Abstract
Toole M, Lutz S, Johnstone PA: Radiation oncology quality: Aggressiveness of cancer care near the end of life. J Am Coll Radiol 2012;9:199-202.
Quality of care near the end of life is an important issue. As such, the American Society of Clinical Oncology has developed extensive quality metrics and goals, such as limiting chemotherapy being provided within the last 14 days of a patient's life, however, there are no similar-quality metrics, and little data, in the field of radiation oncology. In this study the authors reviewed morbidity and mortality records of patients from 2008 to 2011 at Indiana University who received radiation therapy (RT) within 30 days of death; 63 patients met those criteria. Analysis revealed that 22.2% of patients had Karnofsky Performance Status Scale scores >80, whereas 66.7% of patients had scores <60. Just over half of patients (52%) were still on treatment at death, and more than half of patients (54%) had completed less than half of their original RT plans. Six patients had their final treatments on the days of their deaths, and another 43 patients had their last treatments within 10 days of death. Forty-eight percent of patients received RT for less than one-fifth of their final month of life and 21% for more than half of their last month alive. The authors conclude that their data are valuable in ongoing discussions of RT use at the end of life, especially as related to hospice underutilization.
Sawh SB, Selvaraj IP, Danga A, Cotton, AL, Moss J, Patel PB: Use of methylnaltrexone for the treatment of opioid-induced constipation in critical care patients. Mayo Clin Proceed 2012;87:255-259.
Gastrointestinal dysmotility and constipation are common problems in critical care patients. The majority of critical care patients are treated with opioids, which inhibit gastrointestinal (GI) motility and lead to adverse outcomes. We reasoned that methylnaltrexone (MNTX), a peripheral opioid antagonist approved for the treatment of opioid-induced constipation in patients with advanced illness receiving palliative care when response to laxative therapy has not been sufficient, could improve GI function in critically ill patients. The present study included all patients in our intensive care unit who required rescue medication for GI stasis during the 10-week period from September 1 to November 15, 2009. We compared conventional rescue therapy with subcutaneous MNTX. We performed a retrospective chart review of the 88 nonsurgical critical care patients receiving fentanyl infusions, 15 (17%) of whom met the criteria of absence of laxation within 72 hours of intensive care unit admission despite treatment with senna and sodium docusate. Of these 15 patients, 8 subsequently received conventional rescue therapy (combination of sodium picosulfate [5 mg] and 2 glycerin suppositories [4-g mold]), and 7 patients received MNTX (subcutaneous injection, 0.15 mg/kg). Laxation occurred within 24 hours in 6 of the 7 MNTX patients (86%) but in none of the 8 patients receiving conventional rescue therapy (P=.001). The median difference in time to laxation between the two groups was 3.5 days (P<.001). Although not statistically significant, all 7 patients treated with MNTX, but only 4 of 8 (50%) who received conventional rescue therapy, progressed to full target enteral feeding (P=.08). Intensive care unit mortality was 2 of 7 MNTX patients (29%) versus 4 of 8 (50%) in the standard therapy group (P=.61). We hypothesize that MNTX may play an important role in restoration of bowel function in critically ill patients.
Handsaker S, Dempsey L, Pabby C: Identifying and treating depression at the end of life and among the bereaved. Int J Palliat Nurs 2012;18:91-97.
Depression is a common condition among patients at the end of life that can also affect a patient's family both before and after their loved one's death. It is estimated that approximately 25% of palliative care patients are diagnosed with depression during their illness, and that a majority experience depressive symptoms. If left unrecognized and untreated this may lead to more severe illness symptoms, poor communication with family members and, ultimately, reduced quality of life. Early assessment and management using appropriate tools as a guide are essential for enabling treatment so that patients can be comfortable and meet unfulfilled goals during end-of-life (EOL) care. Palliative care staff play an essential role in recognizing and treating depression in patients, and by focusing on those at risk they can help to reduce the number who will go on to develop the condition. This article provides an overview of depression in palliative care patients and bereaved families, and looks at how targeted monitoring and intervention can help to alleviate the burden in the former and how support can benefit the latter.
Howard R, McShane R, Lindesay J, Ritchie C, Baldwin A, Barber A, Burns A, Dening T, Findlay D, Holmes C, Hughes A, Jacoby R, Jones R, Jones R, McKeith I, Macharouthu A, O'Brien J, Passmore P, Sheehan B, Juszczak E, Katona C, Hills R, Knapp M, Ballard C, Brown R, Banerjee S, Onions C, Griffin M, Adams J, Gray R, Johnson T, Bentham P, and Phillips P: Donepezil and memantine for moderate-to-severe Alzheimer's disease. N Engl J Med 2012;366:893-903.
