, and asked them to rate whether particular care needs were presently met or unmet, in their opinion, by the health care team caring for the patient. Following the family meeting, repeat SRIs showed an overall reduction in concerns and increased confidence in dealing with those issues raised. Post-family meeting FIN scores confirmed a greater number of met care needs compared with pre-meeting scores, all of which were sustained over time. The authors conclude that this study confirms the value of planned multidisciplinary family meetings for patients in specialist inpatient palliative care units. It identifies the often-unmet needs of family members and the sustained benefits associated with formal family meetings.