Clinical trials have shown the benefits of cholinesterase inhibitors for the treatment of mild-to-moderate Alzheimer's disease, but it is not known whether treatment benefits continue after progression to moderate-to-severe disease. In this study the authors assigned 295 community-dwelling patients who had been treated with donepezil for at least three months and who had moderate or severe Alzheimer's disease (a score of 5 to 13 on the Standardized Mini-Mental State Examination [SMMSE, on which scores range from 0 to 30, with higher scores indicating better cognitive function]) to either continue donepezil, discontinue donepezil, discontinue donepezil and start memantine, or continue donepezil and start memantine. Patients received the study treatment for 52 weeks. The coprimary outcomes were scores on the SMMSE and on the Bristol Activities of Daily Living Scale (BADLS, on which scores range from 0 to 60, with higher scores indicating greater impairment). The minimum clinically important differences were 1.4 points on the SMMSE and 3.5 points on the BADLS. Results demonstrated that patients assigned to continue donepezil, as compared with those assigned to discontinue donepezil, had a score on the SMMSE that was higher by an average of 1.9 points and a score on the BADLS that was lower (indicating less impairment) by 3.0. Patients assigned to receive memantine, as compared with those assigned to receive memantine placebo, had a score on the SMMSE that was an average of 1.2 points higher and a score on the BADLS that was 1.5 points lower. The efficacy of donepezil and of memantine did not differ significantly in the presence or absence of the other, and there were no significant benefits of the combination of donepezil and memantine over donepezil alone. The authors conclude that in patients with moderate or severe Alzheimer's disease continued treatment with donepezil was associated with cognitive benefits that exceeded the minimum clinically important difference and with significant functional benefits over the course of 12 months.
Mack JW, Cronin A, Taback N, Huskamp HA, Keating, NL, Malin JL, Earle CC, and Weeks JC: End-of-life care discussions among patients with advanced cancer: A cohort study. Ann Intern Med 2012;156:204-210.
National guidelines recommend that physicians discuss EOL care planning with patients with cancer whose life expectancy is less than one year; however, the incidence of such discussions is not really known. In an effort to evaluate the incidence of EOL care discussions for patients with stage IV lung or colorectal cancer and where, when, and with whom these discussions take place, the authors performed a prospective cohort study of patients diagnosed with lung or colorectal cancer from 2003 to 2005. Participants in the study lived in northern California, Los Angeles County, North Carolina, Iowa, or Alabama or received care in 1 of 5 large HMOs or 1 of 15 Veterans Health Administration sites. Patients (n=2155) with stage IV lung or colorectal cancer were studied. Measurements were EOL care discussions reported in patient and surrogate interviews or documented in medical records through 15 months after diagnosis. Results demonstrated that 73% of patients had EOL care discussions identified by at least one source. Among the 1470 patients who died during follow-up, 87% had EOL care discussions, compared with 41% of the 685 patients who were alive at the end of follow-up. Of the 1081 first EOL care discussions documented in records, 55% occurred in the hospital. Oncologists documented EOL care discussions with only 27% of their patients. Among 959 patients with documented EOL care discussions who died during follow-up, discussions took place a median of 33 days before death. The authors conclude that although most patients with stage IV lung or colorectal cancer discuss EOL care planning with physicians before death, many discussions occur during acute hospital care, with providers other than oncologists, and late in the course of illness.
Davis M, Lasheen W, Walsh D, Mahmoud F, Bicanovsky L, Lagman R: A Phase II dose titration study of thalidomide for cancer-associated anorexia. J Pain Symptom Manage 2012;43:78-86.
Sixty-five percent of people with advanced cancer suffer from loss of appetite, a debilitating symptom associated with poor outcomes. Several inflammatory cytokines appear to cause appetite loss in animal models, and studies have been directed at cytokine modulation. Thalidomide is an immunomodulatory drug that has been associated with improved appetite in those with HIV infections and cancer. In this study the authors completed a two-stage Phase II dose titration study of thalidomide, the primary purpose of which was to assess appetite response to thalidomide in cancer-associated anorexia. Individuals older than 18 years of age with active cancer, loss of appetite by numerical rating scale (NRS), life expectancy of at least four weeks, and Eastern Cooperative Oncology Group performance status of 0-3 were entered into the study. Pretreatment screening included medical history, neurologic examination, and symptoms by NRS and categorical scale (CAT). Patients received 50 mg of thalidomide by mouth at bedtime for two weeks. Individuals who did not respond were dose escalated to 100 mg at night for two weeks. Assessment of appetite, early satiety, fatigue, insomnia, night sweats, pain, and quality of life (QOL) occurred at two-week intervals. Toxicity also was assessed. The primary outcome was appetite response defined as a two-point reduction in the NRS or a one-point improvement in the CAT. Results demonstrated that 35 patients entered the study; 33 completed 14 days of therapy and were analyzed for efficacy and toxicity. Sixty-four percent who completed at least two weeks of thalidomide had improved appetite. The CAT scores for appetite, insomnia, and QOL improved significantly. The 95% confidence intervals did not overlap. Five participants dropped out because of toxicity: two before two weeks and three later. The authors conclude that thalidomide reduced multiple symptoms commonly associated with cancer-related anorexia and that it improved QOL. The authors' findings confirmed and validated a previously published single-arm trial. A recent randomized trial demonstrated greater benefits when thalidomide is used combined with other agents to treat cancer-associated anorexia and cachexia. Thalidomide helped cancer-associated anorexia in most patients. It also improved insomnia and QOL in advanced cancer.